nclex questions

When planning emergent care for a patient with a suspected MI, what should the nurse anticipate administrating? a. Oxygen, nitroglycerin, aspirin, and morphine b. Oxygen, furosemide (Lasix), nitroglycerin, and meperidine c. Aspirin, nitroprusside (Nipride), dopamine (Intropin), and oxygen d. Nitroglycerin, lorazepam (Ativan), oxygen, and warfarin (Coumadin)

a The American Heart Association's guidelines for emergency care of the patient with chest pain include the administration of oxygen, nitroglycerin, aspirin, and morphine. These interventions serve to relieve chest pain, improve oxygenation, decrease myocardial workload, and prevent further platelet aggregation. The other medications may be used later in the patient's treatment.

Important teaching for the patient scheduled for a radiofrequency catheter ablation procedure includes explaining that a. ventricular bradycardia may be induced and treated during the procedure. b. a catheter will be placed in both femoral arteries to allow doublecatheter use. c. the procedure will destroy areas of the conduction system that are causing rapid heart rhythms. d. a general anesthetic will be given to prevent the awareness of any "sudden cardiac death" experiences.

. Correct answer: c Rationale: Radiofrequency catheter ablation therapy involves the use of electrical energy to "burn" or ablate areas of the conduction system as definitive treatment of tachydysrhythmias.

A nurse is caring for a client 5 days following a myocardial infarction(MI). the client has sudden onset of shortness of breath. The nurse notes that the client appears Air hungry and is coughing frothy, pink sputum. when auscultating the clients breath sounds, the nurse expects to hear which of the following bilateral sounds? A.) crackles B.) wheezes C.) rhonchi D.) friction rub

A.) crackles

A nurse is caring for a client with hemophilia who has an active bleed in a joint. The appropriate nursing intervention when providing care to this client is which of the following? A.) obtain blood samples for platelet functioning B.) prepare for replacement of the missing Factor C.) provide passive range of motion D.) place the bleeding joint in the dependent position

B.) prepare for replacement of the missing Factor it is not "provide passive range of motion". Passive range of motion should not be part of an exercise regimen since this may cause for the further bleeding. Active range of motion is appropriate so that the client can control activity to tolerance.

What is the priority assessment by the nurse caring for a patient receiving IV nesiritide (Natrecor) to treat heart failure? a. Urine output b. Lung sounds c. Blood pressure d. Respiratory rate

C Although all identified assessments are appropriate for a patient receiving IV nesiritide, the priority assessment would be monitoring for hypotension, the main adverse effect of nesiritide.

A nurse is instructing a client after a myocardial infarction about Lifestyle Changes. A client returns for a follow-up visit to the cardiac clinic hospitalization for an acute myocardial infarction. Which statement made by the client indicates the additional teaching is needed? A.) I should no longer eat foods high in saturated fat B.) before taking my medication I will count my RADIAL pulse rate C.) I will exercise once a week for an hour at the health club D.) after eating I will rest before resuming my daily routine

C.) I will exercise once a week for an hour at the health club it is not "I should no longer eat foods high in saturated fat" Because following an acute myocardial infarction, the clients Lifestyle Changes include consuming foods low in saturated fat. These foods are high in saturated fat and should be avoided.

A complication of the hyperviscosity of polycythemia is a. thrombosis. b. cardiomyopathy. c. pulmonary edema. d. disseminated intravascular coagulation (DIC).

Correct answer: a Rationale: The patient with polycythemia may experience angina, heart failure, intermittent claudication, and thrombophlebitis, which may be complicated by embolization. These manifestations are caused by blood vessel distention, impaired blood flow, circulatory stasis, thrombosis, and tissue hypoxia, caused by the hypervolemia and hyperviscosity. The most common serious acute complication is stroke, caused by thrombosis.

In a severely anemic patient, the nurse would expect to find a. dyspnea and tachycardia. b. cyanosis and pulmonary edema. c. cardiomegaly and pulmonary fibrosis. d. ventricular dysrhythmias and wheezing.

Correct answer: a Rationale: Patients with severe anemia (hemoglobin level, less than 6 g/dL) exhibit the following cardiovascular and pulmonary manifestations: tachycardia, increased pulse pressure, systolic murmurs, intermittent claudication, angina, heart failure, myocardial infarction, tachypnea, orthopnea, and dyspnea at rest.

When caring for a patient with thrombocytopenia, the nurse instructs the patient to a. dab his or her nose instead of blowing. b. be careful when shaving with a safety razor. c. continue with physical activities to stimulate thrombopoiesis. d. avoid aspirin because it may mask the fever that occurs with thrombocytopenia.

Correct answer: a Rationale: Patients with thrombocytopenia should avoid aspirin because it reduces platelet adhesiveness, which contributes to bleeding. Patients should not perform vigorous exercise or lift weights. If a patient is weak and at risk for falling, supervise the patient when he or she is out of bed. Blowing the nose forcefully should be avoided. The patient should gently pat the nose with a tissue if needed. Instruct patients not to shave with a blade; an electric razor should be used.

After teaching about ways to decrease risk factors for CAD, the nurse recognizes that additional instruction is needed when the patient says a. "I would like to add weight lifting to my exercise program." b. "I can only keep my blood pressure normal with medication." c. "I can change my diet to decrease my intake of saturated fats." d. "I will change my lifestyle to reduce activities that increase my stress."

Correct answer: a Rationale: Risk factors for coronary artery disease include elevated serum levels of lipids, elevated blood pressure, tobacco use, physical inactivity, obesity, diabetes, metabolic syndrome, certain psychologic states, and elevated homocysteine levels. Weight lifting is not a cardioprotective exercise. An example of health-promoting regular physical activity is brisk walking (3 to 4 miles/hr) for at least 30 minutes five or more times each week.

The nurse recognizes that primary manifestations of systolic failure include a. ↓ EF and ↑ PAWP. b. ↓ PAWP and ↑ EF. c. ↓ pulmonary hypertension associated with normal EF. d. ↓ afterload and ↓ left ventricular end-diastolic pressure.

Correct answer: a Rationale: Systolic heart failure results in systolic failure in the left ventricle (LV). The LV loses its ability to generate enough pressure to eject blood forward through the aorta. This results in increased pulmonary artery wedge pressure (PAWP). The hallmark of systolic failure is a decrease in the left ventricular ejection fraction (EF).

The nurse is caring for a patient who is 2 days post-MI. The patient reports that she is experiencing chest pain. She states, "It hurts when I take a deep breath." Which action would be a priority? a. Notify the physician STAT and obtain a 12-lead ECG. b. Obtain vital signs and auscultate for a pericardial friction rub. c. Apply high-flow oxygen by face mask and auscultate breath sounds. d. Medicate the patient with PRN analgesic and reevaluate in 30 minutes.

Correct answer: b Rationale: Acute pericarditis is inflammation of the visceral and/or parietal pericardium; it often occurs 2 to 3 days after an acute myocardial infarction. Chest pain may vary from mild to severe and is aggravated by inspiration, coughing, and movement of the upper body. Sitting in a forward position often relieves the pain. The pain is usually different from pain associated with a myocardial infarction. Assessment of the patient with pericarditis may reveal a friction rub over the pericardium.

A hospitalized patient with a history of chronic stable angina tells the nurse that she is having chest pain. The nurse bases his actions on the knowledge that ischemia a. will always progress to myocardial infarction. b. will be relieved by rest, nitroglycerin, or both. c. indicates that irreversible myocardial damage is occurring. d. is frequently associated with vomiting and extreme fatigue.

Correct answer: b Rationale: Chronic stable angina is chest pain that occurs intermittently over a long period with the same pattern of onset, duration, and intensity of symptoms. The chest pain is relieved by rest or by rest and medication (e.g., nitroglycerin). The ischemia is transient and does not cause myocardial damage.

When obtaining assessment data from a patient with a microcytic, hypochromic anemia, the nurse would question the patient about a. folic acid intake. b. dietary intake of iron. c. a history of gastric surgery. d. a history of sickle cell anemia.

Correct answer: b Rationale: Iron-deficiency anemia is a microcytic, hypochromic anemia.

A patient with multiple myeloma becomes confused and lethargic. The nurse would expect that these clinical manifestations may be explained by diagnostic results that indicate a. hyperkalemia. b. hyperuricemia. c. hypercalcemia. d. CNS myeloma.

Correct answer: c Rationale: Bone degeneration in multiple myeloma causes calcium to be lost from bones, which eventually results in hypercalcemia. Hypercalcemia may cause renal, gastrointestinal, or neurologic manifestations, such as polyuria, anorexia, or confusion, and may ultimately cause seizures, coma, and cardiac problems.

DIC is a disorder in which a. the coagulation pathway is genetically altered, leading to thrombus formation in all major blood vessels. b. an underlying disease depletes hemolytic factors in the blood, leading to diffuse thrombotic episodes and infarcts. c. a disease process stimulates coagulation processes with resultant thrombosis, as well as depletion of clotting factors, leading to diffuse clotting and hemorrhage. d. an inherited predisposition causes a deficiency of clotting factors that leads to overstimulation of coagulation processes in the vasculature.

Correct answer: c Rationale: In disseminated intravascular coagulation (DIC), the coagulation process is stimulated, with resultant thrombosis and depletion of clotting factors, which leads to diffuse clotting and hemorrhage. The paradox of this condition is characterized by the profuse bleeding that results from the depletion of platelets and clotting factors.

The most common finding in individuals at risk for sudden cardiac death is a. aortic valve disease. b. mitral valve disease. c. left ventricular dysfunction. d. atherosclerotic heart disease.

Correct answer: c Rationale: Left ventricular dysfunction (ejection fraction less than 30%) and ventricular dysrhythmias after myocardial infarction are the strongest predictors of sudden cardiac death (SCD).

A patient is recovering from an uncomplicated MI. Which rehabilitation guideline is a priority to include in the teaching plan? a. Refrain from sexual activity for a minimum of 3 weeks. b. Plan a diet program that aims for a 1- to 2-pound weight loss per week. c. Begin an exercise program that aims for at least five 30-minute sessions per week. d. Consider the use of erectile agents and prophylactic NTG before engaging in sexual activity.

Correct answer: c Rationale: Physical activity should be regular, rhythmic, and repetitive, with the use of large muscles to build up endurance (e.g., walking, cycling, swimming, rowing). Physical activity sessions should be at least 30 minutes long. Instruct the patient to begin slowly at personal tolerance (perhaps only 5 to 10 minutes) and build up to 30 minutes.

A compensatory mechanism involved in HF that leads to inappropriate fluid retention and additional workload of the heart is a. ventricular dilation. b. ventricular hypertrophy. c. neurohormonal response. d. sympathetic nervous system activation.

Correct answer: c Rationale: The following mechanisms in heart failure lead to inappropriate fluid retention and additional workload of the heart: activation of the renin-angiotensin-aldosterone system (RAAS) cascade and release of antidiuretic hormone from the posterior pituitary gland in response to low cerebral perfusion pressure that results from low cardiac output.

The nurse is monitoring the ECG of a patient admitted with ACS. Which ECG characteristics would be most suggestive of myocardial ischemia? a. Sinus rhythm with a pathologic Q wave b. Sinus rhythm with an elevated ST segment c. Sinus rhythm with a depressed ST segment d. Sinus rhythm with premature atrial contractions

Correct answer: c Rationale: Typical electrocardiographic (ECG) changes that are seen in myocardial ischemia include ST-segment depression and T-wave inversion.

The nurse is aware that a major difference between Hodgkin's lymphoma and non-Hodgkin's lymphoma is that a. Hodgkin's lymphoma occurs only in young adults. b. Hodgkin's lymphoma is considered potentially curable. c. non-Hodgkin's lymphoma can manifest in multiple organs. d. non-Hodgkin's lymphoma is treated only with radiation therapy.

Correct answer: c Rationale: Non-Hodgkin's lymphoma can originate outside the lymph nodes, the method of spread can be unpredictable, and most affected patients have widely disseminated disease.

You are caring for a patient with ADHF who is receiving IV dobutamine (Dobutrex). You know that this drug is ordered because it (select all that apply) a. increases SVR. b. produces diuresis. c. improves contractility. d. dilates renal blood vessels. e. works on the β1-receptors in the heart.

Correct answers: c, e Rationale: Dobutamine (Dobutrex) has a positive chronotropic effect and increases heart rate and improves contractility. It is a selective β-adrenergic agonist and works primarily on the β1-adrenergic receptors in the heart. It is frequently used in the short-term management of acute decompensated heart failure (ADHF).

A patient admitted with ACS has continuous ECG monitoring. An examination of the rhythm strip reveals the following characteristics: atrial rate 74 beats/min and regular; ventricular rate 62 beats/min and irregular; P wave normal shape; PR interval lengthens progressively until a P wave is not conducted; QRS normal shape. The priority nursing intervention would be to a. perform synchronized cardioversion. b. administer epinephrine 1 mg IV push. c. observe for symptoms of hypotension or angina. d. apply transcutaneous pacemaker pads on the patient.

Correct answer: c Rationale: The rhythm is a second-degree atrioventricular (AV) block, type I (i.e., Mobitz I or Wenckebach heart block). The rhythm is characterized by a gradual lengthening of the PR interval. Type I AV block is usually a result of myocardial ischemia or infarction and typically is transient and well tolerated. The nurse should assess for bradycardia, hypotension, and angina. If the patient experiences symptoms, atropine or a temporary pacemaker may be needed.

The most common type of leukemia in older adults is a. acute myelocytic leukemia. b. acute lymphocytic leukemia. c. chronic myelocytic leukemia. d. chronic lymphocytic leukemia.

Correct answer: d Rationale: Chronic lymphocytic leukemia is a disease primarily of older adults.

Complications of transfusions that can be decreased by the use of leukocyte depletion or reduction of RBC transfusion are a. chills and hemolysis. b. leukostasis and neutrophilia. c. fluid overload and pulmonary edema. d. transmission of cytomegalovirus and fever.

Correct answer: d Rationale: Infectious viruses, such as human immunodeficiency virus (HIV), human herpesvirus, hepatitis B and C type 6 (HCV-6), Epstein-Barr virus (EBV), human T-cell leukemia virus type 1 (HTLV-1), and cytomegalovirus (CMV), and other agents, such as the agent that causes malaria, can be transmitted by blood transfusion. Leukocyte-reduced blood products drastically reduce the risk for viral infections associated with blood transfusions, including CMV.

Because myelodysplastic syndrome arises from the pluripotent hematopoietic stem cell in the bone marrow, laboratory results the nurse would expect to find include a(n) a. excess of T cells. b. excess of platelets. c. deficiency of granulocytes. d. deficiency of all cellular blood components.

Correct answer: d Rationale: Myelodysplastic syndrome (MDS) commonly manifests as infection and bleeding. It is caused by inadequate numbers of ineffective functioning circulating granulocytes or platelets.

The nurse prepares a patient for synchronized cardioversion knowing that cardioversion differs from defibrillation in that a. defibrillation requires a lower dose of electrical energy. b. cardioversion is indicated to treat atrial bradydysrhythmias. c. defibrillation is synchronized to deliver a shock during the QRS complex. d. patients should be sedated if cardioversion is done on a nonemergency basis.

Correct answer: d Rationale: Synchronized cardioversion is the therapy of choice for patients with hemodynamically unstable ventricular or supraventricular tachydysrhythmias. A synchronized circuit in the defibrillator delivers a countershock that is programmed to occur on the R wave of the QRS complex of the electrocardiogram. The synchronizer switch must be turned on when cardioversion is planned. The procedure for synchronized cardioversion is the same as for defibrillation with the following exceptions: If synchronized cardioversion is performed on a nonemergency basis, the patient is sedated before the procedure, and the initial energy needed for synchronized cardioversion is less than the energy needed for defibrillation.

The ECG monitor of a patient in the cardiac care unit after an MI indicates ventricular bigeminy with a rate of 50 beats/min. The nurse would anticipate a. performing defibrillation. b. treating with IV amiodarone. c. inserting a temporary transvenous pacemaker. d. assessing the patient's response to the dysrhythmia.

Correct answer: d Rationale: A premature ventricular contraction (PVC) is a contraction originating in an ectopic focus in the ventricles. When every other beat is a PVC, the rhythm is called ventricular bigeminy. PVCs are usually a benign finding in patients with a normal heart. In patients with heart disease, PVCs may reduce the cardiac output and precipitate angina and heart failure, depending on the frequency. Because PVCs in coronary artery disease (CAD) or acute myocardial infarction indicate ventricular irritability, the patient's physiologic response to PVCs must be monitored. Assessment of the patient's hemodynamic status is important for determining whether treatment with drug therapy is needed.

When reviewing the patient's hematologic laboratory values after a splenectomy, the nurse would expect to find a. leukopenia. b. RBC abnormalities. c. decreased hemoglobin. d. increased platelet count.

Correct answer: d Rationale: Splenectomy can have a dramatic effect in increasing peripheral RBC, white blood cell, and platelet counts.

The nurse would anticipate that a patient with von Willebrand disease undergoing surgery would be treated with administration of vWF and a. thrombin. b. factor VI. c. factor VII. d. factor VIII.

Correct answer: d Rationale: von Willebrand disease involves deficiency of the von Willebrand coagulation protein, variable factor VIII deficiencies, and platelet dysfunction. Treatment includes administration of von Willebrand factor and factor VIII.

Multiple drugs are often used in combinations to treat leukemia and lymphoma because a. there are fewer toxic and side effects. b. the chance that one drug will be effective is increased. c. the drugs are more effective without causing side effects. d. the drugs work by different mechanisms to maximize killing of malignant cells.

Correct answer: d Rationale: Combination therapy is the mainstay of treatment for leukemia. The three purposes for using multiple drugs are to (1) decrease drug resistance, (2) minimize the drug toxicity to the patient by using multiple drugs with varying toxic effects, and (3) interrupt cell growth at multiple points in the cell cycle.

In teaching a patient about coronary artery disease, the nurse explains that the changes that occur in this disorder include (select all that apply) a. diffuse involvement of plaque formation in coronary veins. b. abnormal levels of cholesterol, especially low-density lipoproteins. c. accumulation of lipid and fibrous tissue within the coronary arteries. d. development of angina due to a decreased blood supply to the heart muscle. e. chronic vasoconstriction of coronary arteries leading to permanent vasospasm.

Correct answers: b, c, d Rationale: Atherosclerosis is the major cause of coronary artery disease (CAD) and is characterized by a focal deposit of cholesterol and lipids, primarily within the intimal wall of the artery. The endothelial lining of the coronary arteries becomes inflamed from the presence of unstable plaques and the oxidation of low-density lipoprotein (LDL) cholesterol. Fibrous plaque causes progressive changes in the endothelium of the arterial wall. The result is a narrowing of the vessel lumen and a reduction in blood flow to the myocardial tissue.

A patient with chronic HF and atrial fibrillation is treated with a digitalis glycoside and a loop diuretic. To prevent possible complications of this combination of drugs, what does the nurse need to do (select all that apply)? a. Monitor serum potassium levels. b. Teach the patient how to take a pulse rate. c. Keep an accurate measure of intake and output. d. Teach the patient about dietary restriction of potassium. e. Withhold digitalis and notify health care provider if heart rate is irregular.

Correct answers: a, b Rationale: Hypokalemia, which can be caused by the use of potassium-depleting diuretics (e.g., thiazides, loop diuretics), is one of the most common causes of digitalis toxicity. Low serum levels of potassium enhance the action of digitalis, causing a therapeutic dose to achieve toxic levels. Hypokalemia can also precipitate dysrhythmias. Monitoring the serum potassium levels of patients receiving digitalis preparations and potassium-depleting diuretics is essential. Patients taking digitalis preparations should be taught how to measure their pulse rate because bradycardia and atrioventricular blocks are late signs of digitalis toxicity. In addition, patients should know what pulse rate would necessitate a call to the health care provider.

Nursing interventions for a patient with severe anemia related to peptic ulcer disease include (select all that apply) a. monitoring stools for guaiac. b. instructions for high-iron diet. c. taking vital signs every 8 hours. d. teaching self-injection of erythropoietin. e. administration of cobalamin (vitamin B12) injections.

Correct answers: a, b Rationale: Stool guaiac test is performed to determine the cause of iron-deficiency anemia that is related to gastrointestinal bleeding. Iron is increased in the diet. Teach the patient which foods are good sources of iron. If nutrition is already adequate, increasing iron intake by dietary means may not be practical. The patient with iron deficiency related to acute blood loss may require a transfusion of packed red blood cells (RBCs).

Priority nursing actions when caring for a hospitalized patient with a new-onset temperature of 102.2° F and severe neutropenia include (select all that apply) a. administering the prescribed antibiotic STAT. b. drawing peripheral and central line blood cultures. c. ongoing monitoring of the patient's vital signs for septic shock. d. taking a full set of vital signs and notifying the physician immediately. e. administering transfusions of WBCs treated to decrease immunogenicity.

Correct answers: a, b, c, d Rationale: Early identification of an infective organism is a priority, and cultures should be obtained from various sites. Serial blood cultures (at least two) or one from a peripheral site and one from a venous access device should be obtained promptly. In a febrile neutropenic patient, antibiotics should be started immediately (within 1 hour). Cultures of the nose, throat, sputum, urine, stool, obvious lesions, and blood may be indicated. Ongoing febrile episodes or a change in the patient's assessment findings (or vital signs) necessitates a call to the physician for additional cultures, diagnostic tests, addition of antimicrobial therapies, or a combination of these.

The nursing management of a patient in sickle cell crisis includes (select all that apply) a. monitoring CBC. b. optimal pain management and O2 therapy. c. blood transfusions if required and iron chelation. d. rest as needed and deep vein thrombosis prophylaxis. e. administration of IV iron and diet high in iron content.

Correct answers: a, b, c, d Rationale: Complete blood count (CBC) is monitored. Infections are common with elevated white blood cell counts, and anemia may occur with low hemoglobin levels and low RBC counts. Oxygen may be administered to treat hypoxia and control sickling. Rest may be instituted to reduce metabolic requirements, and prophylaxis for deep vein thrombosis (with anticoagulants) is prescribed. Transfusion therapy is indicated when an aplastic crisis occurs. Patients may require iron chelation therapy to reduce transfusion-produced iron overload. Pain occurring during an acute crisis is usually undertreated; patients should have optimal pain control with opioid analgesics, nonsteroidal antiinflammatory agents, antineuropathic pain medications, local anesthetics, or nerve blocks.

A patient is admitted to the ICU with a diagnosis of unstable angina. Which medication(s) would the nurse expect the patient to receive (select all that apply)? a. ACE inhibitor b. Antiplatelet therapy c. Thrombolytic therapy d. Prophylactic antibiotics e. Intravenous nitroglycerin

Correct answers: a, b, e Rationale: In addition to oxygen, several medications may be used to treat unstable angina (UA): nitroglycerin, aspirin (chewable), and morphine. For patients with UA with negative cardiac markers and ongoing angina, a combination of aspirin, heparin, and a glycoprotein IIb/IIIa inhibitor (e.g., eptifibatide [Integrilin]) is recommended. Angiotensin-converting enzyme (ACE) inhibitors decrease myocardial oxygen demand by producing vasodilation, reducing blood volume, and slowing or reversing cardiac remodeling.

Which patient teaching points should the nurse include when providing discharge instructions to a patient with a new permanent pacemaker and the caregiver (select all that apply)? a. Avoid or limit air travel. b. Take and record a daily pulse rate. c. Obtain and wear a Medic Alert ID or bracelet at all times. d. Avoid lifting arm on the side of the pacemaker above shoulder. e. Avoid microwave ovens because they interfere with pacemaker function.

Correct answers: b, c, d Rationale: Pacemaker discharge teaching should include the following instructions: First, air travel is not restricted. The patient should inform airport security of the presence of a pacemaker because it may set off the metal detector. If a hand-held screening wand is used, it should not be placed directly over the pacemaker. Manufacturer information may vary with regard to the effect of metal detectors on the function of the pacemaker. Second, the patient should monitor the pulse and inform the cardiologist if it drops below a predetermined rate. Third, the patient should obtain and wear a Medic Alert ID or bracelet at all times. Fourth, the patient must avoid lifting the arm on the pacemaker side above the shoulder until this is approved by the cardiologist. Fifth, microwave ovens are safe to use, and they do not interfere with pacemaker function. Table 36-13 provides additional discharge teaching guidelines for a patient with a pacemaker.

Patients with a heart transplantation are at risk for which complications in the first year after transplantation (select all that apply)? a. Cancer b. Infection c. Rejection d. Vasculopathy e. Sudden cardiac death

Correct answers: b, c, e Rationale: A variety of complications can occur after heart transplantation. In the first year after transplantation, the major causes of death are acute rejection and infection. Heart transplant recipients also are at risk for sudden cardiac death. Later, malignancy (especially lymphoma) and cardiac vasculopathy (accelerated CAD) are major causes of death.

A nurse is caring for a client whose abdominal aortic aneurysm is extending. The manifestations that the nurse should expect to observe include which of the following? A.) sternal chest pain B.) decreased heart rate and palpitations C.) elevated blood pressure D.) back and abdominal pain

D.) back and abdominal pain Abdominal aortic aneurysm involves a widening, stretching or ballooning of the aorta. Back and abdominal pain indicate that the aneurysm is extending downward and pressing on lumbar spinal nerve Roots causing pain.

A nurse is caring for an adult client with sickle cell disease who has a history of having received many transfusions. the nurse realizes that because of this history, the client is at risk for which of the following? A.) hypokalemia B.) lead poisoning C.) hypercalcemia D.) iron toxicity

D.) iron toxicity it is not "hypercalcemia". Client receiving a transfusion of several units of blood are at risk for hypocalcemia. The citrate in the transfused blood bonds with calcium causing it to be excreted.

A nurse is caring for a client experiencing an acute angina attack. The nurse should monitor a client for which of the following? A.) bradycardia B.) transient diastolic murmur c.) pulsus paradoxes D.) transient abnormal PMI ( point of maximal impulse)

D.) transient abnormal PMI ( point of maximal impulse) It is not a transient diastolic murmur, because murmur is usually associated with a valvular defect and it's not an assessment finding with angina

A patient will receive a hematopoietic stem cell transplant (HSCT). What is the nurse's priority after the patient receives combination chemotherapy before the transplant? a. Prevent patient infection. b. Avoid abnormal bleeding. c. Give pneumococcal vaccine. d. Provide companionship while isolated.

a After combination chemotherapy for HSCT, the patient's bone marrow is destroyed in preparation to receive the bone marrow graft. Thus the patient is immunosuppressed and is at risk for a life-threatening infection. The priority is preventing infection. Bleeding is not usually a problem. Giving the pneumococcal vaccine at this time should not be done, but should have been done previously. Providing companionship is not the primary role of the nurse, although the patient will need support during the time of isolation.

A patient with a recent diagnosis of heart failure has been prescribed furosemide (Lasix) in an effort to physiologically do what for the patient? a. Reduce preload. b. Decrease afterload. c. Increase contractility. d. Promote vasodilation.

a Diuretics such as furosemide are used in the treatment of HF to mobilize edematous fluid, reduce pulmonary venous pressure, and reduce preload. They do not directly influence afterload, contractility, or vessel tone.

The patient is admitted with hypercalcemia, polyuria, and pain in the pelvis, spine, and ribs with movement. Which hematologic problem is likely to display these manifestations in the patient? a. Multiple myeloma b. Thrombocytopenia c. Megaloblastic anemia d. Myelodysplastic syndrome

a Multiple myeloma typically manifests with skeletal pain and osteoporosis that may cause hypercalcemia, which can result in polyuria, confusion, or cardiac problems. Serum hyperviscosity syndrome can cause renal, cerebral, or pulmonary damage. Thrombocytopenia, megaloblastic anemia, and myelodysplastic syndrome are not characterized by these manifestations.

Which individuals would the nurse identify as having the highest risk for CAD? a. A 45-year-old depressed male with a high-stress job b. A 60-year-old male with below normal homocysteine levels c. A 54-year-old female vegetarian with elevated high-density lipoprotein (HDL) levels d. A 62-year-old female who has a sedentary lifestyle and body mass index (BMI) of 23 kg/m2

a The 45-year-old depressed male with a high-stress job is at the highest risk for CAD. Studies demonstrate that depression and stressful states can contribute to the development of CAD. Elevated HDL levels and low homocysteine levels actually help to prevent CAD. Although a sedentary lifestyle is a risk factor, a BMI of 23 kg/m2 depicts normal weight, and thus the patient with two risk factors is at greatest risk for developing CAD.

The patient with leukemia has acute disseminated intravascular coagulation (DIC) and is bleeding. What diagnostic findings should the nurse expect to find? a. Elevated D-dimers b. Elevated fibrinogen c. Reduced prothrombin time (PT) d. Reduced fibrin degradation products (FDPs)

a The D-dimer is a specific marker for the degree of fibrinolysis and is elevated with DIC. FDP is elevated as the breakdown products from fibrinogen and fibrin are formed. Fibrinogen and platelets are reduced. PT, PTT, aPTT, and thrombin time are all prolonged.

The nurse receives a physician's order to transfuse fresh frozen plasma to a patient suffering from an acute blood loss. Which procedure is most appropriate for infusing this blood product? a. Infuse the fresh frozen plasma as rapidly as the patient will tolerate. b. Hang the fresh frozen plasma as a piggyback to the primary IV solution. c. Infuse the fresh frozen plasma as a piggyback to a primary solution of normal saline. d. Hang the fresh frozen plasma as a piggyback to a new bag of primary IV solution without KCl.

a The fresh frozen plasma should be administered as rapidly as possible and should be used within 24 hours of thawing to avoid a decrease in Factors V and VIII. Fresh frozen plasma is infused using any straight-line infusion set. Any existing IV should be interrupted while the fresh frozen plasma is infused, unless a second IV line has been started for the transfusion.

The patient with chronic heart failure is being discharged from the hospital. What information should the nurse emphasize in the patient's discharge teaching to prevent progression of the disease to ADHF? a. Take medications as prescribed. b. Use oxygen when feeling short of breath. c. Only ask the physician's office questions. d. Encourage most activity in the morning when rested.

a The goal for the patient with chronic HF is to avoid exacerbations and hospitalization. Taking the medications as prescribed along with nondrug therapies such as alternating activity with rest will help the patient meet this goal. If the patient needs to use oxygen at home, it will probably be used all the time or with activity to prevent respiratory acidosis. Many HF patients are monitored by a care manager or in a transitional program to assess the patient for medication effectiveness and monitor for patient deterioration and encourage the patient. This nurse manager can be asked questions or can contact the health care provider if there is evidence of worsening HF.

The community health nurse is planning health promotion teaching targeted at preventing coronary artery disease (CAD). Which ethnic group would the nurse select as the highest priority for this intervention? a. White male b. Hispanic male c. African American male d. Native American female

a The incidence of CAD and myocardial infarction (MI) is highest among white, middle-aged men. Hispanic individuals have lower rates of CAD than non-Hispanic whites or African Americans. African Americans have an earlier age of onset and more severe CAD than whites and more than twice the mortality rate of whites of the same age. Native Americans have increased mortality in less than 35-year-olds and have major modifiable risk factors such as diabetes.

Before beginning a transfusion of RBCs, which action by the nurse would be of highest priority to avoid an error during this procedure? a. Check the identifying information on the unit of blood against the patient's ID bracelet. b. Select new primary IV tubing primed with lactated Ringer's solution to use for the transfusion. c. Remain with the patient for 60 minutes after beginning the transfusion to watch for signs of a transfusion reaction. d. Add the blood transfusion as a secondary line to the existing IV and use the IV controller to maintain correct flow.

a The patient's identifying information (name, date of birth, medical record number) on the ID bracelet should exactly match the information on the blood bank tag that has been placed on the unit of blood. If any information does not match, the transfusions should not be hung because of possible error and risk to the patient. The transfusion is hung on blood transfusion tubing, not a secondary line, and cannot be hung with lactated Ringer's because it will cause RBC hemolysis. Usually, the patient will need continuous monitoring for 15 minutes after the transfusion is started, as this is the time most transfusion reactions occur. Then the patient should be monitored every 30 to 60 minutes during the administration.

A patient admitted with heart failure appears very anxious and complains of shortness of breath. Which nursing actions would be appropriate to alleviate this patient's anxiety (select all that apply)? a. Administer ordered morphine sulfate. b. Position patient in a semi-Fowler's position. c. Position patient on left side with head of bed flat. d. Instruct patient on the use of relaxation techniques. e. Use a calm, reassuring approach while talking to patient.

a b d e Morphine sulfate reduces anxiety and may assist in reducing dyspnea. The patient should be positioned in semi-Fowler's position to improve ventilation that will reduce anxiety. Relaxation techniques and a calm reassuring approach will also serve to reduce anxiety.

The patient has heart failure (HF) with an ejection fraction of less than 40%. What core measures should the nurse expect to include in the plan of care for this patient (select all that apply)? a. Left ventricular function is documented. b. Controlling dysrhythmias will eliminate HF. c. Prescription for digoxin (Lanoxin) at discharge d. Prescription for angiotensin-converting enzyme (ACE) inhibitor at discharge e. Education materials about activity, medications, weight monitoring, and what to do if symptoms worsen

a d e The Joint Commission has identified these three core measures for heart failure patients. Although controlling dysrhythmias will improve CO and workload, it will not eliminate HF. Prescribing digoxin for all HF patients is no longer done because there are newer effective drugs and digoxin toxicity occurs easily related to electrolyte levels and the therapeutic range must be maintained.

A nurse is caring for a post-operative client who requires one unit of blood because of a hemorrhage that occurred during surgery. Within 30 minutes of hanging the unit of blood, the client develops itching and hives. Which of the following actions should the nurse take first?

stop the infusion

When providing nutritional counseling for patients at risk for CAD, which foods would the nurse encourage patients to include in their diet (select all that apply)? a. Tofu Correct b. Walnuts Correct c. Tuna fish Correct d. Whole milk Incorrect e. Orange juice Incorrect

a, b, c Tuna fish, tofu, and walnuts are all rich in omega-3 fatty acids, which have been shown to reduce the risks associated with CAD when consumed regularly.

The patient with cancer is having chemotherapy treatments and has now developed neutropenia. What care should the nurse expect to provide and teach the patient about (select all that apply)? a. Strict hand washing b. Daily nasal swabs for culture c. Monitor temperature every hour. d. Daily skin care and oral hygiene e. Encourage eating all foods to increase nutrients. f. Private room with a high-efficiency particulate air (HEPA) filter

a, d, f Strict hand washing and daily skin and oral hygiene must be done with neutropenia, because the patient is predisposed to infection from the normal body flora, other people, and uncooked meats, seafood, eggs, unwashed fruits and vegetables, and fresh flowers or plants. The private room with HEPA filtration reduces the aerosolized pathogens in the patient's room. Blood cultures and antibiotic treatment are used when the patient has a temperature of 100.4° F or more, but temperature is not monitored every hour.

A 57-year-old patient has been diagnosed with acute myelogenous leukemia (AML). The nurse explains to the patient that collaborative care will focus on what? a. Leukapheresis b. Attaining remission c. One chemotherapy agent d. Waiting with active supportive care

b Attaining remission is the initial goal of collaborative care for leukemia. The methods to do this are decided based on age and cytogenetic analysis. The treatments include leukapheresis or hydroxyurea to reduce the WBC count and risk of leukemia-cell-induced thrombosis. A combination of chemotherapy agents will be used for aggressive treatment to destroy leukemic cells in tissues, peripheral blood, and bone marrow and minimize drug toxicity. In nonsymptomatic patients with chronic lymphocytic leukemia (CLL), waiting may be done to attain remission, but not with AML.

After teaching a patient with chronic stable angina about nitroglycerin, the nurse recognizes the need for further teaching when the patient makes which statement? a. "I will replace my nitroglycerin supply every 6 months." b. "I can take up to five tablets every 3 minutes for relief of my chest pain." c. "I will take acetaminophen (Tylenol) to treat the headache caused by nitroglycerin." d. "I will take the nitroglycerin 10 minutes before planned activity that usually causes chest pain."

b The recommended dose of nitroglycerin is one tablet taken sublingually (SL) or one metered spray for symptoms of angina. If symptoms are unchanged or worse after 5 minutes, the patient should be instructed to activate the emergency medical services (EMS) system. If symptoms are improved, repeat the nitroglycerin every 5 minutes for a maximum of three doses and contact EMS if symptoms have not resolved completely.

Which patient is most likely to experience anemia related to an increased destruction of red blood cells? a. A 59-year-old man whose alcoholism has precipitated folic acid deficiency b. A 23-year-old African American man who has a diagnosis of sickle cell disease c. A 30-year-old woman with a history of "heavy periods" accompanied by anemia d. A 3-year-old child whose impaired growth and development is attributable to thalassemi

b A result of a sickling episode in sickle cell anemia involves increased hemolysis of the sickled cells. Thalassemias and folic acid deficiencies cause a decrease in erythropoiesis, whereas the anemia related to menstruation is a direct result of blood loss.

The nurse is providing teaching to a patient recovering from an MI. How should resumption of sexual activity be discussed? a. Delegated to the primary care provider b. Discussed along with other physical activities c. Avoided because it is embarrassing to the patient d. Accomplished by providing the patient with written material

b Although some nurses may not feel comfortable discussing sexual activity with patients, it is a necessary component of patient teaching. It is helpful to consider sex as a physical activity and to discuss or explore feelings in this area when other physical activities are discussed. Although providing the patient with written material is appropriate, it should not replace a verbal dialogue that can address the individual patient's questions and concerns.

Before starting a transfusion of packed red blood cells for an older anemic patient, the nurse would arrange for a peer to monitor his or her other assigned patients for how many minutes when the nurse begins the transfusion? a. 5 b. 15 c. 30 d. 60

b As part of standard procedure, the nurse remains with the patient for the first 15 minutes after starting a blood transfusion. Patients who are likely to have a transfusion reaction will more often exhibit signs within the first 15 minutes that the blood is infusing. Monitoring during the transfusion will be every 30 to 60 minutes.

The blood bank notifies the nurse that the two units of blood ordered for an anemic patient are ready for pick up. Which action should the nurse take to prevent an adverse effect during this procedure? a. Immediately pick up both units of blood from the blood bank. b. Infuse the blood slowly for the first 15 minutes of the transfusion. c. Regulate the flow rate so that each unit takes at least 4 hours to transfuse. d. Set up the Y-tubing of the blood set with dextrose in water as the flush solution.

b Because a transfusion reaction is more likely to occur at the beginning of a transfusion, the nurse should initially infuse the blood at a rate no faster than 2 mL/min and remain with the patient for the first 15 minutes after hanging a unit of blood. Only one unit of blood can be picked up at a time, must be infused within 4 hours, and cannot be hung with dextrose.

What nursing intervention should be the priority in the care of a 30-year-old woman who has a diagnosis of immune thrombocytopenic purpura (ITP)? a. Administration of packed red blood cells b. Administration of oral or IV corticosteroids c. Administration of clotting factors VIII and IX d. Maintenance of reverse isolation and application of standard precautions

b Common treatment modalities for ITP include corticosteroid therapy to suppress the phagocytic response of splenic macrophages. Blood transfusions, administration of clotting factors, and reverse isolation are not interventions that are indicated in the care of patients with ITP. Standard precautions are used with all patients.

What should the nurse recognize as an indication for the use of dopamine (Intropin) in the care of a patient with heart failure? a. Acute anxiety b. Hypotension and tachycardia c. Peripheral edema and weight gain d. Paroxysmal nocturnal dyspnea (PND)

b Dopamine is a β-adrenergic agonist whose inotropic action is used for treatment of severe heart failure accompanied by hemodynamic instability. Such a state may be indicated by tachycardia accompanied by hypotension. PND, anxiety, edema, and weight gain are common signs and symptoms of heart failure, but these do not necessarily warrant the use of dopamine.

A patient with a diagnosis of hemophilia had a fall down an escalator earlier in the day and is now experiencing bleeding in her left knee joint. What should be the emergency nurse's immediate response to this? a. Immediate transfusion of platelets b. Resting the patient's knee to prevent hemarthroses c. Assistance with intracapsular injection of corticosteroids d. Range-of-motion exercises to prevent thrombus formation

b In patients with hemophilia, joint bleeding requires resting of the joint in order to prevent deformities from hemarthrosis. Clotting factors, not platelets or corticosteroids, are administered. Thrombus formation is not a central concern in a patient with hemophilia.

A patient who has sickle cell disease has developed cellulitis above the left ankle. What is the nurse's priority for this patient? a. Start IV fluids. b. Maintain oxygenation. c. Maintain distal warmth. d. Check peripheral pulses.

b Maintaining oxygenation is a priority as sickling episodes are frequently triggered by low oxygen tension in the blood which is commonly caused by an infection. Antibiotics to treat cellulitis, pain control, and fluids to reduce blood viscosity will also be used, but oxygenation is the priority.

What will caring for a patient with a diagnosis of polycythemia vera likely require the nurse to do? a. Encourage deep breathing and coughing. b. Assist with or perform phlebotomy at the bedside. c. Teach the patient how to maintain a low-activity lifestyle. d. Perform thorough and regularly scheduled neurologic assessments.

b Primary polycythemia vera often requires phlebotomy in order to reduce blood volume. The increased risk of thrombus formation that accompanies the disease requires regular exercises and ambulation. Deep breathing and coughing exercises do not directly address the etiology or common sequelae of polycythemia, and neurologic manifestations are not typical.

The nurse is preparing to administer digoxin to a patient with heart failure. In preparation, laboratory results are reviewed with the following findings: sodium 139 mEq/L, potassium 5.6 mEq/L, chloride 103 mEq/L, and glucose 106 mg/dL. What should the nurse do next? a. Withhold the daily dose until the following day. b. Withhold the dose and report the potassium level. c. Give the digoxin with a salty snack, such as crackers. d. Give the digoxin with extra fluids to dilute the sodium level.

b The normal potassium level is 3.5 to 5.0 mEq/L. The patient is hyperkalemic, which makes the patient more prone to digoxin toxicity. For this reason, the nurse should withhold the dose and report the potassium level. The physician may order the digoxin to be given once the potassium level has been treated and decreases to within normal range.

The nurse notes a physician's order written at 10:00 AM for two units of packed red blood cells to be administered to a patient who is anemic as a result of chronic blood loss. If the transfusion is picked up at 11:30 AM, the nurse should plan to hang the unit no later than what time? a. 11:45 AM b. 12:00 noon c. 12:30 PM d. 3:30 PM

b The nurse must hang the unit of packed red blood cells within 30 minutes of signing them out from the blood bank.

The patient comes to the ED with severe, prolonged angina that is not immediately reversible. The nurse knows that if the patient once had angina related to a stable atherosclerotic plaque and the plaque ruptures, there may be occlusion of a coronary vessel and this type of pain. How will the nurse document this situation related to pathophysiology, presentation, diagnosis, prognosis, and interventions for this disorder? a. Unstable angina b. Acute coronary syndrome (ACS) c. ST-segment-elevation myocardial infarction (STEMI) d. Non-ST-segment-elevation myocardial infarction (NSTEMI)

b The pain with ACS is severe, prolonged, and not easy to relieve. ACS is associated with deterioration of a once-stable atherosclerotic plaque that ruptures, exposes the intima to blood, and stimulates platelet aggregation and local vasoconstriction with thrombus formation. The unstable lesion, if partially occlusive, will be manifest as unstable angina or NSTEMI. If there is total occlusion, it is manifest as a STEMI.

When caring for a patient with metastatic cancer, the nurse notes a hemoglobin level of 8.7 g/dL and hematocrit of 26%. What should the nurse place highest priority on initiating interventions to reduce? a. Thirst b. Fatigue c. Headache d. Abdominal pain

b The patient with a low hemoglobin and hematocrit is anemic and would be most likely to experience fatigue. Fatigue develops because of the lowered oxygen-carrying capacity that leads to reduced tissue oxygenation to carry out cellular functions. Thirst, headache, and abdominal pain are not related to anemia.

A 22-year-old female patient has been diagnosed with stage 1A Hodgkin's lymphoma. The nurse knows that which chemotherapy regimen is most likely to be prescribed for this patient? a. Brentuximab vedotin (Adcetris) b. Two to four cycles of ABVD: doxorubicin (Adriamycin), bleomycin, vinblastine, and dacarbazine c. Four to six cycles of ABVD: doxorubicin (Adriamycin), bleomycin, vinblastine, and dacarbazine d. BEACOPP: bleomycin, etoposide, doxorubicin (Adriamycin), cyclophosphamide, vincristine (Oncovin), procarbazine, and prednisone

b The patient with stage favorable prognosis early-stage Hodgkin's lymphoma will receive two to four cycles of ABVD. The unfavorable prognostic featured (stage 1B) Hodgkin's lymphoma would be treated with four to six cycles of chemotherapy. Advanced-stage Hodgkin's lymphoma is treated more aggressively with more cycles or with BEACOPP. Brentuximab vedotin (Adcetris) is a newer agent that will be used to treat patients who have relapsed or refractory disease.

The nurse is examining the ECG of a patient who has just been admitted with a suspected MI. Which ECG change is most indicative of prolonged or complete coronary occlusion? a. Sinus tachycardia b. Pathologic Q wave c. Fibrillatory P waves d. Prolonged PR interval

b The presence of a pathologic Q wave, as often accompanies STEMI, is indicative of complete coronary occlusion. Sinus tachycardia, fibrillatory P waves (e.g., atrial fibrillation), or a prolonged PR interval (first-degree heart block) are not direct indicators of extensive occlusion.

A patient with a diagnosis of heart failure has been started on a nitroglycerin patch by his primary care provider. What should this patient be taught to avoid? a. High-potassium foods b. Drugs to treat erectile dysfunction c. Nonsteroidal antiinflammatory drugs d. Over-the-counter H2-receptor blockers

b The use of erectile drugs concurrent with nitrates creates a risk of severe hypotension and possibly death. High-potassium foods, NSAIDs, and H2-receptor blockers do not pose a risk in combination with nitrates.

The nurse would assess a patient with complaints of chest pain for which clinical manifestations associated with a myocardial infarction (MI) (select all that apply)? a. Flushing b. Ashen skin c. Diaphoresis d. Nausea and vomiting d. S3 or S4 heart sounds

b, c, d, e During the initial phase of an MI, catecholamines are released from the ischemic myocardial cells, causing increased sympathetic nervous system (SNS) stimulation. This results in the release of glycogen, diaphoresis, and vasoconstriction of peripheral blood vessels. The patient's skin may be ashen, cool, and clammy (not flushed) as a result of this response. Nausea and vomiting may result from reflex stimulation of the vomiting center by severe pain. Ventricular dysfunction resulting from the MI may lead to the presence of the abnormal S3 and S4 heart sounds.

Which antilipemic medications should the nurse question for a patient with cirrhosis of the liver (select all that apply)? a. Niacin (Nicobid) b. Ezetimibe (Zetia) c. Gemfibrozil (Lopid) d. Atorvastatin (Lipitor) Cholestyramine (Questran)

b, d Ezetimibe (Zetia) should not be used by patients with liver impairment. Adverse effects of atorvastatin (Lipitor), a statin drug, include liver damage and myopathy. Liver enzymes must be monitored frequently and the medication stopped if these enzymes increase. Niacin's side effects subside with time, although decreased liver function may occur with high doses. Cholestyramine is safe for long-term use.

A nurse is caring for a client dx with complete heart block who has a demand pacemaker inserted? The pace is set for 72 bpm. Which EKG pattern indicates to the nurse a failure to capture? a.) QRS complexes occuring at 73bpm and no sharp spikes b.) sharp spikes at 72; QRS at 50 c.) P waves at 78: QRS at 50 d.) QRS at 100 bpm

b.) sharp spikes at 72; QRS at 50 beats/min the pacemaker is firing at the set rate, but the heart is only beating 50 times/min. this may be due to poor positioning of the pacer electrode and is referred to as a lack of capture

When computing a heart rate from the ECG tracing, the nurse counts 15 of the small blocks between the R waves of a patient whose rhythm is regular. From these data, the nurse calculates the patient's heart rate to be a. 60 beats/min. b. 75 beats/min. Incorrect c. 100 beats/min. Correct d. 150 beats/min.

c

The nurse knows that hemolytic anemia can be caused by which extrinsic factors? a. Trauma or splenic sequestration crisis b. Abnormal hemoglobin or enzyme deficiency c. Macroangiopathic or microangiopathic factors d. Chronic diseases or medications and chemicals

c Macroangiopathic or microangiopathic extrinsic factors lead to acquired hemolytic anemias. Trauma or splenic sequestration crisis can lead to anemia from acute blood loss. Abnormal hemoglobin or enzyme deficiency are intrinsic factors that lead to hereditary hemolytic anemias. Chronic diseases or medications and chemicals can decrease the number of RBC precursors which reduce RBC production.

Postoperative care of a patient undergoing coronary artery bypass graft (CABG) surgery includes monitoring for what common complication? a. Dehydration b. Paralytic ileus c. Atrial dysrhythmias d. Acute respiratory distress syndrome

c Postoperative dysrhythmias, specifically atrial dysrhythmias, are common in the first 3 days following CABG surgery. Although the other complications could occur, they are not common complications.

The nurse assesses the right femoral artery puncture site as soon as the patient arrives after having a stent inserted into a coronary artery. The insertion site is not bleeding or discolored. What should the nurse do next to ensure the femoral artery is intact? a. Palpate the insertion site for induration. b. Assess peripheral pulses in the right leg. c. Inspect the patient's right side and back. d. Compare the color of the left and right legs.

c The best method to determine that the right femoral artery is intact after inspection of the insertion site is to logroll the patient to inspect the right side and back for retroperitoneal bleeding. The artery can be leaking and blood is drawn into the tissues by gravity. The peripheral pulses, color, and sensation of the right leg will be assessed per agency protocol.

When preparing to administer an ordered blood transfusion, which IV solution does the nurse use when priming the blood tubing? a. Lactated Ringer's b. 5% dextrose in water c. 0.9% sodium chloride d. 0.45% sodium chloride

c The blood set should be primed before the transfusion with 0.9% sodium chloride, also known as normal saline. It is also used to flush the blood tubing after the infusion is complete to ensure the patient receives blood that is left in the tubing when the bag is empty. Dextrose and lactated Ringer's solutions cannot be used with blood as they will cause RBC hemolysis.

After the diagnosis of disseminated intravascular coagulation (DIC), what is the first priority of collaborative care? a. Administer heparin. b. Administer whole blood. c. Treat the causative problem. d. Administer fresh frozen plasma.

c Treating the underlying cause of DIC will interrupt the abnormal response of the clotting cascade and reverse the DIC. Blood product administration occurs based on the specific component deficiencies and is reserved for patients with life-threatening hemorrhage. Heparin will be administered if the manifestations of thrombosis are present and the benefit of reducing clotting outweighs the risk of further bleeding.

In caring for the patient with angina, the patient said, "I walked to the bathroom. While I was having a bowel movement, I started having the worst chest pain ever, like before I was admitted. I called for a nurse, but the pain is gone now." What further assessment data should the nurse obtain from the patient? a. "What precipitated the pain?" b. "Has the pain changed this time?" c. "In what areas did you feel this pain?" d. "Rate the pain on a scale from 0 to 10, with 0 being no pain and 10 being the worst pain you can imagine."

c Using PQRST, the assessment data not volunteered by the patient is the radiation of pain, the area the patient felt the pain, and if it radiated. The precipitating event was going to the bathroom and having a bowel movement. The quality of the pain was "like before I was admitted," although a more specific description may be helpful. Severity of the pain was the "worst chest pain ever," although an actual number may be needed. Timing is supplied by the patient describing when the pain occurred and that he had previously had this pain.

An older patient relates that she has increased fatigue and a headache. The nurse identifies pale skin and glossitis on assessment. In response to these findings, which teaching will be helpful to the patient if she has microcytic, hypochromic anemia? a. Take enteric-coated iron with each meal. b. Take cobalamin with green leafy vegetables. c. Take the iron with orange juice one hour before meals. d. Decrease the intake of the antiseizure medications to improve.

c With microcytic, hypochromic anemia, there may be an iron, B6, or copper deficiency, thalassemia, or lead poisoning. The iron prescribed should be taken with orange juice one hour before meals as it is best absorbed in an acid environment. Megaloblastic anemias occur with cobalamin (vitamin B12) and folic acid deficiencies. Vitamin B12 may help RBC maturation if the patient has the intrinsic factor in the stomach. Green leafy vegetables provide folic acid for RBC maturation. Antiseizure drugs may contribute to aplastic anemia or folic acid deficiency, but the patient should not stop taking the medications. Changes in medications will be prescribed by the health care provider.

A patient experienced sudden cardiac death (SCD) and survived. What should the nurse expect to be used as preventive treatment for the patient? a. External pacemaker b. An electrophysiologic study (EPS) c. Medications to prevent dysrhythmias d. Implantable cardioverter-defibrillator (ICD)

d An ICD is the most common approach to preventing recurrence of SCD. An external pacemaker may be used in the hospital but will not be used for the patient living daily life at home. An EPS may be done to determine if a recurrence is likely and determine the most effective medication treatment. Medications to prevent dysrhythmias are used but are not the best prevention of SCD.

After having an MI, the nurse notes the patient has jugular venous distention, gained weight, developed peripheral edema, and has a heart rate of 108/minute. What should the nurse suspect is happening? a. ADHF b. Chronic HF c. Left-sided HF d. Right-sided HF

d An MI is a primary cause of heart failure. The jugular venous distention, weight gain, peripheral edema, and increased heart rate are manifestations of right-sided heart failure.

The nurse is administering a dose of digoxin (Lanoxin) to a patient with heart failure (HF). The nurse would become concerned with the possibility of digitalis toxicity if the patient reported which symptom(s)? a. Muscle aches b. Constipation c. Pounding headache d. Anorexia and nausea

d Anorexia, nausea, vomiting, blurred or yellow vision, and cardiac dysrhythmias are all signs of digitalis toxicity. The nurse would become concerned and notify the health care provider if the patient exhibited any of these symptoms.

The nurse is caring for a patient who is to receive a transfusion of two units of packed red blood cells. After obtaining the first unit from the blood bank, the nurse would ask which health team member in the nurses' station to assist in checking the unit before administration? a. Unit secretary b. A physician's assistant c. Another registered nurse d. An unlicensed assistive personnel Incorrect

d Before hanging a transfusion, the registered nurse must check the unit with another RN or with a licensed practical (vocational) nurse, depending on agency policy. The unit secretary, physician's assistant, or unlicensed assistive personnel should not be asked.

Beyond the first year after a heart transplant, the nurse knows that what is a major cause of death? a. Infection b. Acute rejection c. Immunosuppression d. Cardiac vasculopathy

d Beyond the first year after a heart transplant, malignancy (especially lymphoma) and cardiac vasculopathy (accelerated CAD) are the major causes of death. During the first year after transplant, infection and acute rejection are the major causes of death. Immunosuppressive therapy will be used for posttransplant management to prevent rejection and increases the patient's risk of an infection.

When evaluating a patient's knowledge regarding a low-sodium, low-fat cardiac diet, the nurse recognizes additional teaching is needed when the patient selects which food choice? a. Baked flounder b. Angel food cake c. Baked potato with margarine d. Canned chicken noodle soup

d Canned soups are very high in sodium content. Patients need to be taught to read food labels for sodium and fat content.

A male patient who has coronary artery disease (CAD) has serum lipid values of LDL cholesterol 98 mg/dL and HDL cholesterol 47 mg/dL. What should the nurse include in the patient teaching? a. Consume a diet low in fats. b. Reduce total caloric intake. c. Increase intake of olive oil. d. The lipid levels are normal.

d For men, the recommended LDL is less than 100 mg/dL, and the recommended level for HDL is greater than 40mg/dL. His normal lipid levels should be included in the patient teaching and encourage him to continue taking care of himself. Assessing his need for teaching related to diet should also be done.

A female patient who has type 1 diabetes mellitus has chronic stable angina that is controlled with rest. She states that over the past few months she has required increasing amounts of insulin. What goal should the nurse use to plan care that should help prevent cardiovascular disease progression? a. Exercise almost every day. Incorrect b. Avoid saturated fat intake. c. Limit calories to daily limit. d. Keep Hgb A1C less than 7%

d If the Hgb A1C is kept below 7%, this means that the patient has had good control of her blood glucose over the past 3 months. The patient indicates that increasing amounts of insulin are being required to control her blood glucose. This patient may not be adhering to the dietary guidelines or therapeutic regimen, so teaching about how to maintain diet, exercise, and medications to maintain stable blood glucose levels will be needed to achieve this goal.

The patient is being dismissed from the hospital after ACS and will be attending rehabilitation. What information does the patient need to be taught about the early recovery phase of rehabilitation? a. Therapeutic lifestyle changes should become lifelong habits. b. Physical activity is always started in the hospital and continued at home. c. Attention will focus on management of chest pain, anxiety, dysrhythmias, and other complications. d. Activity level is gradually increased under cardiac rehabilitation team supervision and with ECG monitoring

d In the early recovery phase after the patient is dismissed from the hospital, the activity level is gradually increased under supervision and with ECG monitoring. The late recovery phase includes therapeutic lifestyle changes that become lifelong habits. In the first phase of recovery, activity is dependent on the severity of the angina or MI, and attention is focused on the management of chest pain, anxiety, dysrhythmias, and other complications. With early recovery phase, the cardiac rehabilitation team may suggest that physical activity be initiated at home, but this is not always done.

For which problem is percutaneous coronary intervention (PCI) most clearly indicated? a. Chronic stable angina b. Left-sided heart failure c. Coronary artery disease d. Acute myocardial infarction

d PCI is indicated to restore coronary perfusion in cases of myocardial infarction. Chronic stable angina and CAD are normally treated with more conservative measures initially. PCI is not relevant to the pathophysiology of heart failure, such as left-sided heart failure.

A male patient with a long-standing history of heart failure has recently qualified for hospice care. What measure should the nurse now prioritize when providing care for this patient? a. Taper the patient off his current medications. b. Continue education for the patient and his family. c. Pursue experimental therapies or surgical options. d. Choose interventions to promote comfort and prevent suffering.

d The central focus of hospice care is the promotion of comfort and the prevention of suffering. Patient education should continue, but providing comfort is paramount. Medications should be continued unless they are not tolerated. Experimental therapies and surgeries are not commonly used in the care of hospice patients.

A patient was admitted to the emergency department (ED) 24 hours earlier with complaints of chest pain that were subsequently attributed to ST-segment-elevation myocardial infarction (STEMI). What complication of MI should the nurse anticipate? a. Unstable angina b. Cardiac tamponade c. Sudden cardiac death d. Cardiac dysrhythmias

d The most common complication after MI is dysrhythmias, which are present in 80% of patients. Unstable angina is considered a precursor to MI rather than a complication. Cardiac tamponade is a rare event, and sudden cardiac death is defined as an unexpected death from cardiac causes. Cardiac dysfunction in the period following an MI would not be characterized as sudden cardiac death.

A stable patient with acute decompensated heart failure (ADHF) suddenly becomes dyspneic. Before positioning the patient on the bedside, what should the nurse assess first? a. Urine output b. Heart rhythm c. Breath sounds d. Blood pressure

d The nurse should evaluate the blood pressure before dangling the patient on the bedside because the blood pressure can decrease as blood pools in the periphery and preload decreases. If the patient's blood pressure is low or marginal, the nurse should put the patient in the semi-Fowler's position and use other measures to improve gas exchange.

The patient is being treated for non-Hodgkin's lymphoma (NHL). What should the nurse first teach the patient about the treatment? a. Skin care that will be needed b. Method of obtaining the treatment c. Gastrointestinal tract effects of treatment d. Treatment type and expected side effects

d The patient should first be taught about the type of treatment and the expected and potential side effects. Nursing care is related to the area affected by the disease and treatment. Skin care will be affected if radiation is used. Not all patients will have gastrointestinal tract effects of NHL or treatment. The method of obtaining treatment will be included in the teaching about the type of treatment.

a nurse is caring for a client with aplastic anemia. the nurse expects the client to have which of the following symptoms?

pancytopenia, fatigue, and pale mucous membranes these are all manifestations of aplastic anemia. dyspnea on exertion may also be present in aplasti anemia, all three major blood components (rbc's, wbc's, and plt's) are reduced or absent. manifestations usually develop gradually