NCLEX Saunders Mix (heme unit, PVD, PAD, AAA)

Several labs are prescribed for a pt, and the nurse reviews the results of the test. Which lab test results should the nurse report? SATA. a) Platelets 35,000 mm b) Sodium 150 mEq/L c) Potassium 5.0 mEq/L d) Segmented neutrophils 40% e) Serum creatinine 1mg/dL f) WBC 3000mm

1) Answer a, b, d, f -no rationale needed. Check your lab values

The nurse is conducting a history and monitoring labs on a pt w multiple myeloma. What assessment findings should the nurse expect to note? Select all that APPLY a) Pathological fracture b) Urinalysis positive for Bence jones protein c) Hemoglobin level of 15.5g/dL d) Calcium level of 8.6 mg/dL e) Serum creatinine level of 2.0 mg/dL

1) Answer a, b, e Multiple myeloma is a B cell neoplastic condition characterized by abnormal malignant proliferation of plasma cells and the accumulation of mature plasma cells in the bone marrow. The pt w multiple myeloma may experience pathological fractures, hypercalcemia, anemia, recurrent infections and renal failure. In addition, Bence Jones Protienuria is a finding. A serum calcium level of 8.6 mg/dL and a hemoglobin level of 15.5 g/dL are normal values. A serum creatinine level of 2.0 mg/dL is elevated indicating a renal problem.

The nurse is planning to reinforce instructions to a client with peripheral arterial disease about measures to limit disease progression. The nurse should include which items on a list of suggestions to be given to the client? Select all that apply. 1. Wear elastic stockings. 2. Be careful not to injure the legs or feet. 3. Use a heating pad on the legs to aid vasodilation. 4. Walk each day to increase circulation to the legs. 5. Cut down on the amount of fats consumed in the diet.

2. Be careful not to injure the legs or feet. 4. Walk each day to increase circulation to the legs. 5. Cut down on the amount of fats consumed in the diet. Long-term management of peripheral arterial disease consists of measures that increase peripheral circulation (exercise), relieve pain, and maintain tissue integrity (foot care and nutrition). Elastic stockings will not increase circulation. They are worn with peripheral vascular disease, but not peripheral arterial disease. Application of heat directly to the extremity is contraindicated. The affected extremity may have decreased sensitivity and is at risk for burns. Direct application of heat raises oxygen and nutritional requirements of the tissue even further.

The nurse is collecting data from a client about medications being taken, and the client tells the nurse that he is taking herbal supplements for the treatment of varicose veins. The nurse understands that the client is most likely taking which? A. Bilberry B. Ginseng C. Feverfew D. Evening primrose

A. Bilberry Bilberry is an herbal supplement that has been used to treat varicose veins. This supplement has also been used to treat cataracts, retinopathy, diabetes mellitus, and peripheral vascular disease. Ginseng has been used to improve memory performance and decrease blood glucose levels in type 2 diabetes mellitus. Feverfew is used to prevent migraine headaches and to treat rheumatoid arthritis. Evening primrose is used to treat eczema and skin irritation.

The nurse is evaluating the effects of care for the client with deep vein thrombosis. Which limb observations should the nurse note as indicating the least success in meeting the outcome criteria for this problem? A. Pedal edema that is 3+ B. Slight residual calf tenderness C. Skin warm, equal temperature both legs D. Calf girth ⅛ inch larger than unaffected limb

A. Pedal edema that is 3+ Symptoms of deep vein thrombosis include leg warmth, redness, edema, tenderness, and enlarged calf. If the problem is not resolved, or is minimally resolved, these symptoms will remain. Option 3 indicates full resolution of the problem, whereas options 2 and 4 indicate partial resolution. Option 1 is the correct option because it indicates the least degree of symptom reversal.

The nurse notes bilateral 2+ edema in the lower extremities of a client with known coronary artery disease who was admitted to the hospital 2 days ago. Based on this finding, the nurse should implement which action? A. Reviews the intake and output records for the last 2 days B. Prescribes daily weights starting on the following morning C. Changes the time of diuretic administration from morning to evening D. Requests a sodium restriction of 1 g/day from the health care provider

A. Reviews the intake and output records for the last 2 days Edema is the accumulation of excess fluid in the interstitial spaces, which can be determined by intake greater than output and by a sudden increase in weight (2.2 lb = 1 kg). To determine the extent of fluid accumulation, the nurse first reviews the intake and output records for the past 2 days. Diuretics should be given in the morning whenever possible to avoid nocturia. Strict sodium restrictions are reserved for clients with severe symptoms.

A 24-year-old man seeks medical attention for complaints of claudication in the arch of the foot. The nurse also notes superficial thrombophlebitis of the lower leg. The nurse should check the client for which next? A. Smoking history B. Recent exposure to allergens C. History of recent insect bites D. Familial tendency toward peripheral vascular disease

A. Smoking history The mixture of arterial and venous manifestations (claudication and phlebitis, respectively) in the young male client suggests thromboangiitis obliterans (Buerger's disease). This is a relatively uncommon disorder, characterized by inflammation and thrombosis of smaller arteries and veins. This disorder is typically found in young men who smoke. The cause is unknown but is suspected to have an autoimmune component.

The nurse is preparing to care for a client who will be arriving from the recovery room after an above-the-knee amputation. The nurse ensures that which priority item is available for emergency use? A. Surgical tourniquet B. Dry sterile dressings C. Incentive spirometer D. Over-the-bed trapeze

A. Surgical tourniquet Monitoring for complications is an important aspect of initial postoperative care. Vital signs and pulse oximetry values are monitored closely until the client's condition stabilizes. The wound and any drains are monitored closely for excessive bleeding because hemorrhage is the primary immediate complication of amputation. Therefore, a surgical tourniquet needs to be readily available in case of acute bleeding. An over-the-bed trapeze increases the client's independence in self-care activities but is not a priority in the immediate postoperative period. An incentive spirometer and dry sterile dressings also should be available, but these are not priority items.

A four-year-old diagnosed w leukemia is hospitalized for chemotherapy. The child is fearful of the hospitalization. Which nursing intervention should be implemented to alleviate the child's fears? a) Encourage the child's parents to stay w the child b) Encourage play w other children of the same age c) Advise the fam to visit only during the scheduled visiting hours d) Provide a private room, allowing the child to bring fav toys from home.

Answer a -Although the preschooler already may be spending time away from parents at a daycare center or preschool, illness adds a stressor that makes separation more difficult. The child may ask repeatedly when parents will be coming for a visit or may constantly want to call the parents. Option c & d increase stress r/t separation anxiety. Option b is unrelated to the subject of the question and in addition, may not be appropriate for a child with leukemia who may be immunocompromised and at risk for infection.

The nurse is reviewing the labs of a pt diagnosed w multiple myeloma. Which would the nurse expect to note specifically in this disorder? a) Increased calcium level b) Increased white blood cells c) Decreased blood urea nitrogen level d) Decreased number of plasma cells in the bone marrow.

Answer a -Findings indicative of multiple myeloma are an increased number of plasma cells in the bone marrow, anemia, hypercalcemia caused by the release of calcium from the deteriorating bone tissue, and an elevated blood urea nitrogen level. An increased white blood cell count may or may not be present and is not related specifically to multiple myeloma.

The nurse is caring for a pt w a diagnosis of breast cancer who is immunosuppressed. The nurse would consider implementing neutropenic precautions if the pts wbc count was which value? a) 2000 mm b) 5800 mm c) 8400 mm d) 11,500 mm

Answer a -Normal WBC count 5000-10,000. The pt who has a decrease in number of circulating WBCs is immunosuppressed. The nurse implements neutropenic precautions when the pts values fall sufficiently below the normal level. The specific value for implementing neutropenic precautions usually is determined by agency policy.

The nurse is creating a plan of care for the pt with multiple myeloma and includes which priority intervention in the plan? a) Encouraging fluids b) Providing frequent oral care c) Coughing and deep breathing d) Monitoring the red blood cell count

Answer a Hypercalcemia caused by bone destruction is a priority concern in the pt w multiple myeloma. The nurse should administer fluids in adequate amounts to maintain a urine output of 1.5 - 2 L/day; this requires about 3L of fluid intake per day. The fluid is needed not only to dilute the calcium overload but also to prevent protein from precipitating in renal tubules. Option 2, 3 and 4 may be components of the plan of care but aren't the priority in this pt.

The nurse is providing dietary teaching for a pt with a diagnosis of chronic gastritis. The nurse instructs the pt to include which foods rich in Vitamin B12 in the diet? Select ALL THAT APPLY a) Nuts b) Corn c) Liver d) Apples e) Lentils f) Bananas

Answer a, c, e -Chronic gastritis causes deterioration and atrophy of the lining of the stomach, leading to the loss of function of the parietal cells. The source of intrinsic factor is lost, which results in an inability to absorb b12 by increasing consumption of foods rich in this vitamin, such as nuts, organ meats, dried beans, citrus fruits, green leafy vegetables, and yeast. Ask Sara about this because from what I understand if the intrinsic factor is missing you can't absorb it through food at all and would require IM B12 injections monthly for life.

The nurse is reviewing a healthcare provider's prescriptions for a child w sickle cell anemia who was admitted to the hospital for the treatment of vaso-occlusive crisis. Which prescriptions documented in the child's record should the nurse question? SELECT ALL THAT APPLY a) Restrict fluid intake b) Position for comfort c) Avoid strain on painful joints d) Apply nasal oxygen at 2L/min e) Provide a high-calorie, high-protein diet f) Give meperidine (Demerol), 25mg intravenously, every 4h for pain.

Answer a, f -Sickle cell anemia is where hemoglobin A is replaced by Hemoglobin S. It's an inherited gene. Hemoglobin S is sensitive to O2 changes in the oxygen content of the RBCs; insufficient oxygen causes the cells to assume a sickle shape, and the cells become rigid and clumped together, obstructing capillary blood flow. Oral and IV fluids are an important part of treatment. Meperidine (Demerol) isn't recommended for a child w sickle cell disease because of the risk for normeperidine seizures. The nurse would question the rx for restricted fluids and meperidine for pain control. Positioning for comfort, avoiding strain on painful joints, oxygen, and a high-calorie and high-protein diet are also important parts of the treatment plan.

A pt w acute myelocytic leukemia is being treated w Busulfan. Which lab value would the nurse specifically monitor during treatment w this medication? a) Clotting time b) Uric acid level c) Potassium level d) Blood glucose level

Answer b -Busulfan can cause an increase in the uric acid level. Hyperuricemia can produce uric acid nephropathy, renal stones, and acute kidney injury.

The nurse is instructing a pt w iron deficiency anemia regarding the admin of a liquid oral iron supplement. Which instruction should the nurse tell the pt? a) Administer the iron at mealtimes b) Administer the iron through a straw c) Mix the iron w cereal to administer d) Add the iron to apple juice for easy administration

Answer b -In iron deficiency anemia, iron stores are depleted resulting in a decreased supply of iron for the manufacture of hemoglobin in red blood cells. An oral iron supplement should be administered through a straw or medicine dropper placed at the back of the mouth, because the iron stains the teeth. The pt should be instructed to brush or wipe their teeth after admin. Iron is administered between meals because absorption is decreased if there is food in the stomach. Iron requires and acid environment to facilitate its absorption in the duodenum. Iron isn't mixed w cereal or other food items.

The nurse is instructing the parents of a child w iron deficiency anemia regarding the admin of a liquid oral iron supplement. Which instruction should the nurse tell the parents? a) Administer the iron at mealtimes b) Administer the iron through a straw c) Mix the iron w cereal to administer d) Add the iron to formula for easy administration

Answer b -In iron deficiency anemia, iron stores are depleted, resulting in a decreased supply of iron for the manufacture of hemoglobin in RBCs. An oral iron supplement should be administered through a straw or medicine dropper placed at the back of the mouth, because the iron stains the teeth. The parents should be instructed to brush or wipe the child's teeth or have the child brush the teeth after administration. Iron is administered between meals because absorption is decreased if there is food in the stomach. Iron requires an acid environment to facilitate its absorption in the duodenum. Iron is not added to formula or mixed w cereal or other food items.

A pt w a-fib who is receiving maintenance therapy of warfarin has a PT of 35 sec. On the basis of this lab value, the nurse anticipates which prescription? a) Adding a dose of heparin b) Holding the next dose of warfarin c) Increasing the next dose of warfarin d) Administering the next dose of warfarin

Answer b -The PT is 11 to 12.5 sec. A therapeutic PT level is 1.5 to 2 times higher than the normal level. Because the value of 35 sec is high, the nurse should anticipate that the pt wouldn't receive further doses at this time.

The nurse is conducting a dietary assessment on a pt who is on a vegan diet. The nurse provides dietary teaching and should focus on foods high in which vitamin that may be lacking in a vegan diet? a) Vitamin A b) Vitamin B12 c) Vitamin C d) Vitamin E

Answer b -Vegans don't consume any animal products. Vit B12 is found exclusively in animal products and therefore would MOST LIKELY be lacking in a vegan diet. They can get their iron from other vegan sources but b12 is dairy and other animal sources.

In preparation for discharge of a client with arterial insufficiency and Raynaud's disease, client teaching instructions should include: a. Walking several times each day as an exercise program b. Keeping the heat up so that the environment is warm c. Wearing TED hose during the day d. Using hydrotherapy for increasing oxygenation

Answer b The client's instructions should include keeping the environment warm to prevent vasoconstriction. Wearing gloves, warm clothes, and socks will also be useful when preventing vasoconstriction, but TED hose would not be therapeutic. Walking would most likely increase pain.

The clinic nurse is assessing a child who is scheduled to receive a live virus vaccine (immunization) What are the general contraindications associated w receiving a live virus vaccine? Select ALL that APPLY a) The child has symptoms of a cold b) The child had a previous anaphylactic reaction to the vaccine c) The mother reports that the child is having intermittent episodes of diarrhea d) The mother reports that the child has not had an appetite and has been fussy e) The child has a disorder that caused a severely deficient immune system. f) The mother reports that the child has recently been exposed to an infectious disease.

Answer b, e -The general contraindications for receiving live virus vaccines include a previous anaphylactic reaction to a vaccine or a component of a vaccine. In addition live virus vaccines generally are NOT administered to a pt with a severely deficient immune system, individuals w a sensitivity to gelatin, or pregnant women.

With peripheral arterial insufficiency, leg pain during rest can be reduced by: a. Elevating the limb above heart level b. Lowering the limb so it is dependent c. Massaging the limb after application of cold compresses d. Placing the limb in a plane horizontal to the body

Answer b. Lowering the limb so it is dependent

The nurse analyzes the lab results of a child w hemophilia. The nurse understands that which result will most likely be abnormal in this child? a) Platelet count b) Hematocrit level c) Hemoglobin level d) Partial thromboplastin time

Answer d -Hemophilia refers to a group of bleeding disorders resulting from a deficiency of specific coagulation proteins. Results of tests that measure platelet function are normal; results of tests that measure clotting factor function may be abnormal. Abnormal lab results in hemophilia indicate a prolonged PTT. The platelet count, hemoglobin level, and hematocrit level are normal in hemophilia.

As part of chemo education, the nurse teaches a female pt about the risk for bleeding and self-care during the period of greatest bone marrow suppression (the nadir). The nurse understands that further teaching is needed if the pt makes which statement. a) I should avoid blowing my nose. b) I may need a platelet transfusion if my platelet count is too low c) I'm going to take aspirin for my headache as soon as I get home d) I will count the number of pads and tampons I use when on my period.

Answer c -During the period of greatest bone marrow suppression (the nadir), the platelet count may be low, less than 20,000 cells mm. The correct option describes an incorrect statement by the client. Aspirin and nonsteroidal anti-inflammatory drugs and products that contain aspirin should be avoided because of their antiplatelet activity. Options a, b, and d are correct statements by the pt to prevent and monitor bleeding.

The nurse creates a plan of care for a pt w DVT. Which pt position or activity in the plan should be included? a) Out-of-bed activities as desired b) Bed rest w the affected extremity kept flat c) Bed rest w elevation of the affected extremity d) Bed rest w the affected extremity in a dependent position.

Answer c -For the pt w DVT, elevation of the affected leg facilitates blood flow by the force of gravity and also decreases venous pressure, which in turn relieves edema and pain. Bed rest is indicated to prevent emboli and to prevent pressure fluctuations in the venous system that occur w walking.

A 10-year-old with hemophilia A has slipped on the ice and bumped his knee. The nurse should prepare to administer which prescription? a) Injection of factor X b) Intravenous infusion of iron c) Intravenous infusion of factor VIII d) Intramuscular Z-track iron

Answer c -Hemophilia (A) is a bleeding disorder resulting from a deficiency of the protein factor VIII. The primary treatment is replacement of the missing clotting factor. A child w hemophilia A is at risk for joint bleeding after a fall. Factor VIII would be prescribed IV to replace the missing clotting factor and minimize the bleeding. Factor X and iron are NOT used to treat children w hemophilia A. Pain meds may be prescribed, but the priority is the replacement clotting factor.

The nurse is analyzing the labs of a pt w leukemia who has received a regimen of chemotherapy. Which lab value would the nurse specifically note as a result of the massive cell destruction that occurred from chemotherapy? a) Anemia b) Decreased Platelets c) Increased uric acid level d) Decreased leukocyte count

Answer c -Hyperuricemia is especially common following treatment for leukemias and lymphomas, because chemotherapy results in massive cell kill. Although options 1,2, and 4 also may be noted, an increased uric acid level is related specifically to cell destruction.

The nurse should plan to implement which intervention in the care of a pt experiencing neutropenia as a result of chemo? a) Restrict all visitors b) Restrict fluid intake c) Teach to pt and fam about the need for hand hygiene? d) Insert an indwelling urinary catheter to prevent skin breakdown.

Answer c -In the neutropenic pt, meticulous hand hygiene ed is implemented for the pt, fam, visitors, and staff. Not all visitors are restricted, but the pt is protected from persons w known infections. Fluids should be encouraged. Invasive measures such as an indwelling foley should be avoided to prevent infections.

An adult female pt has a hemoglobin level of 10.8g/dL. The nurse interprets that this result is most likely caused by which condition noted in the pts history? *good rationale on this one a) Dehydration b) Heart Failure c) Iron Deficiency Anemia d) Chronic Obstructive Pulmonary Disease

Answer c -The norm hemoglobin level for an adult female is 12-16 g/dL. Iron deficiency anemia can result in lower hemoglobin levels. Note that dehydration can increase the hemoglobin level by hemoconcentration. Heart failure and COPD may actually increase the hemoglobin level as a result of the body's need for more oxygen carrying capacity (compensation).

The nurse is providing home care instructions to the parents of a 10-year-old child w hemophilia. Which sport activity should the nurse suggest for this child? a) Soccer b) Basketball c) Swimming d) Field hockey

Answer c, swimming -Hemophilia is a bleeding disorder. Children w hemophilia need to avoid contact sports and to take precautions such as wearing elbow and knee pads and helmets w other sports. The safe activity for them is swimming.

A pt w a history of upper gastrointestinal bleeding has a platelet count of 300,000 mm. The nurse should take which action after seeing the lab results? a) Report the abnormally low count b) Report the abnormally high count c) Place the pt on bleeding precautions d) Place the normal report in the pts medical record

Answer d -A normal platelet count ranges from 150,000 to 400,000 mm. The nurse should place the report with the normal lab platelet value in the pts chart.

The nurse is teaching a pt who has iron deficiency anemia about foods she should include in the diet. The nurse determines the pt understands the dietary modification if which items are selected from the menu? a) Nuts & milk b) Coffee and tea c) Cooked rolled oats & fish d) Oranges and dark green leafy vegetables

Answer d -Dark green leafy vegetables are a good source of iron, and oranges are a good source of vitamin C, which enhances iron absorption. All the others aren't foods high in iron & C.

A pt brought to the ED states that he has accidentally been taking 2X his prescribed dose of warfarin for the past week. After noting that the pt has no evidence of obvious bleeding, the nurse plans to take which action? a) Prepare to admin antidote b) Draw a sample for type & cross and transfuse pt c) Draw a sample for an aPTT level d) Draw a sample for a PT and INR

Answer d -Draw a PT and INR level to determine the pt's anticoagulation status and risk for bleeding. These results will give the info as to how to best treat this pt. aPTT is for heparin.

The nurse is caring for a pt who had a resection of an abdominal aortic aneurysm yesterday. The pt has an IV infustion at a rate of 150 ml/h unchanged for the last 10h. The pts urine output for the last 3h has been 90, 50, and 28mL (28 ml is most recent). The pt's blood urea nitrogen level is 35mg/dL and the serum creatinine is 1.8 mg/dL measured this morning. Which nursing action is the PRIORITY? a) Check the serum albumin level b) Check the urine specific gravity c) Continue monitoring urine output d) Call the primary health care provider (PHCP)

Answer d -Following abdominal aortic aneurysm rescection or repair, the nurse monitors the pt for signs of acute kidney injury. AKI can occur because often much blood is lost during the surgery and, depending on the aneurysm location, the renal arteries may be hypoperfused for a short period during surgery. Urine output <30mL/h is reported.

The pt is admitted to the hospital w a suspected diagnosis of Hodgkin's disease. Which assessment finding would the nurse expect to note specifically in the pt? a) Fatigue b) Weakness c) Weight gain Enlarged lymph nodes

Answer d -Hodgkin's disease is a chronic progressive neoplastic disorder of lymphoid tissue characterized by the painless enlargement of lymph nodes w progression to extralymphatic sites, such as the spleen and liver. Weight loss is most likely to be noted. Fatigue and weakness may occur but are not related significantly to the disease.

The clinic nurse instructs parents of a child w sickle cell anemia about the precipitating factors r/t sickle cell crisis. Which, if identified by the parents as a precipitating factor, indicates the need for further teaching? a) Stress b) Trauma c) Infection d) Fluid Overload

Answer d -Sickle cell crisis are acute exacerbations of the disease, which vary considerabley in severity and frequency; these include vaso-occlusive crisis, spleen involvement, hyper-hemolytic crisis, and aplastic crisis. Sickle cell crisis may be precipitated by infection, dehydration, hypoxia, trauma, or physical or emotional stress. The mom of a child w sicle cell disease should encourage fluid intake of 1.5-2 times the daily requirement to prevent dehydration.

A child with B-thalassemia is receiving a long-term blood transfusion therapy for the treatment of the disorder. Chelation therapy is prescribed as a result of too much iron from the transfusions. Which med should the nurse anticipate being prescribed? a) Fragmin b) Meropenem c) Metoprolol d) Deferoxamine

Answer d -The major complication of long-term transfusion therapy is an overload of iron in the blood. To prevent organ damage from too much iron, chelation therapy w either Deferasirox or Deferoxamine (think De-Fer for ferrous) may be prescribed. Deferoxamine is classified as an antidote for acute iron toxicity. Nclex loves antidotes!

Lab studies are performed for a child suspected to have iron deficiency anemia. The nurse reviews the lab results knowing that which result indicates this type of anemia? a) Elevated hemoglobin level b) Decreased reticulocyte count c) Elevated red blood cell count d) Red blood cells that are microcytic and hypochromic

Answer d -The results of a complete blood count in children w iron deficiency anemia show decreased hemoglobin levels and microcytic & hypochromic (small and pale) RBCs. The RBC count is decreased. The Reticulocyte count is usually normal or slightly elevated.

The nurse manager is teaching about s/s r/t hypercalcemia in a pt w metastatic cancer and tells the staff that which is a LATE sign or symptom of this oncological emergency? a) Headache b) Dysphagia c) Constipation d) Electrocardiographic changes

Answer d Hypercalcemia is a manifestation of bone metastasis in late-stage cancer. Headache and dysphagia are not associated w hypercalcemia. Constipation may occur early in the process. Electrocardiogram changes include shortened ST segment and a widened T wave.

The nurse has just received a prescription to transfuse a unit of packed red blood cells for an assigned client. What action should the nurse take next? a. Check a set of vital signs. b. Order the blood from the blood bank. c. Obtain Y-site blood administration tubing d. Check to be sure that consent for the transfusion has been signed.

Answer d Rationale: After receiving a prescription for a blood transfusion, the first action the nurse should take should be to check to be sure that consent for the transfusion has been signed by the client. If the client has consented, the nurse should then check a set of vital signs to be sure there is no contraindication for a transfusion at that time, such as an elevation in temperature. If the vital signs are acceptable, the nurse can then gather supplies to administer the transfusion and order the blood from the blood bank.

During an assessment of a patient's abdomen, a pulsating abdominal mass is noted by the healthcare provider. Which of the following should be the healthcare provider's next action?A. Assess femoral pulses B. Obtain a bladder scan C. Measure the abdominal circumference D. Ask the patient to perform a Valsalva maneuver

Answer: A

The nurse has received a prescription to transfuse a client with a unit of packed red blood cells. Before explaining the procedure to the client, the nurse should ask which initial question? a. "Have you ever had a transfusion before?" b. "Why do you think that you need the transfusion?" c. "Have you ever gone into shock for any reason in the past?" d. "Do you know the complications and risks of a transfusion?"

Answer: a Rationale: Asking the client about personal experience with transfusion therapy provides a good starting point for client teaching about this procedure. Questioning about previous history of shock and knowledge of complications and risks of transfusion is not helpful because it may elicit a fearful response from the client. Although determining whether the client knows the reason for the transfusion is important, it is not an appropriate statement in terms of eliciting information from the client regarding an understanding of the need for the transfusion.

The nurse is caring for a client with peripheral arterial disease (PAD). For which symptoms does the nurse assess? A. Reproducible leg pain with exercise B. Unilateral swelling of affected leg C. Decreased pain when legs are elevated D. Pulse oximetry reading of 90%

Answer: a Claudication (leg pain with ambulation due to ischemia) is reproducible in similar circumstances. Unilateral swelling is typical of venous problems such as deep vein thrombosis. With PAD, pain decreases with legs in the dependent position. Pulse oximetry readings reflect the amount of oxygen bound to hemoglobin; PAD results from atherosclerotic occlusion of peripheral arteries.

The nurse has obtained a unit of blood from the blood bank and has checked the blood bag properly with another nurse. Just before beginning the transfusion, the nurse should assess which priority item? a. Vital signs b. Skin color c. Urine output d. Latest hematocrit level

Answer: a Rationale: A change in vital signs during the transfusion from baseline may indicate that a transfusion reaction is occurring. This is why the nurse assesses vital signs before the procedure and again after the first 15 minutes and thereafter per agency policy. The other options do not identify assessments that are a priority just before beginning a transfusion.

A client receiving a transfusion of packed red blood cells (PRBCs) begins to vomit. The client's blood pressure is 90/50 mm Hg from a baseline of 125/78 mm Hg. The client's temperature is 100.8 °F (38.2 °C) orally from a baseline of 99.2 °F (37.3 °C) orally. The nurse determines that the client may be experiencing which complication of a blood transfusion? a. Septicemia b. Hyperkalemia c. Circulatory overload d. Delayed transfusion reaction

Answer: a Rationale: Septicemia occurs with the transfusion of blood contaminated with microorganisms. Signs include chills, fever, vomiting, diarrhea, hypotension, and the development of shock. Hyperkalemia causes weakness, paresthesias, abdominal cramps, diarrhea, and dysrhythmias. Circulatory overload causes cough, dyspnea, chest pain, wheezing, tachycardia, and hypertension. A delayed transfusion reaction can occur days to years after a transfusion. Signs include fever, mild jaundice, and a decreased hematocrit level.

Which person should the nurse identify as having the highest risk for abdominal aortic aneurysm? a A 70-year-old male, with high cholesterol and hypertension b A 40-year-old female with obesity and metabolic syndrome c A 60-year-old male with renal insufficiency who is physically inactive d A 65-year-old female with hyperhomocysteinemia and substance abuse

Answer: a The most common etiology of descending abdominal aortic aneurysm (AAA) is atherosclerosis. Male gender, age 65 years or older, and tobacco use are the major risk factors for AAAs of atherosclerotic origin. Other risk factors include the presence of coronary or peripheral artery disease, high blood pressure, and high cholesterol.

The nurse is conducting staff in-service training on Von Willebrand's disease. Which should the nurse include as characteristics of Von Willebrand's disease? SELECT ALL THAT APPLY a) Easy bruising occurs b) Gum bleeding occurs c) It is a hereditary bleeding disorder d) Treatment and care are similar to that for hemophilia e) It is characterized by extremely high creatinine levels f) The disorder causes platelets to adhere to damaged endothelium.

Answer: a, b, c, d, f -Von Willebrand's disease is a hereditary bleeding disorder characterized by a deficiency of or a defect in the Von Willebrand factor. The disorder causes platelets to adhere to damaged endothelium. It is characterized by an increased tendency to bleed from mucous membranes. Assessment findings include epistaxis, gum bleeding, easy bruising, and excessive menstrual bleeding. An elevated creatinine level isn't associated w this disorder.

A patient presenting to the ER with a hypertensive crisis (BP greater than 180/120), may have damage to which of the following? a. Brain b. Kidney c. Liver d. Heart e. Stomach f. Eyes

Answer: a, b, d, f CVA, retinopathy, heart failure, renal failure, IV beta blocker will be ordered immediately for a pt in a hypertensive crisis

A client requiring surgery is anxious about the possible need for a blood transfusion during or after the procedure. The nurse suggests to the client to take which actions to reduce the risk of possible transfusion complications? Select all that apply. a. Ask a family member to donate blood ahead of time. b. Give an autologous blood donation before the surgery. c. Take iron supplements before surgery to boost hemoglobin levels. d. Request that any donated blood be screened twice by the blood bank. e. Take adequate amounts of vitamin C several days prior to the surgery date.

Answer: a, b. Rationale: A donation of the client's own blood before a scheduled procedure is autologous. Donating autologous blood to be reinfused as needed during or after surgery reduces the risk of disease transmission and potential transfusion complications. The next most effective way is to ask a family member to donate blood before surgery. Blood banks do not provide extra screening on request. Preoperative iron supplements are helpful for iron deficiency anemia but are not helpful in replacing blood lost during the surgery. Vitamin C enhances iron absorption, but also is not helpful in replacing blood lost during surgery.

The nurse who is about to begin a blood transfusion knows that blood cells start to deteriorate after a certain period of time. The nurse takes which actions in order to prevent a complication of the blood transfusion as it relates to deterioration of blood cells? Select all that apply. a. Checks the expiration date b. Inspects for the presence of clots c. Checks the blood group and type d. Checks the blood identification number e. Hangs the blood within the specified time frame per agency policy

Answer: a, e Rationale: The nurse notes the expiration date on the unit of blood to ensure that the blood is fresh. Blood cells begin to deteriorate over time, so safe storage usually is limited to 35 days. Careful notation of the expiration date by the nurse is an essential part of the verification process before hanging a unit of blood. The nurse also needs to hang the blood within the specified time frame after receiving it from the blood bank per agency policy to ensure that the blood being transfused is fresh. The blood bank keeps the blood regulated at a specific temperature, and therefore it must be infused within a specified time frame once received on the unit. The nurse also notes the blood identification (unit) number, blood group and type, and client's name, but this is not specifically related to the degradation of blood cells. The nurse also inspects the unit of blood for leaks, abnormal color, clots, and bubbles and returns the unit to the blood bank if clots are noted. Again, this is not related to the degradation of blood cells over time.

A nurse is caring for a client who had a percutaneous insertion of an inferior vena cava filter and was on heparin therapy before surgery. The nurse would inspect the surgical site most closely for signs of: a. Thrombosis and infection b. Bleeding and infection c. Bleeding and wound dehiscence .d. Wound dehiscence and evisceration.

Answer: b After inferior vena cava insertion, the nurse inspects the surgical site for bleeding and signs and symptoms of infection. Otherwise, care is the same as for any post-op client

A client comes to the outpatient clinic and tells the nurse that he has had legs pains that begin when he walks but cease when he stops walking. Which of the following conditions would the nurse assess for? a. An acute obstruction in the vessels of the legs b. Peripheral vascular problems in both legs c. Diabetes d. Calcium deficiency

Answer: b Intermittent claudication is a condition that indicates vascular deficiencies in the peripheral vascular system. If an obstruction were present, the leg pain would persist when the client stops walking. Low calcium levels may cause leg cramps but would not necessarily be related to walking.

A nurse is assessing a client with an abdominal aortic aneurysm. Which of the following assessment findings by the nurse is probably unrelated to the aneurysm? a. Pulsatile abdominal mass b. Hyperactive bowel sounds in that area c. Systolic bruit over the area of the mass d. Subjective sensation of "heart beating" in the abdomen.

Answer: b Not all clients with abdominal aortic aneurysms exhibit symptoms. Those who do describe a feeling of the "heart beating" in the abdomen when supine or be able to feel the mass throbbing. A pulsatile mass may be palpated in the middle and upper abdomen. A systolic bruit may be auscultated over the mass. Hyperactive bowel sounds are not related specifically to an abdominal aortic aneurysm

The nurse caring for a client who has had abdominal aortic aneurysm (AAA) repair would be most alarmed by which finding? a. Urine output of 20 mL over 2 hours b. Blood pressure of 106/58 mm Hg c Absent bowel sounds d. +3 pedal pulses

Answer: b Rationale: Complications post AAA stent repair include bleeding, which may manifest as signs of hypovolemia and oliguria

For a client with an 8-cm abdominal aortic aneurysm, which problem must be addressed immediately to prevent rupture? a. Heart rate 52 beats/min b. Blood pressure 192/102 mm Hg c. Report of constipation d. Anxiety

Answer: b Rationale: Elevated blood pressure can increase the rate of aneurysmal enlargement and risk for early rupture.

Following infusion of a unit of packed red blood cells, the client has developed new onset of tachycardia, bounding pulses, crackles, and wheezes. Which action should the nurse implement first? a. Maintain bed rest with legs elevated. b. Place the client in high-Fowler's position. c. Increase the rate of infusion of intravenous fluids. d. Consult with the health care provider (HCP) regarding initiation of oxygen therapy.

Answer: b Rationale: New onset of tachycardia, bounding pulses, and crackles and wheezes post-transfusion is evidence of fluid overload, a complication associated with blood transfusions. Placing the client in a high-Fowler's (upright) position will facilitate breathing. Measures that increase blood return to the heart, such as leg elevation and administration of IV fluids, should be avoided at this time. In addition, administration of fluids cannot be initiated without a prescription. Consulting with the HCP regarding administration of oxygen may be necessary, but positional changes take a short amount of time to do and should be initiated first.

When caring for a client with an abdominal aortic aneurysm (AAA), the nurse suspects dissection of the aneurysm when the client makes which statement? a. "I feel my heart beating in my abdominal area." b. "I just started to feel a tearing pain in my belly." c. "I have a headache. May I have some acetaminophen?" d. "I have had hoarseness for a few weeks."

Answer: b Rationale: Severe pain of sudden onset in the back or lower abdomen, which may radiate to the groin, buttocks, or legs, is indicative of impending rupture of AAA.

A client has a prescription to receive a unit of packed red blood cells. The nurse should obtain which intravenous (IV) solution from the IV storage area to hang with the blood product at the client's bedside? a. Lactated Ringer's b. 0.9% sodium chloride c. 5% dextrose in 0.9% sodium chloride d. 5% dextrose in 0.45% sodium chloride

Answer: b Rationale: Sodium chloride 0.9% (normal saline) is a standard isotonic solution used to precede and follow infusion of blood products. Dextrose is not used because it could result in clumping and subsequent hemolysis of red blood cells (RBCs). Lactated Ringer's is not the solution of choice with this procedure.

A patient is admitted to the hospital with a diagnosis of abdominal aortic aneurysm. Which signs and symptoms would suggest that his aneurysm has ruptured? a. Sudden shortness of breath and hemoptysis b. Sudden, severe low back pain and bruising along his flank c. Gradually increasing substernal chest pain and diaphoresis d. Sudden, patchy blue mottling on feet and toes and rest pain

Answer: b Rationale: The clinical manifestations of a ruptured abdominal aortic aneurysm include severe back pain, back or flank ecchymosis (Grey Turner's sign), and hypovolemic shock (tachycardia, hypotension, pale clammy skin, decreased urine output, altered level of consciousness, and abdominal tenderness).

The first priority of collaborative care of a patient with a suspected acute aortic dissection is to a. reduce anxiety b. control blood pressure. c. monitor for chest pain. d. increase myocardial contractility.

Answer: b Rationale: The initial goals of therapy for acute aortic dissection without complications are blood pressure (BP) control and pain management. BP control reduces stress on the aortic wall by reducing systolic BP and myocardial contractility.

The patient had aortic aneurysm repair. What priority nursing action will the nurse use to maintain graft patency? a Assess output for renal dysfunction. b Use IV fluids to maintain adequate BP. c Use oral antihypertensives to maintain cardiac output. d Maintain a low BP to prevent pressure on surgical site

Answer: b Rationale: The priority is to maintain an adequate BP (determined by the surgeon) to maintain graft patency. A prolonged low BP may result in graft thrombosis, and hypertension may cause undue stress on arterial anastomoses resulting in leakage of blood or rupture at the suture lines, which is when IV antihypertensives may be used. Renal output will be assessed when the aneurysm repair is above the renal arteries to assess graft patency, not maintain it.

Which are probable clinical findings in a person with an acute lower extremity VTE (select all that apply)? a .Pallor and coolness of foot and calf b. Mild to moderate calf pain and tenderness c. Grossly diminished or absent pedal pulses d. Unilateral edema and induration of the thigh e. Palpable cord along a superficial varicose vein

Answer: b, d Rationale: The patient with lower extremity venous thromboembolism (VTE) may or may not have unilateral leg edema, extremity pain, a sense of fullness in the thigh or calf, paresthesias, warm skin, erythema, or a systemic temperature greater than 100.4 F (38 C). If the calf is involved, it may be tender to palpation.

The nurse, listening to the morning report, learns that an assigned client received a unit of granulocytes the previous evening. The nurse makes a note to assess the results of which daily serum laboratory studies to assess the effectiveness of the transfusion? a. Hematocrit level b. Erythrocyte count c. Hemoglobin level d. White blood cell count

Answer: d Rationale: The client who has neutropenia may receive a transfusion of granulocytes, or WBCs. These clients often have severe infections and are unresponsive to antibiotic therapy. The nurse notes the results of follow-up WBC counts and differential to evaluate the effectiveness of the therapy. The nurse also continues to monitor the client for signs and symptoms of infection. Erythrocyte count and hemoglobin and hematocrit levels are determined after transfusion of packed red blood cells.

. The nurse is caring for a client who is receiving a blood transfusion and is complaining of a cough. The nurse checks the client's vital signs, which include temperature of 97.2 °F (36.2 °C), pulse of 108 beats per minute, blood pressure of 152/76 mm Hg, respiratory rate of 24 breaths per minute, and an oxygen saturation level of 95% on room air. The client denies pain at this time. Based on this information, what initial action should the nurse take? a. Collect a urine sample for analysis. b. Place the client in an upright position. c. Compare current data to baseline data. d. Slow the rate of the blood transfusion.

Answer: c Rationale: For the client receiving a blood transfusion, the nurse should monitor for potential complications of a transfusion. One of the complications is circulatory overload. Signs and symptoms of circulatory overload include cough, dyspnea, chest pain, wheezing on auscultation of the lungs, headache, hypertension, tachycardia and a bounding pulse, and distended neck veins. Based on the data in the question, the nurse should compare current data to baseline data. The nurse should also further assess the client for other signs and symptoms of circulatory overload. If the nurse still suspects this complication after comparing to baseline data, the nurse should then place the client in an upright position with the feet in a dependent position and slow the rate of the infusion. Collection of a urine sample should occur if the nurse suspects a transfusion reaction, such as a hemolytic reaction.

A client is brought to the emergency department having experienced blood loss related to an arterial laceration. Which blood component should the nurse expect the health care provider to prescribe? a. Platelets b. Granulocytes c. Fresh-frozen plasma d. Packed red blood cells

Answer: c Rationale: Fresh-frozen plasma is often used for volume expansion as a result of fluid and blood loss. It is rich in clotting factors and can be thawed quickly and transfused quickly. Platelets are used to treat thrombocytopenia and platelet dysfunction. Granulocytes may be used to treat a client with sepsis or a neutropenic client with an infection that is unresponsive to antibiotics. Packed red blood cells are a blood product used to replace erythrocytes.

Packed red blood cells have been prescribed for a female client with a hemoglobin level of 7.6 g/dL (76 mmol/L) and a hematocrit level of 30% (0.30). The nurse takes the client's temperature before hanging the blood transfusion and records 100.6 °F (38.1 °C) orally. Which action should the nurse take? a. Begin the transfusion as prescribed. b. Administer an antihistamine and begin the transfusion. c. Delay hanging the blood and notify the health care provider (HCP). d. Administer 2 tablets of acetaminophen and begin the transfusion.

Answer: c Rationale: If the client has a temperature higher than 100 °F (37.8 °C), the unit of blood should not be hung until the PHCP is notified and has the opportunity to give further prescriptions. The PHCP likely will prescribe that the blood be administered regardless of the temperature, or may instruct the nurse to administer prescribed acetaminophen and wait until the temperature has decreased before administration, but the decision is not within the nurse's scope of practice to make. The nurse needs an PHCP's prescription to administer medications to the client.

The nurse determines that a client is having a transfusion reaction. After the nurse stops the transfusion, which action should be taken next? a. Remove the intravenous (IV) line. b. Run a solution of 5% dextrose in water. c. Run normal saline at a keep-vein-open rate. d. Obtain a culture of the tip of the catheter device removed from the client.

Answer: c Rationale: If the nurse suspects a transfusion reaction, the nurse stops the transfusion and infuses normal saline at a keep-vein-open rate pending further health care provider prescriptions. This maintains a patent IV access line and aids in maintaining the client's intravascular volume. The nurse would not remove the IV line because then there would be no IV access route. Obtaining a culture of the tip of the catheter device removed from the client is incorrect. First, the catheter should not be removed. Second, cultures are performed when infection, not transfusion reaction, is suspected. Normal saline is the solution of choice over solutions containing dextrose because saline does not cause red blood cells to clump.

A client with severe blood loss resulting from multiple trauma requires rapid transfusion of several units of blood. The nurse asks another health team member to obtain which device for use during the transfusion procedure to help reduce the risk of cardiac dysrhythmias? a. Infusion pump b. Pulse oximeter c. Cardiac monitor d. Blood-warming device

Answer: d Rationale: If several units of blood are to be administered rapidly, a blood warmer should be used. Rapid transfusion of cool blood places the client at risk for cardiac dysrhythmias. To prevent this, the nurse warms the blood with a blood-warming device. Pulse oximetry and cardiac monitoring equipment are useful for the early assessment of complications but do not reduce the occurrence of cardiac dysrhythmias. Electronic infusion devices are not helpful in this case because the infusion must be rapid, and infusion devices generally are used to control the flow rate. In addition, not all infusion devices are made to handle blood or blood products.

A client has received a transfusion of platelets. The nurse evaluates that the client is benefiting most from this therapy if the client exhibits which finding? a. Increased hematocrit level b. Increased hemoglobin level c. Decline of elevated temperature to normal d. Decreased oozing of blood from puncture sites and gums

Answer: d Rationale: Platelets are necessary for proper blood clotting. The client with insufficient platelets may exhibit frank bleeding or oozing of blood from puncture sites, wounds, and mucous membranes. Increased hemoglobin and hematocrit levels would occur when the client has received a transfusion of red blood cells. An elevated temperature would decline to normal after infusion of granulocytes because these cells were instrumental in fighting infection in the body.

Which client who has just arrived in the emergency department does the nurse classify as emergent and needing immediate medical evaluation? a) A 60-year-old with venous insufficiency who has new-onset right calf pain and tenderness b) A 64-year-old with chronic venous ulcers who has a temperature of 100.1° F (37.8° C) c) A 69-year-old with a 40-pack-year cigarette history who is reporting foot numbness d) A 70-year-old with a history of diabetes who has "tearing" back pain and is diaphoretic

Answer: d Rationale: The 70-year-old's history and clinical manifestations suggest possible aortic dissection. The nurse will immediately assess the client's blood pressure and plan for IV antihypertensive therapy, rapid diagnostic testing, and possible transfer to surgery

A male patient was admitted for a possible ruptured aortic aneurysm, but had no back pain. Ten minutes later his assessment includes the following: sinus tachycardia at 138, BP palpable at 65 mm Hg, increasing waist circumference, and no urine output. How should the nurse interpret this assessment about the patient's aneurysm? a Tamponade will soon occur b The renal arteries are involved. c Perfusion to the legs is impaired. d He is bleeding into the abdomen.

Answer: d Rationale: The lack of back pain indicates the patient is most likely exsanguinating into the abdominal space, and the bleeding is likely to continue without surgical repair. A blockade of the blood flow will not occur in the abdominal space as it would in the retroperitoneal space where surrounding anatomic structures may control the bleeding. The lack of urine output does not indicate renal artery involvement, but that the bleeding is occurring above the renal arteries, which decreases the blood flow to the kidneys. There is no assessment data indicating decreased perfusion to the legs.

A client is admitted with a venous stasis leg ulcer. A nurse assesses the ulcer, expecting to note that the ulcer: a. Has a pale colored base b. Is deep, with even edges c. Has little granulation tissue d. Has brown pigmentation around it.

Answer: d Venous leg ulcers, also called stasis ulcers, tend to be more superficial than arterial ulcers, and the ulcer bed is pink. The edges of the ulcer are uneven, and granulation tissue is evident. The skin has a brown pigmentation from accumulation of metabolic waste products resulting from venous stasis. The client also exhibits peripheral edema. (options 1, 2, and 3 is due to tissue malnutrition; and thus us an arterial problem)

The nurse suspects that a client has developed an acute arterial occlusion of the right lower extremity based on which signs/symptoms? (Select all that apply.) a. Hypertension b. Tachycardia c. Bounding right pedal pulses d. Cold right foot e. Numbness and tingling of right foot f. Mottling of right foot and lower leg

Answer: d, e, f Rationale: Pain, pallor, pulselessness, paresthesia, paralysis, poikilothermia (cool limb), and mottled color are characteristics of acute arterial occlusion.

The nurse reinforces instructions to a client at risk for thrombophlebitis regarding measures to minimize its occurrence. Which statement by the client indicates an understanding of this information? A. "I need to avoid pregnancy by taking oral contraceptives." B. "I should avoid sitting in one position for long periods of time." C. "I can finally stop wearing these support stockings that you gave me." D. "I will be sure to maintain my fluid intake to at least four glasses daily."

B. "I should avoid sitting in one position for long periods of time." Avoidance of sitting or standing for a prolonged period of time is one of the measures for the prevention of venous stasis and thrombophlebitis. Taking oral contraceptives causes hypercoagulability that could result in thrombophlebitis. Support stockings are used to promote venous return, to maintain normal coagulability, and to prevent injury to the endothelial wall. Adequate hydration is maintained to prevent hypercoagulability, and four glasses daily are an inadequate amount of fluid.

The nurse has reinforced instructions to the client with Raynaud's disease about self-management of the disease process. The nurse determines that the client needs further teaching if the client states which? A. "Smoking cessation is very important." B. "Moving to a warmer climate should help." C. "Sources of caffeine should be eliminated from the diet." D. "Taking nifedipine (Procardia) as prescribed will decrease vessel spasm."

B. "Moving to a warmer climate should help." Raynaud's disease responds favorably to the elimination of nicotine and caffeine. Medications such as calcium channel blockers may inhibit vessel spasm and prevent symptoms. Avoiding exposure to cold through a variety of means is very important. However, moving to a warmer climate may not necessarily be beneficial because the symptoms could still occur with the use of air conditioning and during periods of cooler weather.

A client who has undergone femoropopliteal bypass grafting says to the nurse, "I hope I don't have any more problems that could make me lose my leg. I'm so afraid that I'll have gone through this for nothing." Which is an appropriate nursing response? A. "There is nothing to worry about." B. "You are concerned about losing your leg?" C. "There are many people with the same problem, and they are doing just fine." D. "You have the best health care provider in the city, and your health care provider will not let anything happen to you."

B. "You are concerned about losing your leg?" The appropriate response is the one that uses the therapeutic technique of restatement. Option 2 restates the client's concern and provides an opportunity for the client to further discuss the concern. Options 1, 3, and 4 are inappropriate because they provide false reassurance and do not address the client's concern.

The nurse is monitoring a client with an abdominal aortic aneurysm (AAA). Which finding is probably unrelated to the AAA? A. Pulsatile abdominal mass B. Hyperactive bowel sounds in the area C. Systolic bruit over the area of the mass D. Subjective sensation of "heart beating" in the abdomen

B. Hyperactive bowel sounds in the area Not all clients with abdominal aortic aneurysm exhibit symptoms. Those who do may describe a feeling of the "heart beating" in the abdomen when supine, or being able to feel the mass throbbing. A pulsatile mass may be palpated in the middle and upper abdomen. A systolic bruit may be auscultated over the mass. Hyperactive bowel sounds are not specifically related to an abdominal aortic aneurysm.

The nurse is checking the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago after undergoing an aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable and unchanged from admission. The nurse interprets that the neurovascular status is which? A. Moderately impaired, and the surgeon should be called B. Normal, caused by increased blood flow through the leg C. Slightly deteriorating, and should be monitored for another hour D. Adequate from an arterial approach, but venous complications are arising

B. Normal, caused by increased blood flow through the leg An expected outcome of surgery is warmth, redness, and edema in the surgical extremity caused by increased blood flow. Options 1, 3, and 4 are incorrect.

A client returns to the nursing unit after an above knee amputation of the right leg. In which position should the nurse place the client? A. Prone with the head on a pillow B. With the foot of the bed elevated C. Reverse Trendelenburg's position D. With the residual limb flat on the bed

B. With the foot of the bed elevated During the first 24 hours after amputation, the nurse elevates the foot of the bed (but not the residual limb itself) to reduce edema. After the first 24 hours, the bed is kept flat to prevent hip flexion contractures. The health care provider's postoperative prescriptions regarding positioning are always followed.

A client has an inoperable abdominal aortic aneurysm (AAA). Which measure should the nurse anticipate reinforcing when teaching the client? A. Bed rest B. Restricting fluids C. Antihypertensives D. Maintaining a low-fiber diet

C. Antihypertensives The medical treatment for abdominal aortic aneurysm is controlling blood pressure. Hypertension creates added stress on the blood vessel wall, increasing the likelihood of rupture. There is no need for the client to restrict fluids or to be on bed rest. A low-fiber diet is not helpful and will cause constipation.

A client is diagnosed with thrombophlebitis. The nurse should tell the client that which prescription is indicated? A. Bed rest, with bathroom privileges only B. Bed rest, keeping the affected extremity flat C. Bed rest, with elevation of the affected extremity D. Bed rest, with the affected extremity in a dependent position

C. Bed rest, with elevation of the affected extremity Elevation of the affected leg facilitates blood flow by the force of gravity and decreases venous pressure, which in turn relieves edema and pain. The foot of the bed is elevated and bed rest is indicated to prevent emboli and pressure fluctuations in the venous system that occur with walking. The positions in the remaining options are incorrect.

The client scheduled for a right femoropopliteal bypass graft is at risk for compromised tissue perfusion to the extremity. The nurse takes which action before surgery to address this risk? A. Having the client void before surgery B. Completing a preoperative checklist C. Marking the location of the pedal pulses on the right leg D. Checking the results of any baseline coagulation studies

C. Marking the location of the pedal pulses on the right leg A problem with compromised tissue perfusion in the client scheduled for a femoropopliteal bypass grafting is likely to indicate the presence of diminished peripheral pulses. It is important to mark the location of any pulses that are palpated or auscultated. This provides a baseline for comparison in the postoperative period. The other options are part of routine preoperative care.

The nurse is caring for a client diagnosed with Buerger's disease. Which finding should the nurse determine is a potential complication associated with this disease? A. Pain with diaphoresis B. Discomfort in one digit C. Numbness and tingling in the legs D. Cramping in the foot while resting

C. Numbness and tingling in the legs Buerger's disease (thromboangiitis obliterans), which affects men between 20 and 40 years of age, has an unknown etiology. It is a recurring inflammation of the small and medium-sized arteries and veins of the upper and lower extremities that results in thrombus formation and occlusion of blood vessels. Options 1, 2, and 4 are not complications of this disorder. The finding that can be interpreted as a complication of the disorder is numbness and tingling in the legs.

A client diagnosed with thrombophlebitis 1 day ago suddenly complains of chest pain and shortness of breath, and the client is visibly anxious. The nurse understands that a life-threatening complication of this condition is which? A. Pneumonia B. Pulmonary edema C. Pulmonary embolism D. Myocardial infarction

C. Pulmonary embolism Pulmonary embolism is a life-threatening complication of deep vein thrombosis and thrombophlebitis. Chest pain is the most common symptom, which is sudden in onset and may be aggravated by breathing. Other signs and symptoms include dyspnea, cough, diaphoresis, and apprehension.

The nurse is collecting data from a client with varicose veins. Which finding would the nurse identify as an indication of a potential complication associated with this disorder? A. Legs are unsightly in appearance and distress the client. B. The client complains of aching and feelings of heaviness in the legs. C. The client complains of leg edema, and skin breakdown has started. D. The health care provider finds that the legs become distended when the tourniquet is released during the Trendelenburg's test.

C. The client complains of leg edema, and skin breakdown has started. Complications of varicose veins include leg edema, skin breakdown, ulceration of the legs, trauma leading to rupture of a varicosity, deep vein thrombosis, or chronic insufficiency. The client with varicose veins may be distressed about the unsightly appearance of the varicosities. Complaints of heaviness and aching in the legs are common. Option 4 describes the Trendelenburg's test findings, which are indicative of varicose veins. In the test, the health care provider has the client lie down and elevate the legs to empty the veins. A tourniquet is then applied to occlude the superficial veins, after which the client stands and the tourniquet is released. If the veins are incompetent, they will quickly become distended due to backflow.

A client with chronic kidney disease is receiving ferrous sulfate (Feosol). The nurse should monitor the client for which common side effect associated with this medication? a. Diarrhea b. Weakness c. Headache d. Constipation

Constipation

A client is seen in the health care provider's office for a physical examination after experiencing unusual fatigue over the last several weeks. Height is 5 feet, 8 inches, with a weight of 220 pounds. Vital signs are temperature 98.6° F oral, pulse 86 beats per minute, respirations 18 breaths per minute, and blood pressure 184/96 mm Hg. Random blood glucose is 110 mg/dL. In order to best collect relevant data, which question should the nurse ask the client first? A. "Do you exercise regularly?" B. "Would you consider losing weight?" C. "Is there a history of diabetes mellitus in your family?" D. "When was the last time you had your blood pressure checked?"

D. "When was the last time you had your blood pressure checked?" The client is hypertensive, which is a known major modifiable risk factor for coronary artery disease (CAD). The other major modifiable risk factors for CAD not exhibited by this client include smoking and hyperlipidemia. The client is overweight, which is also a contributing risk factor. The client's nonmodifiable risk factors are age and gender. Because the client presents with several risk factors, the nurse places priority on the client's major modifiable risk factors.

A client seeks medical attention for intermittent episodes in which the fingers of both hands become cold, pale, and numb. The client states that they then become reddened and swollen with a throbbing, achy pain and Raynaud's disease is diagnosed. Which factor would precipitate these episodes? A. Exposure to heat B. Being in a relaxed environment C. Prolonged episodes of inactivity D. Ingestion of coffee or chocolate

D. Ingestion of coffee or chocolate Raynaud's disease is a bilateral form of intermittent arteriolar spasm, which can be classified as obstructive or vasospastic. Episodes are characterized by pallor, cold, numbness, and possible cyanosis, followed by erythema, tingling, and aching pain in the fingers. Attacks are triggered by exposure to cold, nicotine, caffeine, trauma to the fingertips, and stress.

A client has an Unna boot applied for treatment of a venous stasis leg ulcer. The nurse notes that the client's toes are mottled, and cool and the client verbalizes some numbness and tingling of the foot. Which interpretation should the nurse make of these findings? A. The boot has not yet dried. B. The boot is controlling leg edema. C. The boot is impairing venous return. D. The boot has been applied too tightly.

D. The boot has been applied too tightly. An Unna boot that is applied too tightly can cause signs of arterial occlusion. The nurse assesses the circulation in the foot and teaches the client to do the same. The other options are incorrect interpretations.

A client is admitted to the hospital with a venous stasis leg ulcer. The nurse inspects the ulcer expecting to note which observation? A. The ulcer has a pale-colored base. B. The ulcer is deep, with even edges. C. The ulcer has little granulation tissue. D. The ulcer has a brownish or "brawny" appearance.

D. The ulcer has a brownish or "brawny" appearance. Venous leg ulcers, also called stasis ulcers, are typically partial-thick wounds that extend through the epidermis and portions of the dermis. The skin of the lower leg is leathery, with a characteristic brownish or "brawny" appearance from the hemosiderin deposition. The edges of the ulcer are irregular and the tissue is a ruddy color. The client also may exhibit peripheral edema. Therefore, options 1, 2, and 3 are incorrect descriptions.

Varicose veins can cause changes in what component of Virchow's triad? a. Blood coagulability b. Vessel walls c. Blood flow d. Blood viscosity

c. Blood flow