NU310 HESI (Cardiovascular alterations)
which physiological alteration would be expected with a higher-than-normal red blood cell (RBC) count? A) increased blood pH B) Decreased hematocrit C) increased blood viscosity D) decreased immune response
C) increased blood viscosity --> viscosity, a measure of a fluids internal resistance to flow, is increased as the number of red blood cells suspended in plasma increases. The number of cells does not affect the blood pH. The hematocrit will be higher. RBCs do not affect immunity.
In what order does normal cardiac conduction occur through the heart?
1) Sinoatrial node 2) Atrioventricular (AV) node 3) Bundle of His 4) Bundle branches 5) purkinje fibers
in what order does normal cardiac conduction occur through the heart?
1) sinoatrial node 2) atrioventricular (AV) node 3) bundle of His 4) Bundle branches 5) Purkinje fibers
the mean arterial pressure (MAP) for a client who has a blood pressure of 180/95 mm Hg is ...
123 ((2x95) + 180/3)
a client with heart failure weighed 175 lb yesterday, and todays weight is 181 lb. How many mL of fluid has the client retained?
2700 mL --> one liter of fluid equals 1000mL ; each liter of fluid is equal to 1 kg of weight. 175 lbs equals 79.4kg and 181 lb equals 82.1kg (82.1kg - 79.4kg = 2.7 kg = 2700mL)
Which electrical activity of the cardiac conduction system is reflected in the P wave? A) Atrial depolarization B) Atrial repolarization C) ventricular depolarization D) ventricular repolarization
A) Atrial depolarization --> The P wave represents atrial depolarization. The QRS complex represents ventricular depolarization. Atrial repolarization also occurs simultaneously to ventricular depolarization, but because of the larger muscle mass of the ventricles, the QRS complex obscures visualization of atrial repolarization. The T wave represents ventricular repolarization
which statement by an unlicensed assiting personnel (UAO) who is assisting the nurse in caring for a group of clients indicates a correct understanding of the UAP's role? A) " I will turn off clients intravenous lines that have infiltrated" B) "I will take clients vital signs after their procedures are over" C) "I will use unit written material to teach clients before surgery D) "I will help by giving medications to clients who are slow in taking pills."
B) "I will take clients vital signs after their procedures are over"
which item would the client with palpitations from premature heartbeats be taught to avoid? A) bananas B) tomatoes C) energy drinks D) green leafy veggies
C) energy drinks
which is the purpose of encouraging active leg and foot exercises for a client who has had hip surgery? A) maintain muscle strength B) reduce leg discomfort C) prevent clot formation D) improve wound healing
C) prevent clot formation
how far would the nurse depress the lower sternum when performing cardiac compression on an adult client? A) 0.75 to 1 inch (2-2.5 cm) B) 0.5 to 0.75 inch (1.302 cm) C) 1 to 1.4 inches (2.5-3.6 cm) D) 2 to 2.4 inches (5-6 cm)
D) 2 to 2.4 inches (5-6 cm)
which type of shock is associated with a ruptures abdominal aneurysm? A) vasogenic shock B) neurogenic shock C) cardiogenic shock D) hypovolemic shock
D) hypovolemic shock
which physiological alteration would be expected with a higher-than-normal red blood cell (RBC) count? A) increased blood pH B) decreased hematocrit C) increased blood viscosity D) decreased immune response
C) increased blood viscosity --> viscosity, a measure of a fluids internal resistance to flow, is increased as the number of red blood cells suspended in plasma increases. the number of cells does not affect the blood pH. The hematocrit will be higher. RBCs do not affect immunity
Which distinguishing sign unique to a fat embolus will a nurse monitor for in a client with distal femoral shaft fracture who is at risk for developing a fat embolus? A) oliguria B) dyspnea C) petechiae D) confusion
C) petechiae
which assessment finding after an open reduction and internal fixation (ORIF) of a fractured hip would cause the nurse to suspect and monitor for signs and symptoms of a fat embolism? A) fever and chest pain B) positive Homans sign C) loss of sensation in the operative leg D) tachycardia and petechiae over the chest
D) tachycardia and petechiae over the chest --> tachycardia occurs because of an impaired gas exchange; petechiae are caused by occlusion of small vessels within the skin
which blood types can potentially be used for transfusion when a client has type A negative blood? A) type O positive B) type AB positive C) type A or O negative D) type A or AB negative
C) type A or O negative
How would the nurse describe cardiogenic shock when a family member of a client asks for more info about the condition? A) an irreversible phenomenon B) a failure of the circulatory pump C) usually a fleeting reaction to tissue injury D) generally caused by decreased blood volume
B) a failure of the circulatory pump
which group of clients would the nurse anticipate to have the highest incidence of non-Hodgkin lymphomas? A) children B) older adults C) young adults D) middle0aged persons
B) older adults
which condition would the nurse conclude that the client is experiencing when the monitor shows a PQRST wave for each beat, indicates a rate of 120 beats per min, and the rhythm is regular? A) Atrial fibrillation B) sinus tachycardia C) ventricular fibrillation D) first-degree atrioventricular block
B) sinus tachycardia
which info would the nurse include when teaching a client with varicose veins about ligation and stripping surgery? A) plaque from within the veins is scraped B) the dilated saphenous veins are removed C) superficial veins are sown together into deep veins D) an umbrella filter is placed in the large affected veins
B) the dilated saphenous veins are removed
which answer would the nurse provide when a client who has had a myocardial infarction asks why thallium scan has been prescribed? A) to check heart valve function B) to establish viability of heart muscle C) to visualize ventricular systole and diastole D) to monitor the hearts electrical conduction
B) to establish viability of heart muscle
which complication is most likely to occur in the immediate postoperative period after a client has had a splenectomy? A) infection B) peritonitis C) hemorrhage D) intestinal obstruction
C) hemorrhage
Which complication would the nurse consider in a client who just had a total hip replacement and is experiencing restlessness and changes in mentation? A) bladder spasms B) polycythemia vera C) hypovolemic shock D) pulmonary hypertension
C) hypovolemic shock --> these signs occur with hypovolemic shock because less blood is being circulated to vital centers in the brain. A large loss of blood may occur during and after orthopedic surgery
which type of shock would the nurse monitor for in a client with a ruptured abdominal aortic aneurysm? A) obstructive B) neurogenic C) cardiogenic D) hypovolemic
D) hypovolemic
which explanation would the nurse give to a client with a diagnosis of myocardial infarction who asks the nurse, "what is causing the pain I am having?" A) compression of the heart muscle B) release of myocardial isoenzymes C) rapid vasodilation of the coronary arteries D) inadequate oxygenation of the myocardium
D) inadequate oxygenation of the myocardium
which intervention would the nurse perform when caring for a client in the emergency department reporting chest pain? Select all: A) providing oxygen B) assessing vital signs C) obtaining a 12-lead EKG D) drawing blood for cardiac enzymes E) auscultating heart sounds F) administering nitroglycerin
all of the above
which complication will the nurse monitor for when caring for a client with an infection caused by group A beta-hemolytic streptococci? A) hepatitis A B) Rheumatic fever C) spinal mengingitis D) Rheumatoid arthritis
B) Rheumatic fever --> antibodies produced against group A beta-hemolytic streptococci sometimes interact w antigens in the hearts valves, causing damage and symptoms of rheumatic heart disease
which finding will the nurse expect when caring for a client who is in hypovolemic shock? A) slow heart rate B) cool skin temp C) bounding radial pulses D) increased urine output
B) cool skin temp
which type of lung sounds would the nurse expect to hear when caring for a client with heart failure? a) stridor B) crackles C) wheezes D) Rhonchi
B) crackles
which term will a nurse use to document when a client with peripheral arterial disease tells the nurse about having leg pain and weakness after walking a short distance? A) rest pain B) Raynaud phenomenon C) Intermittent claudication D) Phantom limb sensation
C) Intermittent claudication
which term would the nurse use to document a drop in blood pressure when a client moves rapidly from a lying to a standing position? A) malignant hypotension B) Orthostatic dehydration C) Orthostatic hypotension D) vasomotor instability
C) Orthostatic hypotension
which lab result is important to communicate quickly to the health care provider? A) blood glucose 98 mg/dL (5.44 mmol/L) B) Hemoglobin 14.1 g/dL (141 mmol/L) C) Potassium 3.0 mEq/L (3.0 mmol/L) D) White blood cell 9200/mm to the third (9.2 x 10 to the ninth / L)
C) Potassium 3.0 mEq/L (3.0 mmol/L)
how would the nurse describe heart failure to a client? A) a cardiac condition caused by inqadequate blood volume B) an acute state in which the pulmonary circulation pressure decreases C) an inability of the heart to pump blood in proportion to metabolic needs D) a chronic state in which the systolic blood pressure drops below 90 mm Hg
C) an inability of the heart to pump blood in proportion to metabolic needs
which action would the nurse take when a client develops epistaxis? A) tilt the head backward B) pack the nose w tissue C) apply direct lateral pressure to the nose D) instruct the client to blow the nose gently
C) apply direct lateral pressure to the nose
which activity would the nurse expect to cause the most distress when assessing a client with heart failure fr activity tolerance? A) getting up from bed in the morning B) walking to visit the next door neighbor C) climbing a flight of stairs to the bedroom D) leaving the table immediately after a meal
C) climbing a flight of stairs to the bedroom
which action will the nurse take to create negative pressure in the system after emptying the drainage collection chamber for a postoperative clients portable closed suction wound drainage device? A) attaching the device to a wall suction unit B) milking the tubing toward the suction device C) compressing the device while closing the air plug D) keeping the device in a position lower than the site of insertion
C) compressing the device while closing the air plug
which modifiable risk factor would the nurse include in a community presentation on cardiovascular risk factors? Select all that apply A) weight B) inactivity C) cholesterol D) tobacco use E) Homocysteine
all of the above
which factor would the nurse identify as the cause of the pain experienced by a client who is experiencing acute coronary syndrome? A) arterial aneurysm B) heart muscle ischemia C) blocking of the coronary veins D) irritation of nerve endings in the cardiac plexus
B) heart muscle ischemia --> ischemia causes tissue injury and the release of chemicals, such as bradykinin, that stimulate sensory nerves and produce pain. Arterial aneurysms are not a common cause of myocardial ischemia or infarction. Arteries, not veins, are involved in the pathology of an acute coronary syndrome. Tissue injury and pain occur in the myocardium, not the cardiac plexus
which is involved in the postprocedure nursing care of a child after left-side cardiac catheterization? A) encouraging early ambulation B) monitoring the insertion site for bleeding C) comparing blood pressures in the two extremities D) restricting fluids until the blood pressure has stabilized
B) monitoring the insertion site for bleeding
which action would the nurse take when planning room placement for a client with squamous cell carcinoma of the tongue that is to be treated with interstitially implanted radon seeds? A) assign the client to any type of room B) place the client in a private room C) assign the client to a semiprivate room D) place the client with another client recieving the same type of therapy
B) place the client in a private room
which change that occurs with aging increases the risk for hypothermia in older adults? A) increased metabolic rate B) increased shivering response C) decreased amount of body fat D) diminsihed energy reserves E) chronic medical conditions
C) decreased amount of body fat D) diminsihed energy reserves E) chronic medical conditions
Which explanation would the nurse give about the purpose of the procedure when a client with angina is scheduled to have a cardiac catheterization? A) to obtain the pressures in the heart chambers B) to determine the existence of congenital heart disease C) to visualize the disease process in the coronary arteries D) to measure the oxygen content of various heart chambers
C) to visualize the disease process in the coronary arteries
which part of the elctrocardiogram (ECG) represents depolarization of the ventricles? A) P wave B) T wave C) PR interval D) QRS interval
D) QRS interval --> atrial and ventricular depolarization and repolarization are represented on the ECG as a series of waves: the P wave followed by the QRS complex and the T wave. The QRS represents ventricular depolarization. The P wave occurs with depolarization of the atria The T wave represents ventricular repolarization. The PR interval represents depolarization of the atria and the atrioventricular node
Which behavior would the nurse expect a client to exhibit during the initial stage of grieving after learning that a tumor is malignant and has metastasized to several organs and that the illness is terminal? A) crying uncontrollably B) criticizing medical care C) refusing to receive visitors D) asking for a second opinion
D) asking for a second opinion
which assessment finding will the nurse expect when caring for a client with right ventricular heart failure? A) crackles throughout both lungs B) substernal chest pressure C) redness and swelling of calf D) bilateral lower leg edema
D) bilateral lower leg edema
Which action would the nurse take to prevent venous thrombus formation after abdominal surgery? A) keep the client in a gatch bed to elevate the knees B) have the client dangle the legs off the side of the bed C) help the client use an incentive spirometer every hour D) encourage the client to ambulate multiple times daily
D) encourage the client to ambulate multiple times daily
which clotting factor would a nurse explain is deficient to the parents of a child newly diagnosed with hemophilia A? A) factor 2 B) factor 12 C) factor 9 D) factor 8
D) factor 8 -->Hemophilia type A, the most common type of hemophilia, is from a deficiency of factor 8. Factors 2 and 12 are part of the clotting cascade, but they are not associated with hemophilia. Factor 9 is associated with hemophilia type B
which confirmitory test would the nurse anticipate for a client with a tentative diagnosis of Hodgkin disease? A) bone scan B) lymph node biopsy C) computed tomography (CT) scan D) radioactive iodine uptake study
B) lymph node biopsy
which diagnostic test will the nurse use to confirm the diagnosis when hypokalemia is suspected? A) Complete blood cell count B) serum potassium level C) X-ray film of long bones D) blood cultures x3
B) serum potassium level
which term described the inheritance pattern of hemophilia A? A) X-linked recessive trait B) Y-linked recessive trait C) X-linked dominant trait D) Y-linked dominant trait
A) X-linked recessive trait
which cause of high urinary output would a nurse suspect when a clients urinary output is 3 times the fluid intake after a cardiac catheterization? A) an expected effect of the dye with the procedure B) increased cardiac output as a result of the procedure C) improvement of urinary functioning after the catheterization D) a result of the prescribed IV rate of 50 mL/h
A) an expected effect of the dye with the procedure
which factor is the likely cause of the lab result when arterial blood gases done on a client who is being resuscitated after cardiac arrest show a low pH? A) ketoacidosis B) irregular heartbeat C) lactic acid production D) sodium bicarbonate admin
C) lactic acid production
which finding will the nurse expect when analyzing the cardiac rhythm for a client with first degree atrioventricular (AV) block? A) every P wave is conducted to the ventricles B) some P waves are conducted to the ventricles C) there are no P waves visible on the rhythm strip D) None of the P waves are conducted to the ventricles
A) every P wave is conducted to the ventricles --> In first degree AV block, a P wave precedes every QRS complex, but the PR interval is prolonged. Second degree heart block refers to AV conduction that is intermittently blocked. some P waves are conducted and some are not. When no P waves are visible, rhythms such as junctional dysrhythmias or atrial fibrillation are suspected. Third degree block is often called complete heart block because no atrial impulses are conducted through the AV node to the ventricles
how would anxiety affect outcomes for a client with heart failure? A) increases the cardiac workload B) interferes with usual respirations C) produces an elevation in temp. D) decreases the amount of oxygen used
A) increases the cardiac workload
which clinical manifestation is more likely to occur in women with cornary artery disease compared to men? A) severe fatigue B) sense of unease C) substernal chest pain D) shortness of breath E) pain radiating down the left arm
A) severe fatigue B) sense of unease D) shortness of breath
which dietary restriction will the nurse expect to be included in the plan for a client with left ventricular failure? A) sodium B) calcium C) potassium D) magnesium
A) sodium
Which object would the nurse teach the client with a newly implanted pacemaker to avoid? A) strong magnet B) microwave oven C) mobile telephone D) remote control device
A) strong magnet
which action will the nurse include when developing a plan of care for a client who had a cardiac catheterization via a femoral insertion site? A) ambulating the client 2 hours after the procedure B) checking the vital signs every 15 minutes for 8 hours C) maintaining the supine position for a minimum of 4 hours D) keeping the client NPO for 4 hours after the procedure
C) maintaining the supine position for a minimum of 4 hours
which action would the nurse perform when a client is in ventricular fibrillation? Select all that apply: A) initiating CPR B) assessing the EKG C) using a defibrillator D) obtaining electrolytes E) administering epinephrine
all of the above
which test confirms a diagnosis of multiple myeloma? A) bone marrow biopsy B) serum test for hypercalcemia C) urine test for Bence Jones protein D) X ray films of the ribs, spine and skull
A) bone marrow biopsy
which lymph nodes would the nurse expect to be affected first when a client is diagnosed with Hodgkin disease? A) cervical B) axillary C) inguinal D) mediastinal
A) cervical --> painless enlargement of the cervical lymph nodes is the first sign of Hodgkin disease, a malignant lymphoma of unknown etiology.
which parameter would the nurse assess in a client with right-sided heart failure? A) fluid volume B) lung sounds C) mental status D) respiratory rate E) peripheral pulses
A) fluid volume
which test result would the nurse use to determine whether the daily dose is therapeutic when a client with a venous thrombosis is receiving warfarin? A) international normalized ratio (INR) B) accelerated partial thromboplastin time (APTT) C) bleeding time D) sedimentation rate
A) international normalized ratio (INR)
which physiological response occurs first when a client experiences sudden hypovolemia caused by hemorrhage? A) peripheral vasoconstriction B) Elevation of serum cortisol levels C) release of immature erythrocytes D) increased antidiuretic hormone (ADH)
A) peripheral vasoconstriction --> the initial response to hemorrhage is activation of the sympathetic nervous system, leading to increases in heart rate and peripheral vasoconstriction, which shunts blood to essential core organs.
Which likely cause would a nurse suspect is responsible for a drop in blood pressure after a client sustains multiple internal injuries in a motor vehicle accident and the blood pressure suddenly drops from 134/90 to 80/60 mm Hg? A) reduction in the circulating blood volume B) diminished vasomotor stimulation to the arterial wall C) vasodilation resulting from diminished vasoconstrictor tone D) cardiac decompensation resulting from electrolyte imbalance
A) reduction in the circulating blood volume
which clinical finding is the nurse most likely to identity when completing a history and physical assessment of a client with complete heart block? A) syncope B) headache C) tachycardia D) hemiparesis
A) syncope
which physiological process causes temperature elevation after a client has had a myocardial infarction? A) tissue necrosis and inflammation B) thrombosis followed by thrombolysis C) sympathetic nervous system stimulation D) infectious process of myocardial muscle cells
A) tissue necrosis and inflammation
info about which vitamin would be included when teaching a client with atrial fibrillation about new prescription for warfin? A) vitamin K B) Vitamin D C) Vitamin B1 D) Vitamin B12
A) vitamin K
which statement indicates that the client has a correct understanding of the condition after the nurse has finished teaching a client about sickle cell anemia? A) " I have normal platelets" B) "i have abnormal hemoglobin C) "i have abnormal hematocrit" D) "i have abnormal white blood cells"
B) "i have abnormal hemoglobin -->The patient with sickle cell anemia has abnormal hemoglobin, hemoglobin S, causing the red blood cells to stiffin and elongate into a sickle. The disorder affects hemoglobin rather than platelets or white blood cells. Although it can affect hematocrit, it is really a result of abnormal hemoglobin.
which action would the nurse take when a client with chronic venous insufficiency has ankle edema? A) restrict fluids B) elevate the legs C) apply a Unna boot D) discuss sclerotherapy
B) elevate the legs
how frequently will the nurse plan to assess the blood pressure when a client is admitted to the postanesthesia care unit after surgery? A) every 3 to 5 mins B) every 10 to 15 mins C) every 20 to 30 mins D) every 40 to 60 mins
B) every 10 to 15 mins
which info would the nurse include when explaining the purpose of a thallium scan to the client who has a history of chest pain? A) it monitors action of the heart valves B) it assesses myocardial ischemia and perfusion C) it visualizes ventricular systole and diastole D) It identifies the adequacy of the conduction system
B) it assesses myocardial ischemia and perfusion
where will the nurse place the V1 lead when obtaining a 12 lead electrocardiogram? A) 5th intercostal space, left midaxillary line B) 2nd intercostal space, left sternal border C) 4th intercostal space, right sternal border D) 5th intercostal space, left midclavicular line
C) 4th intercostal space, right sternal border
which action would the nurse take when a client who just returned from a cardiac catheterization reports that the pressure bandage on the right groin is tight? A) Loosen the dressing slightly B) Notify the primary health care provider C) Assess the circulatory status of the extremity D) have the client flex the joints of the right leg
C) Assess the circulatory status of the extremity
which response would the nurse give to a client with type 1 diabetes who asks what causes several brown spots on the skin? A) "the brown spots reflect the accumulation of blood fats in the skin ; they they should disappear." B) "those spots indicate a high glucose content in the skin that may get infected if left untreated" C) "They are the result of diseased small vessels in the skins and may spread if not treated soon" D) "those brown spots result from small blood vessel damage ; the blood contains iron, which leaves a brown spot"
D) "those brown spots result from small blood vessel damage ; the blood contains iron, which leaves a brown spot"
which defense mechanism would a nurse determine is being used by a client who was recently diagnosed as having myelocytic leukemia and discusses the diagnosis by referring to stats, facts and figures. A) projection B) sublimation C) identification D) intellectualization
D) intellectualization --> intellectualization is the use of reasoning and thought processes to avoid the emotional aspects of a situation; this is a defense against anxiety. projection is denying unacceptable traits and regarding them as belonging to another person. Sublimation is a defense wherein the person redirects the energy of unacceptable impulses into socially acceptable behaviors or activities. Identification is the reduction of anxiety by imitating someone respected or feared.
which clinical manifestation would the nurse expect to find when a client is admitted with right ventricular failure? A) chest pain B) bradypnea C) bradycardia D) peripheral edema
D) peripheral edema
which physiological response explains why elevation in body temp occurs in clients who experience acute coronary syndrome? A) parasympathetic reflexes B) inflammatory response C) catecholamine release D) peripheral vasoconstriction
b) inflammatory response
Which finding in a client who has just been admitted indicates that the nurse will anticipate assisting with insertion of a temporary pacemaker? A) shortness of breath B) substernal discomfort C) Third-degree heart block D) Premature ventricular contractions
C) Third-degree heart block
which action would the nurse include in the plan of care for a client admitted with heart failure who has gained 20 pounds in 3 weeks? Select all that apply: A) diuretics B) low salt diet C) daily weight checks D) fluid restriction E) intake and output F) oxygen admin
all of the above
which assessment finding of a client with heart failure would prompt the nurse to contact the health care provider? Select all that apply A) fatigue B) orthopnea C) pitting edema D) dry hacking cough E) 4 - pound weight gain
all of the above
which info would be used to determine the cause of premature atrial contractions (PACs) observed on a clients EKG? Select all that apply A) stress level B) tobacco use C) caffeine intake D) electrolyte levels E) home meds
all of the above
which info will the nurse include when explaining to a client with atrial tachycardia how the use of the Valsalva maneuver may decrease the clients heart rate? A) the vagus nerve is stimulated B) the glottis closes momentarily C) thoracic pressure decreases D) respiratory pattern is intrerupted
A) the vagus nerve is stimulated
which treatment option will the nurse anticipate the need to teach the client about when caring for a client with symptomatic bradycardia caused by heart block? A) overdrive pacing B) demand pacemakers C) cardiac resynchronization therapy D) implantable cardioverter-defibrillators
B) demand pacemakers
which assessment finding is consistent with a client diagnosis of right-sided heart failure? A) collapsed neck veins B) distended abdomen C) dependent edema D) decreased appetite E) cool extremities
B) distended abdomen C) dependent edema D) decreased appetite
which action would the nurse take when performing external cardiac compression? A) extend the fingers over the sternum and chest with the heels of each hand side by side B) place the fingers of 1 hand on the sternum and the fingers of the other hand on top of them C) Interlock the fingers with the heel of 1 hand of the sternum and the heel of the other on top of it. D) Clench the hand into a fist and place the fleshly part of a clenched fist on the lower sternum
C) Interlock the fingers with the heel of 1 hand of the sternum and the heel of the other on top of it.
which condition unrelated to cardiac disease is the major cause of right ventricular failure? A) hypovolemic shock B) chronic kidney disease C) chronic obstructive pulmonary disease (COPD) D) systemic inflammatory response syndrome (SIRS)
C) chronic obstructive pulmonary disease (COPD)
which action by a client who requires an above the knee amputation for peripheral arterial disease best indicates emotional readiness for the surgery? A) explains the goals of the procedure B) displays few signs of anticipatory grief C) participates in learning perioperative care D) verbalizes acceptance of permanent dependancy needs
C) participates in learning perioperative care
which action will the nurse take first when a client with peripheral arterial disease returns to the nursing unit after a femoral angiogram? A) check the oral temp B) encourage the client to void C) place the head of the bed flat D) assess the clients affected leg
C) place the head of the bed flat D) assess the clients affected leg
which action would a nurse take to prevent a parallax error and to ensure accuracy when assessing a clients blood pressure? A) elevate the head of the bed B) use the appropriate cuff size C) read the manometer at eye level D) place the cuff at the level of the heart
C) read the manometer at eye level --> a parallax error is the apparent displacement of an observed object, such as the indicators on the manometer, because of the position of the observer
which info about radiation therapy would guide a nurses response to a 20 year old female client scheduled to receive pelvic radiation for Hodgkin lymphoma who expresses anxiety about her future ability to conceive a child? A) radiation used is not radical enough to destroy ovarian function B) intermittent radiation to the area does not cause permanent sterilization C) reproductive ability may be preserved through a variety of interventions D) ovarian function will be destroyed temporarily but will return in about 6 months
C) reproductive ability may be preserved through a variety of interventions
which client seen at a health fair will be most at risk for hypertension? A) 23 year old white man B) 44 year old white woman C) 50 year old mexican-american woman D) 62 year old african american woman
D) 62 year old african american woman
which suggestion will the nurse make to minimize orthostatic hypotension when teaching a client who has a new prescription for antihypertensive medication? A) wear support hose continuously B) lie down for 30 mins after taking the medication C) avoid tasks that require high-energy expenditure D) change position slowly when going from lying to standing
D) change position slowly when going from lying to standing
which action would the nurse take when calculating a clients heart rate on an electricardiogram (ECG) strip? A) count the P waves B) count the T waves C) count the PR interval D) count the QRS complexes
D) count the QRS complexes --> the heart rate is calculated by counting the QRS complexes, which represent ventricular depolarization. The P wave represents depolarization and would be used if the atrial rate was being calculated. The T wave represents ventricular repolarization. The PR interval represents depolarization of the atria and atrioventricular node.
which info is important for the nurse to consider when caring for a client after a thryroidectomy for cancer of the thyroid? A) hypercalcemia may result from parathyroid damage B) hypotension and bradycardia may result from thyroid storm C) tetany may result from underdosage of thyroid hormone replacement D) hoarseness and airway obstruction may result from laryngeal nerve damage
D) hoarseness and airway obstruction may result from laryngeal nerve damage
which instruction would the nurse include in the teaching plan when a client is at high risk for heart disease? A) avoid eating between meals B) limit unsaturated fats in the diet C) decrease the amt of fat-binding fiber D) increase the quantity of complex carbohydrates
D) increase the quantity of complex carbohydrates
which explanation would the nurse give regarding purpose of early ambulation to a client who had surgery the previous day? A) promote healing of the incision B) decrease the incidence of urinary tract infections C) allow nursing staff to change the bedding D) keep blood from pooling in the legs to prevent clots
D) keep blood from pooling in the legs to prevent clots
