PrepU Exam 4
Which of the following are complications of percutaneous transluminal balloon angioplasty (PTA)? Select all that apply. A) Embolization B) Stent migration C) Hematoma D) Dissection of the vessel E) Bleeding
ALL OF THEM
A nurse is providing care for a child with disseminated intravascular coagulation (DIC). What would alert the nurse to possible neurologic compromise? A) Hematuria B) Equal pupillary response C) Widely fluctuating blood pressure D) Petechiae
C) Widely fluctuating blood pressure
A client has undergone a liver biopsy. Which postprocedure position is appropriate? A) Trendelenburg B) High Fowler C) On the left side D) On the right side
D)
Which blood vessels function without the benefit of having walls comprised of three muscular layers? A) Veins B) Arteries C) Arterioles D) Capillaries
D)
Which condition is an early manifestation of HIV encephalopathy? A) Vacant stare B) Hyperreflexia C) Hallucinations D) Headache
D)
A young woman diagnosed with prostacyclin deficiency is admitted to the hospital with recurrent deep vein thrombosis and an ovarian infarction asks the nurse why she keeps having these problems. Understanding the role of prostacyclin in hemostasis, the nurse explains that prostacyclin enables: A) blood vessel vasodilation and inhibition of platelet aggregation. B) platelet aggregation and adhesion. C) blood vessel vasoconstriction and platelet adhesion. D) blood vessel vasodilation and enhancement of platelet adhesion.
A) blood vessel vasodilation and inhibition of platelet aggregation.
A client tells the nurse "my heart is skipping beats again; I'm having palpitations." After completing a physical assessment, the nurse concludes the client is experiencing occasional premature atrial complexes (PACs). The nurse should instruct the client to A) avoid caffeinated beverages. B) lie down and elevate the feet. C) apply supplemental oxygen. D) request sublingual nitroglycerin.
A)
The anemic client is receiving erythropoietin. If there is a marked increase in red blood cell production, which lab result would increase? A) Reticulocytes B) Lymphocytes C) Platelets D) Neutrophils
A)
The nurse is caring for clients on the neurological unit. Which triad of neurological mechanisms does the nurse identify as most responsible when there is abnormality in ventilation control? A) Aortic arch, pons, and CO2 receptor sites B) Pons, cerebellum, and oxygen receptors C) Medulla oblongata, mitral valve, and central receptors D) Medulla oblongata, cerebellum, and heart rate
A)
Which of the following is the most common complication associated with peptic ulcer? A) Hemorrhage B) Elevated temperature C) Abdominal pain D) Vomiting
A)
A woman who has given birth 12 hours ago is displaying signs and symptoms of disseminated intravascular coagulation (DIC). The client's husband is confused as to why a disease of excessive coagulation can result in bleeding. Which of the nurse's explanations best characterizes DIC? A) "So much clotting takes place that there are no available clotting components left and bleeding ensues." B) "Excessive activation of clotting causes an overload of vital organs, resulting in bleeding." C) "Massive clotting causes irritation, friction, and bleeding in the small blood vessels." D) "These same hormones and bacteria that cause clotting also cause bleeding."
A) "So much clotting takes place that there are no available clotting components left and bleeding ensues."
A patient had a carotid endarterectomy yesterday and when the nurse arrived in the room to perform an assessment, the patient states, "All of a sudden, I am having trouble moving my right side." What concern should the nurse have about this complaint? A) A thrombus formation at the site of the endarterectomy B) This is a normal occurrence after an endarterectomy and would not be a concern. C) Surgical wound infection D) Bleeding from the endarterectomy site
A) A thrombus formation at the site of the endarterectomy
A client suffering a thrombotic stroke is brought into the emergency department by ambulance and the health care team is preparing to administer a synthetic tissue plasminogen activator for which purpose? A) Thrombolysis B) Hemostasis C) Thrombogenesis D) Hemolysis
A) Thrombolysis
A nurse finds the uterus of a postpartum woman to be boggy and somewhat relaxed. This a sign of which condition? A) atony B) hemorrhage C) normal involution D) infection
A) atony
Proper function of the cardiovascular system relies on blood following the correct pathway through the heart. Valves within the heart separate the organ's chambers and prevent blood from flowing in the wrong direction. What valve separates the left atrium and left ventricle? A) Aortic B) Pulmonic C) Mitral D) Tricuspid
C)
The nurse is caring for an infant with a congenital heart defect. What priority health teaching should the nurse offer to the parents of this infant? A) There are no restrictions on play. B) Your child will need oxygen at home. C) It is dangerous to let your child cry. D) Keep feedings small, but frequent.
D)
What complication is the nurse aware of that is associated with deep venous thrombosis? A) Marked tenderness over the anteromedial surface of the thigh B) Immobility because of calf pain C) Swelling of the entire leg owing to edema D) Pulmonary embolism
D)
A grandmother who works as a cook at a nearby school was recently hospitalized when she lost an extensive amount of blood in a work-related accident. The grandmother tells the nurse that she heard that she would keep feeling faint until the brain made more blood. The nurse knows that when the blood pressure dropped, the pressure in the carotid arteries decreased. This was detected by baroreceptors in the carotid arteries. What did the baroreceptors do? A) Increase sympathetic stimulation of the heart and blood vessels B) Inhibit renin release from the kidneys to promote fluid retention C) Increase parasympathetic stimulation of the heart and blood vessels D) Stimulate the brain to form new red blood cells
A)
During an assessment of a client with ankle swelling, the nurse observes jugular venous pulsations 5 cm above the sternal angle when the head of his bed is elevated 45 degrees. What is the correct interpretation of this finding? A) The client has increased pressure related to right-sided heart failure. B) The client has an increased cardiac output. C) The client has decreased fluid volume. D) The client has stenosis of the jugular veins.
A)
Nitroglycerin is the drug of choice in treating angina. What does nitroglycerin release into the vascular smooth muscle of the target tissues? A) Nitric oxide B) Calcium channel blocker C) Platelet-aggregating factor D) Antithrombin factor
A)
Which symptom is an early warning sign of acute coronary syndrome (ACS) and heart failure (HF)? A) fatigue B) weight gain C) hypotension D) change in level of consciousness
A)
Which statement is true regarding hormonal contraception? A) It increases risk for venous thromboembolism. B) It increases risk for benign breast cancer. C) It increases risk for uterine cancer. D) Fetal anomalies are a concern.
A) It increases risk for venous thromboembolism.
A nurse is caring for a client with sepsis who was recently transferred to the intensive care unit following the development of disseminated intravascular coagulation (DIC). The nurse understands that DIC is most likely secondary to the infection causing the release of cytokines, which can cause: A) Petechiae, purpura, and renal failure B) Severe soft-tissue hemorrhages C) Amenorrhea and black, tarry stools D) Oozing from puncture sites and hypertension
A) Petechiae, purpura, and renal failure
The nurse is assessing a child and notices pinpoint hemorrhages appearing on several different areas of the body. The hemorrhages do not blanch on pressure. The nurse documents this finding as: A) petechiae. B) purpura. C) ecchymosis. D) poikilocytosis.
A) petechiae.
The nurse recognizes the value of leg exercises in the prevention of postoperative thrombophlebitis. When should the nurse teach the correct technique for leg exercises to a client? A) prior to surgery B) when early signs of venous stasis are evident C) upon transfer from the postanesthesia care unit (PACU) to the postoperative unit D) in postanesthesia recovery
A) prior to surgery
A 31-year-old woman with a congenital heart defect reports episodes of lightheadedness and syncope, with occasional palpitations. A resting ECG reveals sinus bradycardia, and she is suspected to have sick sinus syndrome. Which diagnostic method is the best choice to investigate the suspicion? A) Electrophysiologic study B) Holter monitoring C) Exercise stress testing D) Signal-averaged ECG
B)
A client is scheduled for elective surgery. To prevent the complications of hypotension and cardiovascular collapse, the nurse should report the use of which medication? A) Hydrochlorothiazide B) Prednisone C) Erythromycin D) Warfarin
B)
Pentoxifylline (Trental) is a medication used for which of the following conditions? A) Elevated triglycerides B) Claudication C) Hypertension D) Thromboemboli
B)
The nurse reviews the lab results of a client who has a thrombocyte count of 60 ×103/µL (60 ×109/L). The client is at risk for: A) Hypercoagulation B) Bleeding C) Disseminated intravascular coagulation D) Deep vein thrombosis
B) Bleeding
A 30-year-old pregnant woman has been prescribed administration of oxytocin. When assessing the patient's drug regimen, the nurse understands that the patient is taking vasopressors. Which risk is the patient most susceptible to if oxytocin is administered along with vasopressors? A) Anaphylactic shock B) Respiratory failure C) Hypertension D) Heart attack
C)
A 75-year-old client with a history of heart valve replacement arrives at the outpatient clinic with multiple red pinpoint lesions. The nurse identifies the lesions as: A) Purpura B) Ecchymoses C) Petechiae D) Erythema
C)
Which zone consists of the area where the injury is most severe and deepest? A) Stasis B) Hyperemia C) Coagulation D) Necrosis
C) Coagulation
A postpartum woman is developing thrombophlebitis in her right leg. Which assessment should the nurse no longer use to assess for thrombophlebitis? A) Ask if she has pain or tenderness in the lower extremities. B) Ask about increased pain with weight bearing. C) Dorsiflex her right foot and ask if she has pain in her calf. D) Assess for redness and warmth.
C) Dorsiflex her right foot and ask if she has pain in her calf.
A client has been diagnosed with inherited hypercoagulability. Select the most likely cause. A) Myocardial infarction B) Prolonged immobility C) Factor V gene mutation D) Hyperestrogenic state
C) Factor V gene mutation
The nurse is assessing a patient who reports no symptoms of heart failure at rest but is symptomatic with increased physical activity. Under what classification does the nurse understand this patient would be categorized? A) I B) IV C) III D) II
D)
A client is readmitted to the facility with a warm, tender, reddened area on the right calf. Which contributing factor should the nurse recognize as most important? A) a history of diabetes mellitus B) an active daily walking program C) history of increased aspirin use D) recent pelvic surgery
D) recent pelvic surgery
Which factor puts a client on her first postpartum day at risk for hemorrhage? A) hemoglobin level of 12 g/dl B) moderate amount of lochia rubra C) thrombophlebitis D) uterine atony
D) uterine atony
The nurse is assessing a client with chronic bronchitis. For which finding should the nurse suspect that the client is developing right-sided heart failure? A) bilateral edema of the feet and ankles B) dyspnea on exertion C) bilateral crackles that clear with coughing D) clubbing of the fingernails on both hands
A)
The nurse is caring for a client diagnosed with aortic stenosis prescribed digoxin. What clinical manifestation will be the rationale for the medication? A) left ventricular dysfunction B) edema C) dyspnea D) angina
A)
The nurse is caring for a client with a history of heart failure and a sudden onset of tachypnea. What is the nurse's priority action? A) Elevate the head of the bed. B) Notify the family of a change in condition. C) Assess pulse oximetry reading. D) Report a decrease in urine output.
A)
The nurse is monitoring a client postoperatively after a permanent pacemaker insertion. Which finding would be most concerning to the nurse? A) heart rate of 48 beats/minute B) urine output of 30 mL over 1 hour C) reports of left chest soreness D) blood pressure of 160/91 mm Hg
A)
When describing the covering on bones to the students, the instructor asks, "Why is periosteum an important part of the bone covering?" The student responses should mention which of the following? It: A) contains blood vessels that assist with providing nutrition to bone tissue. B) is composed of a single layer of osteoprogenitor cells. C) is the site of red blood cell development. D) supplies yellow bone marrow to assist with adipose cell production.
A)
Which assessment finding of a newly admitted 30-year-old male client would be most likely to cause his physician to suspect polyarteritis nodosa? A) The man's blood pressure is 178/102 and he has abnormal liver function tests. B) The man is acutely short of breath and his oxygen saturation is 87%. C) The man's blood work indicates polycythemia (elevated red cells levels) and leukocytosis (elevated white cells). D) The man's temperature is 101.9°F (38.8°C) and he is diaphoretic (heavily sweating).
A)
Which statement about temperature regulation and skin is accurate? A) Arteriovenous anastomoses between an artery and a vein within the skin layer are important for temperature regulation. B) It is primarily the arteries that bring blood from the heart that keeps the body temperature within a normal range. C) Since the skin is avascular, it is the subcutaneous layer that primarily is responsible for temperature control. D) The lymphatic system of the skin is primarily responsible for heating and cooling the skin.
A)
Which symptom occurs in the client diagnosed with mitral regurgitation when pulmonary congestion occurs? A) Shortness of breath B) Tachycardia C) A loud, blowing murmur D) Hypertension
A)
A client is prescribed warfarin. Client teaching has included instructions to maintain a diet rich in foods that contain vitamin K. What sources of food should the nurse instruct the client to eat? A) Cereals, soybeans, and spinach B) Citrus fruits C) Milk and dairy products D) Fish, meats, and vegetable oils
A) Cereals, soybeans, and spinach
A nurse evaluates a client with a temporary pacemaker. The client's ECG tracing shows each P wave followed by the pacing spike. What is the nurse's best response? A) Obtain a 12-lead ECG and a portable chest x-ray B) Document the findings and continue to monitor the client C) Check the security of all connections and increase the milliamperage D) Reposition the extremity and turn the client to left side
B)
A nurse is assessing a female client and notes that her left arm is swollen from the shoulder down to the fingers, with non-pitting edema. The right arm is normal. The client had a left-sided mastectomy 1 year ago. What does the nurse suspect is the problem? A) Arteriosclerosis B) Lymphedema C) Deep vein thrombosis D) Venous stasis
B)
A patient has a diminished flow of deoxygenated blood from the lower extremities. Which chamber of the heart receives deoxygenated blood from the lower extremities? A) Right ventricle B) Right atrium C) Left atrium D) Left ventricle
B)
Many different proteins, enzymes, and hormones are involved in maintaining hemostasis. Which protein is required for platelet adhesion? A) Platelet factor 4 B) von Willebrand factor C) Growth factors D) Ionized calcium
B)
On a holiday trip home, the nurse's mother states that the nurse's father was diagnosed with right-sided heart failure. Which manifestation exhibited by the father does the nurse know might have preceded this diagnosis? A) Vertigo, headache B) Peripheral edema, weight gain C) Dyspnea, cough D) Weakness, palpitations
B)
Severe chest pain is reported by a client during an acute myocardial infarction. Which of the following is the most appropriate drug for the nurse to administer? A) Meperidine hydrochloride (Demerol) B) Morphine sulfate (Morphine) C) Isosorbide mononitrate (Isordil) D) Nitroglycerin transdermal patch
B)
The most important intervention in the nutritional support of a client with a burn injury is to provide adequate nutrition and calories. The nurse recognizes this intervention is to promote A) increased glucose demands. B) decreased catabolism. C) increased metabolic rate. D) increased skeletal muscle breakdown.
B)
While studying the physiology of the heart, the nursing students have learned that which of the following influence the blood flow in the coronary vessels that supply the myocardium? Select all that apply. A) Hypothalamus B) Autoregulatory mechanisms C) Thyroid gland D) Compression of the intramyocardial vessels E) The aortic pressure
B) D) E)
A client's family member asks the nurse why disseminated intravascular coagulation (DIC) occurs. Which statement by the nurse correctly explains the cause of DIC? A) "DIC is caused when hemolytic processes destroy erythrocytes." B) "DIC is caused by abnormal activation of the clotting pathway, causing excessive amounts of tiny clots to form inside organs." C) "DIC is a complication of an autoimmune disease that attacks the body's own cells." D) "DIC occurs when the immune system attacks platelets and causes massive bleeding."
B) "DIC is caused by abnormal activation of the clotting pathway, causing excessive amounts of tiny clots to form inside organs."
A client asks the nurse why her hip fracture (head of the femur) bone has died (osteonecrosis). The nurse responds based on which pathophysiologic principle? A) When the femur head breaks, it dislocates and crushes the surrounding area causing the blood vessels to be occluded. B) Most of the time when the head of the femur breaks, the entire neck region is disconnected to the rest of the bone, so the blood vessels are severed. C) Since the head of the femur has only limited collateral circulation, interruption in the blood flow from the fracture causes necrosis and irreversible damage. D) All fractured bones interrupt blood supply and thereby result in death of bone no matter where it is located.
C)
A client with cirrhosis has portal hypertension, which is causing esophageal varices. What is the goal of the interventions that the nurse will provide? A) Promote optimal neurologic function. B) Cure the cirrhosis. C) Reduce fluid accumulation and venous pressure. D) Treat the esophageal varices.
C)
A client with thrombotic thrombocytopenic purpura (TTP) is signing consent for plasmapheresis. The client asks, "What is this procedure and why do I need it?" Which response by the health care provider is most accurate? A) "It is very similar to donating a unit of blood at the Red Cross." B) "Instead of giving you packed red blood cells, the health care provider will infuse white blood cells into your veins." C) "The laboratory will remove plasma from the withdrawn blood and replace it with fresh-frozen plasma." D) "The health care provider will perform a bone marrow aspiration to withdraw plasma to analyze."
C)
A patient who had a colon resection 3 days ago is complaining of discomfort in the left calf. How should the nurse assess Homan's sign to determine if the patient may have a thrombus formation in the leg? A) Elevate the patient's legs for 20 minutes and then lower them slowly while checking for areas of inadequate blood return. B) Lower the patient's legs and massage the calf muscles to note any areas of tenderness. C) Dorsiflex the foot while the leg is elevated to check for calf pain. D) Extend the leg, plantar flex the foot, and check for the patency of the dorsalis pedis pulse.
C)
Providing postoperative care to a patient who has percutaneous transluminal angioplasty (PTA), with insertion of a stent, for a femoral artery lesion, includes assessment for the most serious complication of: A) Stent dislodgement. B) Thrombosis of the graft. C) Hemorrhage. D) Decreased motor function.
C)
Tetralogy of Fallot is a congenital condition of the heart that manifests in four distinct anomalies of the infant heart. It is considered a cyanotic heart defect because of the right-to-left shunting of the blood through the ventricular septal defect. A hallmark of this condition is the "tet spells" that occur in these children. What is a tet spell? A) A stressful period right after birth that occurs without evidence of cyanosis B) A hyperpneic attack in which the infant loses consciousness C) A hypercyanotic attack brought on by periods of stress D) A hyperoxygenated period when the infant is at rest
C)
The nurse is developing a plan of care for a client with heart failure. The most important information for the nurse to consider would be: A) Increased ejection fraction B) Increased renal blood flow C) Decreased cardiac output D) Decreased retention of sodium
C)
The nurse practitioner is examining a 55-year-old female client. Which of the following findings would be uncommon for this age group? A) Agility gradually decreases B) Presbyopia occurs C) Lower extremity pulses are weak D) Menopause occurs
C)
To evaluate a client's atrial depolarization, the nurse observes which part of the electrocardiogram waveform? A) T wave B) QRS complex C) P wave D) PR interval
C)
When an acute MI occurs, many physiologic changes occur very rapidly. What causes the loss of contractile function of the heart within seconds of the onset of an MI? A) Overproduction of energy capable of sustaining normal myocardial function B) Conversion from anaerobic to aerobic metabolism C) Conversion from aerobic to anaerobic metabolism D) Inadequate production of glycogen with mitochondrial shrinkage
C)
Which factor represents the amount of blood that the heart must pump with each beat and is determined by the stretch of the cardiac muscle fibers and the actions of the heart prior to cardiac contraction? A) Heart rate B) Afterload C) Preload D) Cardiac contractility
C)
A client is seen in the emergency department complaining of chest discomfort, productive cough, and a fever of over 101°F (38.3°C) for 3 days. The nurse performs an electrocardiogram and observes a rate of 110 beats per minute (bpm) with a normal P wave and a PR interval of 0.12 second preceding each QRS complex. What does the nurse determine the rhythm to be? A) Atrial flutter B) Third-degree heart block C) Sick sinus syndrome D) Sinus tachycardia
D)
A client is undergoing diagnostics due to a significant drop in renal output. The physician has scheduled an angiography. This test will reveal details about: A) urine production. B) kidney structure. C) kidney function. D) renal circulation.
D)
A client reporting bone pain has sought care. Diagnostic testing reveals that the client has developed osteonecrosis. When addressing the most likely cause of this complication, the nurse should focus on: A) the client's red cell, hemoglobin, and hematocrit levels. B) any weight bearing that the client has performed in recent days. C) the client's recent use of nonsteroidal anti-inflammatory drugs (NSAIDs). D) the quality and quantity of blood flow to the site.
D)
The client explains to her new provider that she receives periodic phlebotomies to decrease her red blood cell mass. The provider believes the client may have: A) Megaloblastic anemia B) Sickle cell disease C) Beta-thalassemia D) Polycythemia vera
D)
The nurse is teaching leg exercises to the client preoperatively. The client asks why the exercises are important. The best response by the nurse is: A) "Clients are often on bed rest following surgery, and the exercises can help prevent pressure ulcers." B) "Leg exercises help prevent pneumonia while you are on bed rest." C) "Your intestinal tract slows down following surgery, and the exercises will help restore normal intestinal activity." D) "Leg exercises help prevent blood clots in your legs."
D)
The nurse is teaching new nursing assistants on the unit about the phenomenon of muscle hypertrophy. Which client on the unit is most likely to experience muscle hypertrophy? A client with: A) urinary incontinence following a cerebrovascular accident (CVA). B) peripheral edema secondary to heart failure (HF). C) possible rejection symptoms following a liver transplant. D) hypertension, obesity, and decreased activity tolerance.
D)
When teaching a client with peripheral vascular disease about foot care, a nurse should include which instruction? A) Avoid using a nail clipper to cut toenails. B) Avoid wearing cotton socks. C) Avoid using cornstarch on the feet. D) Avoid wearing canvas shoes.
D)
With a severe degree of peripheral arterial insufficiency, leg pain during rest can be reduced by: A) Placing the limb in a plane horizontal to the body. B) Elevating the limb over the heart level. C) Massaging the limb after application of cold compresses. D) Lowering the limb so that it is dependent.
D)
After assessment, the nurse asks how long the client has had red, pinpoint hemorrhages on the lower legs. The client responds, "This is the first time I have noticed this. What is wrong with me that is causing these small hemorrhages?" Which response by the nurse is most accurate? A) "These hemorrhages are called petechiae and occur when platelets are deficit." B) "More than likely, you bumped something and these are a result of trauma to the vessel." C) "You might have a pooling of all your platelets in the spleen. I will assess for that next." D) "Your platelets are developing a deformity as they are being produced by the bone marrow."
A) "These hemorrhages are called petechiae and occur when platelets are deficit."
With a severe degree of peripheral arterial insufficiency, leg pain during rest can be reduced by: A) Massaging the limb after application of cold compresses. B) Placing the limb in a plane horizontal to the body. C) Lowering the limb so that it is dependent. D) Elevating the limb over the heart level.
C)
A nurse is preparing to administer phytonadione to a newborn. After confirming the order, what will the nurse do next? A) Assess the newborn for bleeding. B) Determine the newborn's weight. C) Identify the newborn. D) Administer the medication.
C) Identify the newborn.
A nurse knows that, for a patient with an ischemic stroke, tPA is contraindicated if the blood pressure reading is: A) 175 mm Hg/100 mm Hg B) 185 mm Hg/110 mm Hg C) 170 mm Hg/105 mm Hg D) 190 mm Hg/120 mm Hg
D) 190 mm Hg/120 mm Hg
A client is taking androgens and warfarin. What effect will these two medications have on the client's coagulation? A) Coagulation will not be affected. B) The RBC will be decreased. C) Coagulation will be increased. D) Coagulation will be decreased.
D) Coagulation will be decreased.
A nurse is caring for a client receiving heparin therapy who has developed heparin-induced thrombocytopenia. Which nursing intervention does the nurse anticipate? A) Monitoring the client's blood pressure every 2 hours B) Switching the client to warfarin therapy C) Administration of platelets D) Discontinuation of heparin therapy
D) Discontinuation of heparin therapy
Hematoma and seroma formation are complications of breast surgery. Which of the following is the indicator that should be reported to the surgeon? A) Tightness of the skin B) Pain at the site C) Bruising of the skin D) Gross swelling
D) Gross swelling
A client diagnosed with a stroke is ordered to receive warfarin. Later, the nurse learns that the warfarin is contraindicated and the order is canceled. The nurse knows that the best alternative medication to give is A) dipyridamole. B) clopidogrel. C) ticlopidine. D) aspirin.
D) aspirin.
A postpartum client develops uncontrolled postpartum bleeding, oozing from IV sites, a blood pressure of 82/40, and respiratory distress. Which complication does the nurse suspect is occurring? A) Disseminated intravascular coagulation (DIC) B) Septic shock C) Thrombocytopathia D) Immune thrombocytopenic purpura
A) Disseminated intravascular coagulation (DIC)
A client who is being discharged after a hospitalization for thrombophlebitis will be riding home in a car. During the 2-hour care ride, what should the nurse should advise the client to do? A) Do ankle pumps. B) Elevate the legs. C) Perform arm circles. D) Take an ambulance.
A) Do ankle pumps.
Football fans at a college have been shocked to learn of the sudden death of a star player, an event that was attributed in the media to "an enlarged heart." Which disorder was the player's most likely cause of death? A) Dilated cardiomyopathy (DCM) B) Hypertrophic cardiomyopathy (HCM) C) Arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D) D) Takotsubo cardiomyopathy
B)
A nurse is caring for a client with thrombocytopenia. What is the best way to protect this client? A) Limit visits by family members. B) Encourage the client to use a wheelchair. C) Use the smallest needle possible for injections. D) Maintain accurate fluid intake and output records.
C) Use the smallest needle possible for injections.
A client is seen in the emergency room reporting sharp chest pain that started abruptly. He says it has radiated to his neck and abdomen. He also states that it is worse when he takes a deep breath or swallows. He tells the nurse that when he sits up and leans forward the pain is better. Upon examination the nurse notes a pericardial friction rub and some EKG changes. Which disease should the nurse suspect this client to have? A) Myocardial infarction B) Abdominal aortic aneurysm C) Pneumonia D) Pericarditis
D)
The nurse knows that the main objective of the management of hypertension is to achieve a sustainable level of blood pressure below: A) 100/60 B) 100/90 C) 140/60 D) 140/90
D)
The older adult client with a history of congestive heart failure is upset following the death of her husband yesterday. The practitioner observes the client for which of the following? A) Renal failure B) Anemia C) Cerebrovascular accident D) Dysrhythmias
D)
When assessing pallor, the nurse understands that it is best observed on which of the following areas? A) Ear lobes B) Nail beds C) Bony prominences D) Conjunctivae
D)
A nurse is caring for a client who has just given birth. What is the best method for the nurse to assess this client for postpartum hemorrhage? A) by assessing skin turgor B) by monitoring hCG titers C) by assessing blood pressure D) by frequently assessing uterine involution
D) by frequently assessing uterine involution
A patient who had a colon resection 3 days ago is complaining of discomfort in the left calf. How should the nurse assess Homan's sign to determine if the patient may have a thrombus formation in the leg? A) Dorsiflex the foot while the leg is elevated to check for calf pain. B) Lower the patient's legs and massage the calf muscles to note any areas of tenderness. C) Elevate the patient's legs for 20 minutes and then lower them slowly while checking for areas of inadequate blood return. D) Extend the leg, plantar flex the foot, and check for the patency of the dorsalis pedis pulse.
A) Dorsiflex the foot while the leg is elevated to check for calf pain
A client diagnosed with CKD has begun to experience periods of epistaxis and has developed bruising of the skin and subcutaneous tissues. The nurse recognizes these manifestations as: A) Impaired platelet function B) Increased platelet production C) Increased erythropoietin D) Decreased erythropoietin
A) Impaired platelet function
A client with suspected lung cancer is scheduled for thoracentesis as part of the diagnostic workup. The nurse reviews the client's history for conditions that might contraindicate this procedure. Which condition is a contraindication for thoracentesis? A) bleeding disorder B) chronic obstructive pulmonary disease (COPD) C) seizure disorder D) anemia
A) bleeding disorder
A nurse is reviewing a journal article about a nonsteroidal anti-inflammatory drug (NSAID) that is associated with an increased risk of cardiovascular thrombosis, myocardial infarction, and stroke. The nurse is most likely reading about which drug? A) celecoxib B) oxaprozin C) ketorolac D) sulindac
A) celecoxib
The cardiac cycle describes the pumping action of the heart. Which statement is correct about systole? A) Atria relax and blood fills the heart. B) Ventricles contract and blood is ejected from the heart. C) Atria contract and blood is ejected from the heart. D) Ventricles relax and blood fills the heart.
B)
The nurse is instructing the client with polycythemia vera how to perform isometric exercises such as contracting and relaxing the quadriceps and gluteal muscle during periods of inactivity. What does the nurse understand is the rationale for this type of exercise? A) Isometric exercise decreases the workload of the heart and restores oxygenated blood flow. B) Contraction of skeletal muscle compresses the walls of veins and increases the circulation of venous blood as it returns to the heart. C) This type of exercise increases arterial circulation as it returns to the heart. D) Isometric exercise programs are inclusive of all muscle groups and have an aerobic effect to increase the heart rate.
B)
Which liver function study is used to show the size of the liver and hepatic blood flow and obstruction? A) Angiography B) Radioisotope liver scan C) Electroencephalography D) Magnetic resonance imaging
B)
Which nursing action would help prevent deep vein thrombosis in a client who has had an orthopedic surgery? A) Instruct about using client-controlled analgesia, if prescribed B) Apply antiembolism stockings C) Instruct about exercise, as prescribed D) Apply cold packs
B) Apply antiembolism stockings
Individuals with hemophilia B have a deficiency in factor IX, which can cause excessive blood loss. What is another name for this clotting factor? A) Antihemophilic factor B) Christmas factor C) Proconvertin D) Stuart factor
B) Christmas factor
A nurse is teaching a client about deep venous thrombosis (DVT) prevention. What teaching would the nurse include about DVT prevention? A) Take off the pneumatic compression devices for sleeping. B) Report early calf pain. C) Dangle at the bedside. D) Rely on the IV fluids for hydration.
B) Report early calf pain.
A nurse is monitoring the vital signs and blood results of a client who is receiving anticoagulation therapy. What does nurse identify as a major indication of concern? A) blood pressure of 129/72 mm Hg B) hematocrit of 30% C) heart rate of 87 bpm D) hemoglobin of 16 g/dL
B) hematocrit of 30%
A client asks why he has not had major heart damage since his cardiac catheterization revealed he has 98% blockage of the right coronary artery. The nurse's best response is: A) "With this amount of blockage, your red blood cells get through the vessel one by one and supply oxygen to the muscle." B) "You must have been taking a blood thinner for a long time." C) "You have small channels between some of your arteries, so you can get blood from a patent artery to one severely blocked." D) "You are just a lucky person since most people would have had a massive heart attack by now."
C)
A client comes to the emergency room with all the symptoms of a myocardial infarction. Which lab value, known to have a high specificity for myocardial tissue considered the primary biomarker test for diagnosing an MI, does the nurse suspect the physician will order? A) Potassium B) Creatine kinase C) Troponin assays D) Phosphorous
C)
A client is prescribed digitalis medication. Which condition should the nurse closely monitor when caring for the client? A) Vasculitis B) Enlargement of joints C) nausea and vomiting D) Flexion contractures
C)
A client with newly diagnosed hypertension asks what to do to decrease the risk for related cardiovascular problems. Which risk factor is not modifiable by the client? A) Obesity B) Dyslipidemia C) Age D) Inactivity
C)
A nurse is caring for a client with acute pulmonary edema. To immediately promote oxygenation and relieve dyspnea, what action should the nurse perform? A) have the client take deep breaths and cough B) perform chest physiotherapy C) place the client in high Fowler's position D) administer oxygen
C)
A client is told that she has cardiac valve leaflets, or cusps, that are floppy and fail to shut completely, permitting blood flow even when the valve should be completely closed. The nurse knows that this condition can lead to heart failure and is referred to as: A) Infective endocarditis B) Pericardial effusion C) Valvular stenosis D) Valvular regurgitation
D)
A woman who gave birth to a healthy baby 6 hours ago is having cramps in her legs. Upon further assessment, the nurse identifies leg pain on dorsiflexion. What action should the nurse take? A) Instruct the woman on how to do ankle pumps. B) Tell the woman to massage the area. C) Apply warm compresses to the area. D) Notify the health care provider (HCP).
D)
The nurse assesses a patient with a heart rate of 42 and a blood pressure of 70/46. What type of hypoxia does the nurse determine this patient is displaying? A) Hypoxic hypoxia B) Histotoxic hypoxia C) Anemic hypoxia D) Circulatory hypoxia
D)
The nurse is caring for a client who is being discharged after insertion of a permanent pacemaker. The client, an avid tennis player, is scheduled to play in a tournament in 1 week. What is the best advice the nurse can give related to this activity? A) "You may resume all normal activity in 1 week; if you are used to playing tennis, you may proceed with this activity." B) "Cancel your tennis tournament and wait until fall, then try hockey; skating is much easier on pacemakers." C) "You should avoid tennis; basketball or football would be a good substitute." D) "You will need to cancel this activity; you must restrict arm movement above your head for 2 weeks."
D)
Which nursing intervention should be incorporated into the plan of care to manage the delayed clotting process in a client with leukemia? A) Eliminate direct contact with others who are infectious. B) Apply prolonged pressure to needle sites or other sources of external bleeding. C) Implement neutropenic precautions. D) Monitor temperature at least once per shift.
B) Apply prolonged pressure to needle sites or other sources of external bleeding.
The hospitalized client is experiencing gastrointestinal bleeding with a platelets at 9,000/mm³. The client is receiving prednisone and azathioprine. What action will the nurse take? A) Use contact precautions with this client. B) Teach the client to vigorously floss the teeth to prevent infections. C) Request a prescription of diphenoxylate and atropine for loose stools. D) Perform a neurologic assessment with vital signs.
D) Perform a neurologic assessment with vital signs.
A client who had a knee replacement asks the nurse, "Why do I need this little bulb coming out of my knee?" What is the appropriate nursing response? A) "The drain allows removal of blood and drainage from the surgical wound, which enables healing and protects the skin around the wound." B) "This drain is called a Jackson-Pratt or bulb drain and is compressed and closed shut to create a gentle suction." C) "The drain works by suctioning out blood and drainage from the wound and will be removed when there is minimal or no drainage." D) "The drain has measurement marks on it so that nurses can measure the amount of drainage and report it the health care provider."
A) "The drain allows removal of blood and drainage from the surgical wound, which enables healing and protects the skin around the wound."
Which nursing action should the PACU nurse take to prevent postoperative complications in clients? A) Encourage the client to breathe shallowly to prevent collapse of the alveoli. B) Assist the client to do leg exercises to increase venous return. C) Avoid turning the client in bed until the incision is no longer painful. D) Instruct the client to avoid coughing to prevent injury to the incision.
B) Assist the client to do leg exercises to increase venous return.
A client reports pain in the right heel and is requesting medication. The nurse assesses the client and administers an analgesic. The client experiences no pain relief and states that the heel pain is worse. What is an appropriate intervention by the nurse? A) Repeat the dose of analgesic every hour. B) Call the physician to report the finding. C) Massage the client's foot in a circular motion. D) Apply warm, moist heat to the right ankle area.
B) Call the physician to report the finding.
A toddler who is beginning to walk has fallen and hit his head on the corner of a low table. The caregiver has been unable to stop the bleeding and brings the child to the pediatric clinic. The nurse is gathering data during the admission process and notes several bruises and swollen joints. A diagnosis of hemophilia is confirmed. This child most likely has a deficiency of which blood factor? A) Factor V B) Factor VIII C) Factor XIII D) Factor X
B) Factor VIII
A patient has been diagnosed with thrombocytopenia. What are the primary nursing interventions while instituting corticosteroid therapy in this patient? A) Palpate the lymph nodes and tonsils every shift. B) Gradually taper the dose and frequency of medication. C) Eliminate aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs). D) Examine the extremities for redness.
B) Gradually taper the dose and frequency of medication.
A postoperative client is receiving heparin after developing thrombophlebitis. The nurse monitors the client carefully for bleeding and other adverse effects of heparin. If the client starts to exhibit signs of excessive bleeding, the nurse should expect to administer an antidote that is specific to heparin. Which agent fits this description? A) Thrombin B) Protamine sulfate C) Phytonadione (vitamin K) D) Plasma protein fraction
B) Protamine sulfate
What complication is the nurse aware of that is associated with deep venous thrombosis? A) Swelling of the entire leg owing to edema B) Pulmonary embolism C) Marked tenderness over the anteromedial surface of the thigh D) Immobility because of calf pain
B) Pulmonary embolism
A nurse is treating a client with aplastic anemia. Due to the replacement of normal bone marrow with malignant cells, the nurse teaches the client to prevent scratches, scrapes, and cuts. What root cause likely underlies the client's increased risk for hemorrhage? A) Polycythemia B) Thrombocytopenia C) Disseminated intravascular coagulation (DIC) D) Neutrophilia
B) Thrombocytopenia
A client with an apparent clotting disorder is admitted to hospital. His health record reveals that he has been treated for complications of chronic alcoholism for the past 10 years. The nurse should suspect what cause of his clotting disorder? A) Von Willebrand disease B) Vitamin K deficiency C) Immune thrombocytopenic purpura (ITP) D) Hemophilia
B) Vitamin K deficiency
A client with refractory angina pectoris is scheduled for a percutaneous transluminal coronary angioplasty (PTCA). The cardiologist orders an infusion of abciximab. Before beginning the infusion, the nurse should ensure the client has A) ampule of naloxone at the bedside. B) up-to-date partial thromboplastin time (PTT) result in his record. C) continuous electrocardiogram (ECG) monitoring. D) negative history of tonic-clonic seizures.
B) up-to-date partial thromboplastin time (PTT) result in his record.
A client with venous insufficiency asks the nurse what they can do to decrease their risk of complications. What advice should the nurse provide to clients with venous insufficiency? A) Avoid foods with iodine. B) Refrain from sexual activity for a week. C) Elevate the legs periodically for at least 15 to 20 minutes. D) Elevate the legs periodically for at least an hour.
C)
A nurse is teaching a client who is newly diagnosed with hypertension and diabetes mellitus. What will the nurse specify about this client's target blood pressure? A) 150/95 or lower B) 125/85 or lower C) 130/80 or lower D) 145/95 or lower
C)
The nurse is admitting a client with frothy pink sputum. What does the nurse suspect is the primary underlying disorder of pulmonary edema? A) decreased right ventricular elasticity B) increased left atrial contractility C) decreased left ventricular pumping D) increased right atrial resistance
C)
The nurse is caring for a motor vehicle accident client who is unresponsive on arrival to the emergency department. The client has numerous fractures, internal abdominal injuries, and large lacerations on the head and torso. The family arrives and seeks update on the client's condition. A family member asks, "What causes the body to go into shock?" Given the client's condition, which statement is most correct? A) "The client is in shock because your loved one is not responding and brain dead." B) "The client is in shock because all peripheral blood vessels have massively dilated." C) "The client is in shock because the blood volume has decreased in the system." D) "The client is in shock because the heart is unable to circulate the body fluids."
C)
The nurse is teaching the parents of an infant with an irregular heartbeat how to check the pulse rate. The infant's pulse is very high and irregular. What will the nurse have to do in order to teach these parents how to monitor their infant's pulse rate? A) The parents should be encouraged to get a neighbor or family member to help them check their infant's pulse. B) This infant will need a home cardiac monitor set up. C) The parents will have to be taught how to use a stethoscope so that they can listen to and count the infant's apical pulse. D) The parents will not be able to check the pulse accurately; the nurse will need to do home health checks on this infant on a periodic basis.
C)
When caring for the client with hepatic failure, the nurse recognizes that which problem places the client at increased risk for bleeding? A) Increased vitamin K B) Increased platelet count C) Increased prothrombin time D) Decreased red blood cells
C) Increased prothrombin time
A client has an impaired platelet function that may have developed from inheritance, drugs, disease, or extracorporeal circulation. The health care provider would document this as: A) Fibrinolysis B) Disseminated intravascular coagulation C) Thrombocytopathy D) Plasmapheresis
C) Thrombocytopathy
The nurse is caring for a client who is on warfarin therapy. Which teaching will the nurse provide? A) Buy a hard-bristled toothbrush to ensure proper oral hygiene. B) Reassure the client that prolonged bleeding of wounds and gums is normal. C) Use an electric razor for shaving purposes. D) Take aspirin for headaches that develop.
C) Use an electric razor for shaving purposes.
The nurse is teaching the parents of an infant with an irregular heartbeat how to check the pulse rate. The infant's pulse is very high and irregular. What will the nurse have to do in order to teach these parents how to monitor their infant's pulse rate? A) The parents will not be able to check the pulse accurately; the nurse will need to do home health checks on this infant on a periodic basis. B) The parents should be encouraged to get a neighbor or family member to help them check their infant's pulse. C) This infant will need a home cardiac monitor set up. D) The parents will have to be taught how to use a stethoscope so that they can listen to and count the infant's apical pulse.
D)
A client discharged from the hospital 5 days ago following a stroke has come to the emergency department with facial droop that progressed with hemiplegia and aphasia. The client's spouse is extremely upset because the physician stated that the client cannot receive thrombolytic medications to reestablish cerebral circulation and the spouse asks the nurse why. What is the nurse's most accurate response? A) "The stroke is hemorrhagic, not thrombotic." B) "All the brain tissue damage is already done." C) "The medications do not work with subsequent strokes." D) "Thrombolytics may cause cerebral hemorrhage."
D) "Thrombolytics may cause cerebral hemorrhage."
A client with polycythemia vera reports gouty arthritis symptoms in the toes and fingers. What is the nurse's best understanding of the pathophysiological reason for this symptom? A) The dead red blood cells occlude the small vessels in the joints. B) Excess red blood cells produce extracellular toxins that build up. C) Excess red blood cells cause vascular injury in the joints. D) The dead red blood cells release excess uric acid.
D) The dead red blood cells release excess uric acid.
A woman's obstetrician prescribes vitamin K supplements for a client who is on antiepileptic medications beginning at 36 weeks' gestation. The mother asks the nurse why she is taking this medication. The nurse's best response would be: A) The antiepileptic medications can cause the mother's platelets to drop. B) vitamin K helps in keeping the placenta healthy. C) administration of vitamin K aids in lung maturity of the fetus. D) antiepileptic therapy can lead to vitamin K-deficient hemorrhage of the newborn.
D) antiepileptic therapy can lead to vitamin K-deficient hemorrhage of the newborn.
A nurse is caring for a client with prostate cancer and assesses bleeding gums and hematuria. What serum indicator should the nurse relate the bleeding? A) reticulocyte count of 1% B) lymphocyte count of 30% C) neutrophil count of 40% D) platelet count of 60,000/mm3
D) platelet count of 60,000/mm3
While monitoring a client for the development of disseminated intravascular coagulation (DIC), the nurse should take note of which assessment parameters? A) D-dimer, red blood cell count, and partial thromboplastin time B) platelet count, red blood cell count, and hemoglobin C) thrombin time, fibrinogen, and hemoglobin level D) platelet count, prothrombin time, and partial thromboplastin time
D) platelet count, prothrombin time, and partial thromboplastin time
