Unit 3

Which of the following is the most effective intervention for preventing progression of vascular disease? Risk factor modification Use neutral soaps Avoid trauma Wear sturdy shoes

Risk factor modification

A client receiving a unit of packed red blood cells develops hives and generalized itching. Which actions will the nurse take to help this client? Select all that apply. Stop the transfusion Apply oxygen via a face mask Notify the primary health care provider Slow the rate of the transfusion Administer diphenhydramine as prescribed

Stop the transfusion Notify the primary health care provider Administer diphenhydramine as prescribed

A nurse is caring for a client with a diagnosis of lymphocytopenia. Which assessment finding will the nurse consider most concerning when caring for this client? Prothrombin time 12 seconds INR 0.9 Temperature of 37.7 degrees Celsius Blood pressure 132/92

Temperature of 37.7 degrees Celsius

A nurse is reviewing self-care measures for a client with peripheral vascular disease. Which statement indicates proper self-care measures? "I like to soak my feet in the hot tub every day." "I walk only to the mailbox in my bare feet." "I stopped smoking and use only chewing tobacco." "I have my wife look at the soles of my feet each day."

"I have my wife look at the soles of my feet each day."

A nurse is teaching a client with a vitamin B12 deficiency about appropriate food choices to increase the amount of B12 ingested with each meal. The nurse knows the teaching is effective based on which statement by the client? "I will eat a spinach salad with lunch and dinner." "I will eat a meat source such as chicken or pork with each meal." "I will increase my daily intake of orange vegetables such as sweet potatoes and carrots." "I will eat more dairy products such as milk, yogurt, and ice cream every day."

"I will eat a meat source such as chicken or pork with each meal."

A community health nurse teaches a group of older adults about modifiable risk factors that contribute to the development of peripheral arterial disease (PAD). The nurse knows that the teaching was effective based on which statement? "I will need to stop smoking because the nicotine causes less blood to flow to my hands and feet." "I will need to increase the amount of green leafy vegetables I eat to lower my cholesterol levels." "The older I get the higher my risk for peripheral arterial disease gets." "Because my family is from Italy, I have a higher risk of developing peripheral arterial disease."

"I will need to stop smoking because the nicotine causes less blood to flow to my hands and feet."

Heparin therapy is usually considered therapeutic when the activated partial thromboplastin time (aPTT) is how many times higher than a normal value? 0.5 to 1.5 1.5 to 2.5 2.5 to 3.5 3.5 to 4.5

1.5 to 2.5

The nurse is obtaining the health history of a client suspected of having a hematological condition. The nurse notes the client has a history of alcohol abuse. Which clinical presentation is related to alcohol consumption? Myelodysplastic syndrome Neutropenia Anemia Thrombocytopenia

Anemia

To assess the dorsalis pedis artery, the nurse would use the tips of three fingers and apply light pressure to the: Inside of the ankle just above the heel. Exterior surface of the foot near the heel. Outside of the foot just below the heel. Anterior surface of the foot near the ankle joint.

Anterior surface of the foot near the ankle joint.

You are presenting a workshop at the senior citizens center about how the changes of aging predisposes clients to vascular occlusive disorders. What would you name as the most common cause of peripheral arterial problems in the older adult? Aneurysm Coronary thrombosis Atherosclerosis Raynaud's disease

Atherosclerosis

A client is recovering from surgical repair of a dissecting aortic aneurysm. Which assessment findings indicate possible bleeding or recurring dissection? Urine output of 15 ml/hour and 2+ hematuria Blood pressure of 82/40 mm Hg and heart rate of 125 beats/minute Urine output of 150 ml/hour and heart rate of 45 beats/minute Blood pressure of 82/40 mm Hg and heart rate of 45 beats/minute

Blood pressure of 82/40 mm Hg and heart rate of 125 beats/minute

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? Isometric exercise programs are inclusive of all muscle groups and have an aerobic effect to increase the heart rate. Isometric exercise decreases the workload of the heart and restores oxygenated blood flow. This type of exercise increases arterial circulation as it returns to the heart. Contraction of skeletal muscle compresses the walls of veins and increases the circulation of venous blood as it returns to the heart.

Contraction of skeletal muscle compresses the walls of veins and increases the circulation of venous blood as it returns to the heart.

A patient with chronic kidney disease is being examined by the nurse practitioner for anemia. The nurse has reviewed the laboratory data for hemoglobin and RBC count. What other test results would the nurse anticipate observing? Decreased level of erythropoietin Decreased total iron-binding capacity Increased mean corpuscular volume Increased reticulocyte count

Decreased level of erythropoietin

As the clinic nurse caring for a client with varicose veins, what is an appropriate nursing action for this client? Demonstrate how to self-administer IV infusions. Demonstrate how to apply and remove elastic support stockings. Assess for the sites of bleeding. Assess for skin integrity.

Demonstrate how to apply and remove elastic support stockings.

When conducting a health assessment on a client suspected for having a hematological disorder, the nurse should collect which data? Select all that apply. Dietary intake Medication use Ethnicity Herbal supplements Hair color

Dietary intake Medication use Ethnicity Herbal supplements

A client receiving a unit of packed red blood cells (PRBCs) has been prescribed morphine 1 mg intravenously now for pain. What is the best method for the nurse to administer the morphine? Add the morphine to the blood to be slowly administered. Inject the morphine into a distal port on the blood tubing. Administer the morphine into the closest tubing port to the client for fast delivery. Disconnect the blood tubing, flush with normal saline, and administer morphine.

Disconnect the blood tubing, flush with normal saline, and administer morphine.

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? Elevate the legs periodically for at least an hour. Avoid foods with iodine. Elevate the legs periodically for at least 15 to 20 minutes. Refrain from sexual activity for a week.

Elevate the legs periodically for at least 15 to 20 minutes.

A client receiving a blood transfusion reports shortness of breath, appears anxious, and has a pulse of 125 beats/minute. What is the best action for the nurse to take after stopping the transfusion and awaiting further instruction from the health care provider? Place the client in a recumbent position with legs elevated. Remove the intravenous line. Ensure there is an oxygen delivery device at the bedside. Administer prescribed PRN anti-anxiety agent.

Ensure there is an oxygen delivery device at the bedside.

Which statement is accurate regarding Raynaud disease? The disease generally affects the client trilaterally. It affects more than two digits on each hand or foot. It is most common in men 16 to 40 years of age. Episodes may be triggered by unusual sensitivity to cold.

Episodes may be triggered by unusual sensitivity to cold.

A patient is undergoing platelet pheresis at the outpatient clinic. What does the nurse know is the most likely clinical disorder the patient is being treated for? Essential thrombocythemia Extreme leukocytosis Sickle cell anemia Renal transplantation

Essential thrombocythemia

A client with lower extremity edema is diagnosed with lymphedema. For which medication will the nurse prepare teaching for this client? Oxycodone Furosemide Amoxicillin Heparin

Furosemide

A nurse is caring for a patient who has had a bone marrow aspiration with biopsy. What complication should the nurse be aware of and monitor the patient for? Hemorrhage Blood transfusion reaction Shock Splintering of bone fragments

Hemorrhage

The nurse is caring for a patient who has started anticoagulant therapy with warfarin (Coumadin). When does the nurse understand that therapeutic benefits will begin? Within 12 hours Within the first 24 hours In 2 days In 3 to 5 days

In 3 to 5 days

A client is diagnosed with peripheral arterial disease. Review of the client's chart shows an ankle-brachial index (ABI) on the right of 0.45. This indicates that the right foot has which of the following? Moderate to severe arterial insufficiency No arterial insufficiency Very mild arterial insufficiency Tissue loss to that foot

Moderate to severe arterial insufficiency

The body responds to infection by increasing the production of white blood cells (WBCs). The nurse should evaluate the differential count for what type of WBCs, which are the first WBCs to respond to an inflammatory event? Basophils Neutrophils Eosinophils Monocytes

Neutrophils

A client has been diagnosed with peripheral arterial occlusive disease. Which of the following instructions is appropriate for the nurse to give the client for promoting circulation to the extremities? Keep the extremities elevated slightly. Participate in a regular walking program. Use a heating pad to promote warmth. Massage the calf muscles if pain occurs.

Participate in a regular walking program.

A nurse is caring for a client following an arterial vascular bypass graft in the leg. What should the nurse plan to assess over the next 24 hours? Peripheral pulses every 15 minutes after surgery Ankle-arm indices every 12 hours Blood pressure every 2 hours Color of the leg every 4 hours

Peripheral pulses every 15 minutes after surgery

Which is a symptom of severe thrombocytopenia? Petechiae Inflammation of the mouth Inflammation of the tongue Dyspnea

Petechiae

Under normal conditions, the adult bone marrow produces approximately 70 billion neutrophils. What is the major function of neutrophils? Phagocytosis Rejection of foreign tissue Destruction of tumor cells Production of antibodies called immunoglobulin (Ig)

Phagocytosis

Which is the major function of neutrophils? Rejection of foreign tissue Phagocytosis Destruction of tumor cells Production of immunoglobulins

Phagocytosis

A client is diagnosed with extreme thrombocytosis. The nurse knows this condition is a result of which elevated blood cell count? Neutrophils Platelets Erythocytes Eosinophils

Platelets

A nurse cares for several mothers and babies in the postpartum unit. Which mother does the nurse recognize as being most at risk for a febrile nonhemolytic reaction? Rh-negative mother; Rh-negative child Rh-positive mother; Rh-negative child Rh-negative mother; Rh-positive child Rh-positive mother; Rh-positive child

Rh-negative mother; Rh-positive child

A physician admits a client to the health care facility for treatment of an abdominal aortic aneurysm. When planning this client's care, which goal should the nurse keep in mind as she formulates interventions? Decreasing blood pressure and increasing mobility Increasing blood pressure and reducing mobility Stabilizing heart rate and blood pressure and easing anxiety Increasing blood pressure and monitoring fluid intake and output

Stabilizing heart rate and blood pressure and easing anxiety

A nurse, caring for a client with human immunodeficiency virus (HIV), reviews the client's differential WBC count. What type of WBC will the nurse check the level of? Monocytes B lymphocytes Leukocytes T lymphocytes

T lymphocytes

The nurse is administering a blood transfusion to a client over 4 hours. After 2 hours, the client reports chills and has a fever of 101°F, an increase from a previous temperature of 99.2°F. What does the nurse recognize is occurring with this client? The client is having an allergic reaction to the blood. The client is experiencing vascular collapse. The client is having decrease in tissue perfusion from a shock state. The client is having a febrile nonhemolytic reaction.

The client is having a febrile nonhemolytic reaction.

The nurse is caring for a client with hypoxia. What does the nurse understand is true regarding the client's oxygen level and the production of red blood cells? The kidneys sense low oxygen levels in the blood and stimulate erythropoietin, stimulating the marrow to produce more red blood cells. The bone marrow is stimulated by low oxygen levels in the blood and stimulates erythropoietin, maturing the red blood cells. The brain senses low oxygen levels in the blood and stimulates hemoglobin, which binds to more red blood cells. The kidneys sense low oxygen levels in the blood and stimulate hemoglobin, stimulating the marrow to produce more red blood cells.

The kidneys sense low oxygen levels in the blood and stimulate erythropoietin, stimulating the marrow to produce more red blood cells.

Place the order of the steps of primary hemostasis in correct order. The severed blood vessel constricts. Circulating inactive clotting factors convert to active forms. The circulating platelets aggregate at the site and adhere to the vessel. An unstable hemostatic plug is formed.

The severed blood vessel constricts. The circulating platelets aggregate at the site and adhere to the vessel. An unstable hemostatic plug is formed. Circulating inactive clotting factors convert to active forms.

What symptoms should the nurse assess for in a client with lymphedema as a result of impaired nutrition to the tissue? Loose and wrinkled skin Ulcers and infection in the edematous area Evident scaring Cyanosis

Ulcers and infection in the edematous area

While caring for a client, the nurse notes petechiae on the client's trunk and lower extremities. What precaution will the nurse take when caring for this client? Use an electric razor when assisting client with shaving. Elevate the client's head of the bed. Where a mask when entering the client's room. Apply supplemental oxygen to maintain the client's oxygenation.

Use an electric razor when assisting client with shaving.

A client reports pain and cramping in the thigh when climbing stairs and numbness in the legs after exertion. Which diagnostic test with the physician likely perform right in the office to determine PAD? ankle-brachial index exercise electrocardiography electron beam computed tomography photoplethysmography

ankle-brachial index

The most important reason for a nurse to encourage a client with peripheral vascular disease to initiate a walking program is that this form of exercise: reduces stress. aids in weight reduction. increases high-density lipoprotein (HDL) level. decreases venous congestion.

decreases venous congestion.

A nurse is instructing a client about using antiembolism stockings. Antiembolism stockings help prevent deep vein thrombosis (DVT) by: encouraging ambulation to prevent pooling of blood. providing warmth to the extremity. elevating the extremity to prevent pooling of blood. forcing blood into the deep venous system.

forcing blood into the deep venous system.

A nurse is reviewing a client's morning laboratory results and notes a left shift in the band cells. Based on this result, the nurse can interpret that the client may be developing an infection. may be developing anemia. has leukopenia. has thrombocytopenia.

may be developing an infection.