Med Surg ATI Cardiovascular and
respiratory LATEST VERSION 2025
A nurse in a clinic is assessing the lower extremities and ankles of a client who has a history of peripheral
arterial disease. Which of the following findings should the nurse expect?
Pitting edema
Areas of reddish-brown pigmentation
Dry, pale skin with minimal body hair
Sunburned appearance with desquamation - ANSWER-Dry, pale skin with minimal body hair
A client who has peripheral arterial disease can display dry, scaly, pale, or mottled skin with minimal
body hair because of narrowing of the arteries in the legs and feet. This causes a decrease in blood flow
to the distal extremities, which can lead to tissue damage. Common manifestations are intermittent
claudication (leg pain with exercise), cold or numb feet at rest, loss of hair on the lower legs, and
weakened pulses.
A nurse is administering a unit of packed red blood cells (RBCs) to a client who is postoperative. The
client reports itching and has hives 30 min after the infusion begins. Which of the following actions
should the nurse take first?
Maintain the IV access with 0.9% sodium chloride.
Stop the infusion of blood.
Send the blood container and tubing to the blood bank.
Obtain a urine sample. - ANSWER-Stop the infusion of blood
The nurse should apply the urgent vs. nonurgent priority-setting framework. Using this framework, the
nurse should consider urgent needs the priority because they pose more of a threat to the client. The
nurse might also need to use Maslow's hierarchy of needs, the ABC priority-setting framework, or
nursing knowledge to identify which finding is the most urgent. The nurse should stop the infusion of
blood because the client has manifestations of an allergic reaction.
A nurse is assessing a client for manifestations of aplastic anemia. Which of the following findings should
the nurse expect?
Plethoric appearance of facial skin
Glossitis and weight loss
, Med Surg ATI Cardiovascular and
respiratory LATEST VERSION 2025
Jaundice with an enlarged liver
Petechiae and ecchymosis - ANSWER-Petechiae and ecchymosis
The client who has aplastic anemia will have manifestations of petechiae and ecchymosis. Dyspnea on
exertion also can be present. In aplastic anemia, all three major blood components (red blood cells,
white blood cells, and platelets) are reduced or absent, which is known as pancytopenia. Manifestations
usually develop gradually.
A nurse is assessing a client who has an abdominal aortic aneurysm. Which of the following
manifestations should the nurse expect?
Midsternal chest pain
Thrill
Pitting edema in lower extremities
Lower back discomfort - ANSWER-Lower back discomfort
Abdominal aortic aneurysm involves a widening, stretching, or ballooning of the aorta. Back and
abdominal pain indicate that the aneurysm is extending downward and pressing on lumbar spinal nerve
roots, causing pain.
A nurse is assessing a client who has fluid volume overload from a cardiovascular disorder. Which of the
following manifestations should the nurse expect? (Select all that apply.)
Jugular vein distension
Moist crackles
Postural hypotension
Increased heart rate
Fever - ANSWER-Jugular vein distension is correct. The increase in venous pressure due to excessive
circulating blood volume results in neck vein distension.
respiratory LATEST VERSION 2025
A nurse in a clinic is assessing the lower extremities and ankles of a client who has a history of peripheral
arterial disease. Which of the following findings should the nurse expect?
Pitting edema
Areas of reddish-brown pigmentation
Dry, pale skin with minimal body hair
Sunburned appearance with desquamation - ANSWER-Dry, pale skin with minimal body hair
A client who has peripheral arterial disease can display dry, scaly, pale, or mottled skin with minimal
body hair because of narrowing of the arteries in the legs and feet. This causes a decrease in blood flow
to the distal extremities, which can lead to tissue damage. Common manifestations are intermittent
claudication (leg pain with exercise), cold or numb feet at rest, loss of hair on the lower legs, and
weakened pulses.
A nurse is administering a unit of packed red blood cells (RBCs) to a client who is postoperative. The
client reports itching and has hives 30 min after the infusion begins. Which of the following actions
should the nurse take first?
Maintain the IV access with 0.9% sodium chloride.
Stop the infusion of blood.
Send the blood container and tubing to the blood bank.
Obtain a urine sample. - ANSWER-Stop the infusion of blood
The nurse should apply the urgent vs. nonurgent priority-setting framework. Using this framework, the
nurse should consider urgent needs the priority because they pose more of a threat to the client. The
nurse might also need to use Maslow's hierarchy of needs, the ABC priority-setting framework, or
nursing knowledge to identify which finding is the most urgent. The nurse should stop the infusion of
blood because the client has manifestations of an allergic reaction.
A nurse is assessing a client for manifestations of aplastic anemia. Which of the following findings should
the nurse expect?
Plethoric appearance of facial skin
Glossitis and weight loss
, Med Surg ATI Cardiovascular and
respiratory LATEST VERSION 2025
Jaundice with an enlarged liver
Petechiae and ecchymosis - ANSWER-Petechiae and ecchymosis
The client who has aplastic anemia will have manifestations of petechiae and ecchymosis. Dyspnea on
exertion also can be present. In aplastic anemia, all three major blood components (red blood cells,
white blood cells, and platelets) are reduced or absent, which is known as pancytopenia. Manifestations
usually develop gradually.
A nurse is assessing a client who has an abdominal aortic aneurysm. Which of the following
manifestations should the nurse expect?
Midsternal chest pain
Thrill
Pitting edema in lower extremities
Lower back discomfort - ANSWER-Lower back discomfort
Abdominal aortic aneurysm involves a widening, stretching, or ballooning of the aorta. Back and
abdominal pain indicate that the aneurysm is extending downward and pressing on lumbar spinal nerve
roots, causing pain.
A nurse is assessing a client who has fluid volume overload from a cardiovascular disorder. Which of the
following manifestations should the nurse expect? (Select all that apply.)
Jugular vein distension
Moist crackles
Postural hypotension
Increased heart rate
Fever - ANSWER-Jugular vein distension is correct. The increase in venous pressure due to excessive
circulating blood volume results in neck vein distension.
