AH2 Ch. 33, 35, 36, 39-40 Questions With Complete
Solutions
A 72-year-old client admitted with fatigue and dyspnea has
elevated levels of all of these laboratory results. Which finding
is consistent with acute coronary syndrome (ACS) and should be
communicated immediately to the health care provider?
A. White blood cell count
B. Low-density lipoproteins
C. Serum troponin I level
D. C-reactive protein Correct Answer C. Serum troponin I
level
Rationale: Elevation in serum troponin levels is associated with
acute myocardial injury and indicates a need for immediate
interventions such as angioplasty, anticoagulant administration,
or administration of fibrinolytic medications.
A client admitted for heart failure has a priority problem of
hypervolemia related to compromised regulatory mechanisms.
Which assessment result obtained the day after admission is the
best indicator that the treatment has been effective?
A. The client has diuresis of 400 mL in 24 hours.
B. The client's blood pressure is 122/84 mm Hg.
C. The client has an apical pulse of 82 beats/min.
D. The client's weight decreases by 2.5 kg. Correct Answer D.
The client's weight decreases by 2.5 kg.
Rationale: The best indicator of fluid volume gain or loss is
daily weight; because each kilogram represents approximately 1
liter, this client has lost approximately 2500 mL of fluid.
,A client begins therapy with lisinopril (Prinivil, Zestril). What
does the nurse consider at the start of therapy with this
medication?
A. The client's ability to understand medication teaching
B. The risk for hypotension
C. The potential for bradycardia
D. Liver function tests Correct Answer B. The risk for
hypotension
Rationale: Angiotensin-converting enzyme (ACE) inhibitors are
associated with first-dose hypotension and orthostatic
hypotension, which are more likely in those older than 75 years.
A client has a bone marrow biopsy done. Which nursing
intervention is the priority postprocedure?
A. Applying pressure to the biopsy site
B. Inspecting the site for ecchymoses
C. Sending the biopsy specimens to the laboratory
D. Teaching the client about avoiding vigorous activity Correct
Answer A. Applying pressure to the biopsy site
Rationale: The initial action should be to stop bleeding by
applying pressure to the site.
A client has been admitted to the hospital with chest pain
radiating down the left arm. The pain has been unrelieved by
rest and antacids. Which test result best confirms that the client
sustained a myocardial infarction?
A. C-reactive protein of 1 mg/dL
B. Homocysteine level of 13 mmol/L
C. Creatine kinase (CK) of 125 mg/dL
,D. Troponin of 5.2 ng/mL Correct Answer D. Troponin of 5.2
ng/mL
Rationale: The presence of elevated troponin indicates
myocardial damage; normal troponin should be less than 0.03
ng/mL.
A client has just undergone arterial revascularization. Which
statement by the client indicates a need for further teaching
related to postoperative care?
A. "My leg might turn very white after the surgery."
B. "I should be concerned if my foot turns blue."
C. "I should report a fever or any drainage."
D. "Warmness, redness, and swelling are expected." Correct
Answer A. "My leg might turn very white after the surgery."
Rationale: Pallor is one of the signs of decreased perfusion along
with increased pain, poikilothermia, paresthesia, pulselessness,
and paralysis.
A client has undergone an embolectomy for acute arterial
occlusion after creation of a lower arm arteriovenous fistula for
dialysis. Which finding does the nurse report to the provider
immediately?
A. Swelling and tenseness in the affected area
B. Incisional pain and tenderness at the surgical site
C. Pink, mobile fingers
D. An order for heparin infusion Correct Answer A. Swelling
and tenseness in the affected area
Rationale: Compartment syndrome may develop after an
embolectomy; swelling of skeletal muscle fibers causes
, increasing pain, swelling, and tenseness. A fasciotomy may be
needed to preserve the limb.
A client is receiving unfractionated heparin (UFH) by infusion.
Of which finding does the nurse notify the provider?
A. Partial thromboplastin time (PTT) 60 seconds
B. Platelets 32,000/mm3
C. White blood cells 11,000/mm3
D. Hemoglobin 12.2 g/dL Correct Answer B. Platelets
32,000/mm3
Rationale: UFH can also decrease platelet counts. Notify the
provider if the platelet count is below 100,000 to 120,000/mm3.
Heparin-induced thrombocytopenia, an immune disorder,
presents with platelets less than 150,000/mm3
A client is scheduled for a bone marrow aspiration. What does
the nurse do before taking the client to the treatment room for
the biopsy?
A. Clean the biopsy site with an antiseptic or povidone-iodine
(Betadine).
B. Hold the client's hand and ask about concerns.
C. Review the client's platelet (thrombocyte) count.
D. Verify that the client has given informed consent. Correct
Answer D. Verify that the client has given informed consent.
Rationale: Verifying informed consent must be done before the
procedure can be performed. A signed permit must be on the
client's chart.
Solutions
A 72-year-old client admitted with fatigue and dyspnea has
elevated levels of all of these laboratory results. Which finding
is consistent with acute coronary syndrome (ACS) and should be
communicated immediately to the health care provider?
A. White blood cell count
B. Low-density lipoproteins
C. Serum troponin I level
D. C-reactive protein Correct Answer C. Serum troponin I
level
Rationale: Elevation in serum troponin levels is associated with
acute myocardial injury and indicates a need for immediate
interventions such as angioplasty, anticoagulant administration,
or administration of fibrinolytic medications.
A client admitted for heart failure has a priority problem of
hypervolemia related to compromised regulatory mechanisms.
Which assessment result obtained the day after admission is the
best indicator that the treatment has been effective?
A. The client has diuresis of 400 mL in 24 hours.
B. The client's blood pressure is 122/84 mm Hg.
C. The client has an apical pulse of 82 beats/min.
D. The client's weight decreases by 2.5 kg. Correct Answer D.
The client's weight decreases by 2.5 kg.
Rationale: The best indicator of fluid volume gain or loss is
daily weight; because each kilogram represents approximately 1
liter, this client has lost approximately 2500 mL of fluid.
,A client begins therapy with lisinopril (Prinivil, Zestril). What
does the nurse consider at the start of therapy with this
medication?
A. The client's ability to understand medication teaching
B. The risk for hypotension
C. The potential for bradycardia
D. Liver function tests Correct Answer B. The risk for
hypotension
Rationale: Angiotensin-converting enzyme (ACE) inhibitors are
associated with first-dose hypotension and orthostatic
hypotension, which are more likely in those older than 75 years.
A client has a bone marrow biopsy done. Which nursing
intervention is the priority postprocedure?
A. Applying pressure to the biopsy site
B. Inspecting the site for ecchymoses
C. Sending the biopsy specimens to the laboratory
D. Teaching the client about avoiding vigorous activity Correct
Answer A. Applying pressure to the biopsy site
Rationale: The initial action should be to stop bleeding by
applying pressure to the site.
A client has been admitted to the hospital with chest pain
radiating down the left arm. The pain has been unrelieved by
rest and antacids. Which test result best confirms that the client
sustained a myocardial infarction?
A. C-reactive protein of 1 mg/dL
B. Homocysteine level of 13 mmol/L
C. Creatine kinase (CK) of 125 mg/dL
,D. Troponin of 5.2 ng/mL Correct Answer D. Troponin of 5.2
ng/mL
Rationale: The presence of elevated troponin indicates
myocardial damage; normal troponin should be less than 0.03
ng/mL.
A client has just undergone arterial revascularization. Which
statement by the client indicates a need for further teaching
related to postoperative care?
A. "My leg might turn very white after the surgery."
B. "I should be concerned if my foot turns blue."
C. "I should report a fever or any drainage."
D. "Warmness, redness, and swelling are expected." Correct
Answer A. "My leg might turn very white after the surgery."
Rationale: Pallor is one of the signs of decreased perfusion along
with increased pain, poikilothermia, paresthesia, pulselessness,
and paralysis.
A client has undergone an embolectomy for acute arterial
occlusion after creation of a lower arm arteriovenous fistula for
dialysis. Which finding does the nurse report to the provider
immediately?
A. Swelling and tenseness in the affected area
B. Incisional pain and tenderness at the surgical site
C. Pink, mobile fingers
D. An order for heparin infusion Correct Answer A. Swelling
and tenseness in the affected area
Rationale: Compartment syndrome may develop after an
embolectomy; swelling of skeletal muscle fibers causes
, increasing pain, swelling, and tenseness. A fasciotomy may be
needed to preserve the limb.
A client is receiving unfractionated heparin (UFH) by infusion.
Of which finding does the nurse notify the provider?
A. Partial thromboplastin time (PTT) 60 seconds
B. Platelets 32,000/mm3
C. White blood cells 11,000/mm3
D. Hemoglobin 12.2 g/dL Correct Answer B. Platelets
32,000/mm3
Rationale: UFH can also decrease platelet counts. Notify the
provider if the platelet count is below 100,000 to 120,000/mm3.
Heparin-induced thrombocytopenia, an immune disorder,
presents with platelets less than 150,000/mm3
A client is scheduled for a bone marrow aspiration. What does
the nurse do before taking the client to the treatment room for
the biopsy?
A. Clean the biopsy site with an antiseptic or povidone-iodine
(Betadine).
B. Hold the client's hand and ask about concerns.
C. Review the client's platelet (thrombocyte) count.
D. Verify that the client has given informed consent. Correct
Answer D. Verify that the client has given informed consent.
Rationale: Verifying informed consent must be done before the
procedure can be performed. A signed permit must be on the
client's chart.
