RN Cardiovascular Hematologic and Lymphatic Systems EAQ

The nurse assesses a client for orthostatic hypotension. The results are: Lying heart rate = 70 beats/minute, BP = 110/70; Sitting heart rate = 78 beats/minute, BP = 106/66; Standing heart rate = 85 beats/minute, BP = 100/64. The nurse would expect which prescription from the primary healthcare provider? Increase furosemide from 20 mg by mouth (PO) to 40 mg PO daily Give 1 L of 0.9% normal saline (NS) bolus over 4 hours Start intravenous (IV) infusion of D5 ½ NS to run at 150 mL/hr No prescription change The nurse is providing postprocedure care to a client who had a cardiac catheterization. The client begins to manifest signs and symptoms associated with embolization. Which action should the nurse take? Notify the primary healthcare provider immediately Apply a warm, moist compress to the incision site Increase the intravenous fluid rate by 20 mL/hr Monitor vital signs more frequently A client who just returned from a cardiac catheterization reports to the nurse that the pressure bandage on the right groin is tight. What action should the nurse take? Loosen the dressing slightly. Notify the primary healthcare provider. Assess the pulses distal to the dressing. Have the client flex the joints of the right leg. A client who is considering sclerotherapy asks the nurse to explain what causes varicose veins. Which response by the nurse is best? "The cause is abnormal configurations of the veins." "The cause is incompetent valves of superficial veins." "The cause is decreased pressure within the deep veins." "The cause is atherosclerotic plaque formation in the veins." A nurse in the postanesthesia care unit is caring for a client who received a general anesthetic. Which finding should the nurse report to the primary healthcare provider? Client pushes the airway out. Client has snoring respirations. Client’s respirations are 16 breaths per minute and unlabored. Client’s systolic blood pressure drops from 130 to 90 mm Hg. A client is admitted to the hospital for an emergency cardiac catheterization. What adaptation is the client most likely to complain of after this procedure? Fear of dying Skipped heartbeats Pain at the insertion site Anxiety in response to intensive monitoring A nurse observes a window washer falling 25 feet (7.6 m) to the ground. The nurse rushes to the scene and determines that the person is in cardiopulmonary arrest. What should the nurse do first? Feel for a pulse Begin chest compressions Leave to call for assistance Perform the abdominal thrust maneuver The nurse at a health fair has taken a client's blood pressure twice, 10 minutes apart, in the same arm while the client is seated. The nurse records the two blood pressures of 172/104 mm Hg and 164/98 mm Hg. What is the appropriate nursing action in response to these readings? Refer the client to a nutritionist after providing health teaching about a low-sodium diet. Place the client in a recumbent position and call the paramedics for transport to the hospital. Talk with the client to assess whether there is stress in the client's life and refer to a counseling service. Take the client's blood pressure in the other arm and then schedule a healthcare practitioner's appointment for as soon as possible. What is the most important nursing action when measuring a client’s pulmonary capillary wedge pressure (PCWP)? Deflate the balloon as soon as the PCWP is measured. Have the client bear down when measuring the PCWP. Place the client in a supine position before measuring the PCWP. Flush the catheter with a heparin solution after the PCWP is determined. When an older client with heart failure is transferred from the emergency department to the medical service, what should the nurse on the unit do first? Interview the client for a health history. Assess the client’s heart and lung sounds. Monitor the client’s pulse and temperature. Obtain the client’s blood specimen for electrolytes. The nurse encourages a client with Raynaud disease to stop smoking. Which primary goal is the nurse trying to achieve? Prevent pain and tingling Prevent cyanosis and necrosis Prevent peripheral vasoconstriction Prevent excessive blood oxygen content A nurse identifies that a client who had a myocardial infarction is struggling with an alteration in self-concept. The nurse intervenes to promote client autonomy. Which behavior by the client demonstrates an increase in client autonomy? Active participation in providing self-care Verbalizing realistic expectations of caregivers Discussing necessary lifestyle changes with family members Listing the indicators of recovery after a myocardial infarction A client has a pulse deficit. Which documentation by the nurse supports this finding? Blood pressure of 130/70 mm Hg indicating pulse deficit of 60. Capillary refill greater than 3 seconds indicating pulse deficit. Apical pulse 86 and radial pulse 78 indicating pulse deficit of 8. Radial pulse 80 and pedal pulse 70 indicating pulse deficit of 10. While caring for a client who had an open reduction and internal fixation of the hip, the nurse encourages active leg and foot exercises of the unaffected leg every 2 hours. What does the nurse explain that these exercises will help to do? Prevent clot formation Reduce leg discomfort Maintain muscle strength Limit venous inflammation After surgery for insertion of a coronary artery bypass graft (CABG), a client develops a temperature of 102° F (38.9° C). Which priority concern related to elevated temperatures does a nurse consider when notifying the healthcare provider about the client's temperature? A fever may lead to diaphoresis. A fever increases the cardiac output. An increased temperature indicates cerebral edema. An increased temperature may be a sign of hemorrhage. A nurse determines that the client’s apical pulse rate is higher than the radial pulse and documents the pulse deficit. What does the nurse consider is the primary reason for the pulse deficit? The client’s heart may be beating faster temporarily. The nurse may not know how to take an accurate pulse. The radial pulse site may be surrounded by too much subcutaneous fat. The client may have atrial fibrillation. A nurse is conducting cholesterol screening for a manufacturing corporation during a health fair. A 50-year-old man who is 6 feet (183 cm) tall and weighs 293 pounds (133 kg) puts out his cigarette and asks the nurse how to modify his risk factors for coronary artery disease. On which risk factors should the nurse help the client focus? Select all that apply. Age Height Weight Smoking Family history A client who was in an automobile collision is now in hypovolemic shock. Why is it important for the nurse to take the client’s vital signs frequently during the compensatory stage of shock? Arteriolar constriction occurs. The cardiac workload decreases. Contractility of the heart decreases. The parasympathetic nervous system is triggered. Two hours after a cardiac catheterization that was accessed through the right femoral route, an adult client complains of numbness and pain in the right foot. What action should the nurse take first? Call the primary healthcare provider. Check the client’s pedal pulses. Take the client’s blood pressure. Recognize the response is expected. A client with a suspected dysrhythmia is to wear a Holter monitor for 24 hours at home. What should the nurse instruct the client to do? Keep a record of the day’s activities. Avoid going through laser-activated doors. Record the pulse and blood pressure every 4 hours. Delay taking prescribed medications until the monitor is removed. A nurse is caring for a client with a diagnosis of polycythemia vera. The client asks, "Why do I have an increased tendency to develop blood clots?" Which effect of the polycythemia vera should the nurse include in the teaching session? Elevated blood pressure Increased blood viscosity Fragility of the blood cells Immaturity of red blood cells The nurse is caring for a client who is receiving a thiazide diuretic for hypertension. Which food selection by the client indicates to the nurse that dietary teaching about thiazide diuretics is successful? Apples Broccoli Cherries Cauliflower The plan of care for a postoperative client who has developed a pulmonary embolus includes monitoring and bed rest. The client asks why all activity is restricted. The nurse’s response should be based on what principle about bed rest? It prevents the further aggregation of platelets. It enhances the peripheral circulation in the deep vessels. It decreases the potential for further dislodgment of emboli. It maximizes the amount of blood available to damaged tissues. The primary healthcare provider prescribes two units of packed red blood cells for a client who is bleeding. Before blood administration, what is the nurse’s priority? Obtaining the client’s vital signs Letting the blood reach room temperature Monitoring the hemoglobin and hematocrit levels Determining proper typing and crossmatching of blood A client with a history of a pulmonary embolus is to receive 3 mg of warfarin daily. The client has blood drawn twice weekly to ascertain that the international normalized ratio (INR) stays within a therapeutic range. The nurse provides dietary teaching. Which food selected by the client indicates that further teaching is necessary? Poached eggs Spinach salad Sweet potatoes Cheese sandwich A nurse is assessing a client’s ECG reading. The client's atrial and ventricular heart rates are equal at 88 beats per min. The PR interval is 0.14 seconds, and the QRS width is 0.10 seconds. Rhythm is regular with normal P waves and QRS complexes. How will the nurse interpret this rhythm? Normal sinus rhythm Sinus tachycardia Sinus bradycardia Sinus arrhythmia A client who had extensive pelvic surgery 24 hours ago becomes cyanotic, is gasping for breath, and reports right-sided chest pain. What should the nurse do first? Obtain vital signs Initiate a cardiac arrest code Administer oxygen using a face mask Encourage the use of an incentive spirometer A Foley catheter was placed with an urimeter for a client with heart failure receiving furosemide. The output is 45 mL/hour, cloudy, and has sediment. How should the nurse interpret these findings? The furosemide is causing dehydration. Cloudy urine may be indicative of infection. The client has inadequate hourly urine output. All of the indications are within normal findings. A client with mild chronic heart failure is to be discharged with prescriptions for daily oral doses of an antidysrhythmic, potassium chloride 40 mEq, docusate sodium 100 mg, and furosemide 40 mg twice a day. The client reports having no family members who can help after discharge. What should the nurse help this client identify? Support systems that can assist the client at home Potential nursing homes in which the client can recuperate Agencies that can help the client regain activities of daily living Ways that the client can develop relationships with neighbors The client is in atrial fibrillation. Which information should the nurse consider about atrial fibrillation when planning care for this client? A loss of atrial kick No physiologic changes Increased cardiac output Decreased risk of pulmonary embolism A nurse is advising a client about the risks associated with failing to seek treatment for acute pharyngitis caused by beta-hemolytic streptococcus. For what health problem is the client at risk? Asthma Anemia Endocarditis Reye syndrome A nurse is collecting data from a client with varicose veins who is to have sclerotherapy. What should the nurse expect the client to report? Feeling of heaviness in both legs Intermittent claudication of the legs Calf pain on dorsiflexion of the foot Hematomas of the lower extremities A client is on a cardiac monitor. The monitor begins to alarm showing ventricular tachycardia. What should the nurse do first? Check for a pulse Start cardiac compressions Prepare to defibrillate the client Administer oxygen via an ambu bag A client with a history of hypertension has a blood pressure of 180/102 mm Hg. When the nurse asks whether the client has been taking any medications, the client replies, "I took the blood pressure pills the healthcare provider prescribed for a few weeks, but I didn't feel any different, so I decided I'd only take them when I feel sick." What is the best initial response by the nurse? "You must be quite frightened about having high blood pressure." "I'm glad to hear you have felt well enough to stop the medication." "It is important to take your medications daily to achieve optimal results." "You will need to document daily whether you took your medication or not. A nurse is assessing a client with the diagnosis of primary hypertension. Which clinical finding does the nurse identify as an indicator of primary hypertension? Mild but persistent depression Transient temporary memory loss Occipital headache in the morning Cardiac palpitation during periods of stress An older client who has had multiple hospital admissions for recurring heart failure is returned to the hospital by an adult child. The client is admitted for observation to the coronary care unit and calmly states, "I know I’m sick, but I can really take care of myself at home." What should the nurse conclude that the client most likely is attempting to do? Suppress fears Deny the illness Maintain independence Reassure the adult child The primary healthcare provider prescribes "bathroom privileges only" for a client with pulmonary edema. The client becomes irritable and asks the nurse whether it is really necessary to stay in bed so much. What would be the best reply by the nurse? "Why do you want to be out of bed?" "Bed rest plays a role in most therapy." "Rest helps your body direct energy toward healing." "Would you like me to ask your primary healthcare provider to change the prescription?" A nurse is providing discharge instructions to a client who experienced an anterior septal myocardial infarction (MI). Which statement by the client indicates the nurse needs to follow up? "I want to stay as pain-free as possible." "I am not good at remembering to take medications." "I should not have any problems in reducing my salt intake." "I wrote down my dietary information for future reference." A woman comes to the office of her healthcare provider reporting shortness of breath and epigastric distress that is not relieved by antacids. To which question would a woman experiencing a myocardial infarction respond differently than a man? "Do you have chest pain?" "Are you feeling anxious?" "Do you have any palpitations?" "Are you feeling short of breath?" A client is admitted to the hospital for a total hip replacement. Included in the primary healthcare provider’s prescriptions is a prescription for digoxin 2.5 mg by mouth daily. The nurse knows that digoxin is supplied in 0.125 mg tablets. What should the nurse do? Give half a tablet. Administer two tablets. Ask the client what dose was taken at home. Verify the prescription with the primary healthcare provider. An electrocardiogram (ECG) is performed before a client is to have a cardiac catheterization, and hypokalemia is suspected. What does the nurse expect the primary healthcare provider to prescribe to confirm the presence of hypokalemia? A complete blood count A serum electrolyte level An arterial blood gas panel An x-ray film of long bones Four days after the client's total hip arthroplasty, the nurse is preparing to transfer the client to a rehabilitation center. Before admission the client took warfarin sodium daily for a history of pulmonary embolus. While hospitalized, the client received subcutaneous heparin two times a day. The nurse does not see any anticoagulant therapy listed on the client's transfer prescriptions. What should the nurse do? Contact the healthcare provider to determine which anticoagulant therapy should be prescribed for this client. Arrange for a supply of heparin for the client to take to the rehab center. Explain to the client that anticoagulant therapy will no longer be needed. Instruct the client to talk about anticoagulant needs with the healthcare provider at the rehabilitation center. Each year, a client takes many trips to other countries. The client reports leg swelling during the long flights. How should the nurse best advise this client when traveling? Relax in a reclining position Sit upright with legs extended Walk around at least every hour Sit in any position that relieves pressure on the legs A client with type 1 diabetes asks what causes the several brown spots on the skin. What would be the best response by the nurse? "The brown spots reflect the accumulation of blood fats in the skin; they should disappear." "Those spots indicate a high glucose content in the skin that may get infected if left untreated." "They are the result of diseased small vessels in the shins and may spread if not treated soon." "Those brown spots result from small blood vessel damage; the blood contains iron, which leaves a brown spot." The nurse is monitoring a client's hemoglobin level. The nurse recalls that the amount of hemoglobin in the blood has what effect on oxygenation status? Except with rare blood disorders, hemoglobin seldom affects oxygenation status. There are many other factors that affect oxygenation status more than hemoglobin does. A low hemoglobin level causes reduced oxygen-carrying capacity. Hemoglobin reflects the body's clotting ability and may or may not affect oxygenation status. What should the nurse teach a client who is taking antihypertensives to do to minimize orthostatic hypotension? Wear support hose continuously. Lie down for 30 minutes after taking medication. Avoid tasks that require high-energy expenditure. Sit on the edge of the bed for 5 minutes before standing. What should the nurse do to prevent thrombus formation after most surgeries? Keep the client’s bed gatched to elevate the knees. Have the client dangle the legs off the side of the bed. Have the client use an incentive spirometer every hour. Encourage the client to ambulate with assistance every few hours. A client who develops heart failure has a serum potassium level of 2.3 mEq/L (2.3 mmol/L). Digoxin and potassium chloride are prescribed. What action should the nurse take? Double the dose of potassium chloride and administer it with the prescribed digoxin. Hold the dose of digoxin, administer the potassium chloride, and call the primary healthcare provider immediately. Give the digoxin and potassium chloride as prescribed and report the laboratory results to the primary healthcare provider. Administer the prescribed digoxin and potassium chloride with a glass of orange juice and continue to monitor the client. A client is admitted to the hospital with a long history of hypertension. The nurse should assess the client for which complication? Cataracts Esophagitis Kidney failure Diabetes mellitus A client is diagnosed with varicose veins, and the nurse teaches the client about the pathophysiology associated with this disorder. The client asks, "What can I do to help myself?" How should the nurse respond? "Limit walking to as little as possible." "Reduce fluid intake to 1 L of liquid a day." "Apply moisturizing lotion on your legs several times a day." "Put on compression hose before getting out of bed in the morning." A client presents to the emergency department with weakness and dizziness. The blood pressure is 90/60 mm Hg, pulse is 92 and weak, and body weight reflects a 3-pound (1.4 kilogram) loss in two days. The weather has been hot. Which condition should the nurse conclude is the priority for this client? Deficient fluid volume Impaired skin integrity Inadequate nutritional intake Decreased participation in activities While receiving a blood transfusion, the client suddenly shouts, "I feel like someone is lowering a heavy weight on my chest. I feel like I’m going to die!" Which actions are priority? Administer nitroglycerin and aspirin. Slow the rate and monitor the vital signs. Stop the transfusion and administer normal saline. Ask the client to further describe the feeling and rate the pain. A client is admitted to the hospital with the diagnosis of myocardial infarction. The nurse should monitor this client for which signs and symptoms associated with heart failure? Select all that apply. Weight loss Unusual fatigue Dependent edema Nocturnal dyspnea Increased urinary output A client is in the intensive care unit. The nurse observing the telemetry monitor identifies flattening T waves and peaked P waves. What problem should the nurse consider based on these ECG changes? Hypokalemia Hypocalcemia Hyponatremia Hypomagnesemia A primary healthcare provider prescribes a heart-healthy diet for a client with angina. The client's spouse says to the nurse, "I guess I'm going to have to cook two meals, one for my spouse and one for myself." Which is the most appropriate response by the nurse? "The diet prescribed for your spouse is a healthy diet. It contains guidelines that many of us should follow." "I wouldn't bother. For this diet all that you need to do is to reduce the amount of salt you use and fry foods in peanut oil." "You're right. Be careful to cook a small portion for each of you to eat to not waste food." "This is a difficult diet to follow. I recommend that you shop daily for food so there are no temptations in the kitchen." A client is admitted to the hospital with reports of frequent loose, watery stools, anorexia, malaise, and weight loss during the past week. Laboratory findings indicate leukocytosis and an elevated sedimentation rate. Which condition should the nurse conclude is the probable cause of the client's presenting adaptations? Long-term use of an irritant-type laxative Emotional response resulting in physical symptoms Inadequate dietary practices resulting in altered bowel function Systemic responses of the body to a localized inflammatory process A client returns from a cardiac catheterization procedure and is to remain in the supine position for 4 hours with the affected leg straight. What are these measures intended to prevent? Orthostatic hypotension Headache with disorientation Bleeding at the arterial puncture site Infiltration of radiopaque dye into tissue How can the nurse best describe heart failure to a client? A cardiac condition caused by inadequate circulating blood volume An acute state in which the pulmonary circulation pressure decreases An inability of the heart to pump blood in proportion to metabolic needs A chronic state in which the systolic blood pressure drops below 90 mm Hg A client is scheduled to have a cardiac catheterization via the femoral approach. The nurse teaches the client about postprocedure interventions that protect the catheter insertion site. What should the nurse inform the client of regarding the leg used for catheter insertion? It should be elevated on a pillow. It should be kept extended while on bed rest. It will be positioned dependent to the level of the heart. It will be put through range-of-motion exercises several times an hour A client is diagnosed with hypertension that is related to atherosclerosis. Which information should the nurse consider when planning care for this client? Renin causes a gradual decrease in arterial pressure. Lipid plaque formation occurs within the arterial vessels. Development of atheromas within the myocardium is characteristic. Mobilization of free fatty acid from adipose tissue contributes to plaque formation. A client who has a hemoglobin of 6 gm/dL (60 mmol/L) is refusing blood because of religious reasons. What is the most appropriate action by the nurse? Discuss the case with coworkers. Notify the primary healthcare provider of the client’s refusal of blood products. Explain to the client that they will die without the blood transfusion. The nurse is assessing a client with the diagnosis of left ventricular failure. Which assessment finding does the nurse expect to identify? Crushing chest pain Dyspnea on exertion Jugular vein distention Extensive peripheral edema A client is receiving warfarin. Which test result should the nurse use to determine whether the daily dose of this anticoagulant is therapeutic? International normalized ratio (INR) Accelerated partial thromboplastin time (APTT) Bleeding time Sedimentation rate A client with arterial insufficiency of both lower extremities is visited by the home healthcare nurse. What client teaching is an essentialnursing intervention? "Maintain elevation of both legs." "Massage the legs when they are painful." "Apply a hot water bottle to the legs." "Check pulses in the legs regularly." A nurse is working with an unlicensed assistive personnel (UAP) in caring for a group of clients. Which statement by the UAP indicates a correct understanding of the UAP's role? "I will turn off clients' IVs that have infiltrated." "I will take clients' vital signs after their procedures are over." "I will use unit written materials to teach clients before surgery." "I will help by giving medications to clients who are slow in taking pills." A client is receiving furosemide to help treat heart failure. Which laboratory result will cause the nurse to notify the primary healthcare provider? Hematocrit 46% Hemoglobin 14.1 g/dL (141 mmol/L) Potassium 3.0 mEq/L (3.0 mmol/L) White blood cell 9200/mm 3 (9.2 × 10 9 /L) A nurse is assessing a group of clients. Which client is considered at the highest risk for a dissecting aneurysm? 70-year-old male with peripheral vascular disease 65-year-old male with uncontrolled hypertension 40-year-old female with controlled hypertension 42-year-old female with peripheral vascular disease A nurse is providing dietary instruction to a client with cardiovascular disease. Which dietary selection by the client indicates that the nurse needs to reeducate the client? Whole milk with oatmeal Garden salad with olive oil Tuna fish with a small apple Soluble fiber cereal with yogurt A client who has always been active is diagnosed with atherosclerosis and hypertension. The client is interested in measures that will help promote and maintain health. Which recommendation by the nurse will help the client maintain blood vessel patency? Practice relaxation techniques. Lead a more sedentary lifestyle. Limit cardiovascular exercise. Increase saturated fats in the diet. What must the nurse do to determine a client’s pulse pressure? Multiply the heart rate by the stroke volume. Subtract the diastolic from the systolic reading. Determine the mean blood pressure by averaging the two. Calculate the difference between the apical and radial rate. To prepare a client for surgery, which explanation by a nurse would be accurate related to pneumatic compression devices? They help the venous blood return to the heart. They will not cause discomfort, but gently massage the legs. They are used instead of anticoagulant therapy. They must be worn until the first time the client gets out of bed. On the morning of surgery a client is admitted for resection of an abdominal aortic aneurysm. While awaiting surgery, the client suddenly develops symptoms of shock. Which nursing action is priority? Prepare for blood transfusions. Notify the surgeon immediately. Make the client nothing by mouth (NPO). Administer the prescribed preoperative sedative. A client presenting to the emergency department with chest pain and dizziness is found to be having a myocardial infarction and subsequently suffers cardiac arrest. The healthcare team is able to successfully resuscitate the client. Lab work shows that the client now is acidotic. How does the nurse interpret the cause of the acidosis? The fat-forming ketoacids were broken down. The irregular heartbeat produced oxygen deficit. The decreased tissue perfusion caused lactic acid production. The client received too much sodium bicarbonate during resuscitation effor While the nurse moves a client from a lying to standing position, the client experiences a rapid drop in blood pressure. The nurse would report this finding as what? Malignant hypotension Orthostatic dehydration Orthostatic hypotension Vasomotor instability A client who lives with the parents is diagnosed with stage III Hodgkin disease with a grossly involved spleen and is scheduled for a splenectomy. After the nurse performs preoperative teaching, the client appears anxious. What is the best approach for the nurse to use at this time? Allow the client to regress at this time and rest quietly. State that that the client seems anxious and ask whether the client would like to talk for a while. Consider the reaction an unconscious response and inquire about the client’s relationship with the parents. Understand that anxiety prevented the client from comprehending and repeat the information in simpler terms. The day after surgery a client is encouraged to ambulate. The client angrily asks the nurse, "Why am I being made to walk so soon after surgery?" How should the nurse explain the primary purpose of early ambulation? To promote healing of the incision To decrease the incidence of urinary tract infections To use energy to help the client sleep better at night To keep blood from pooling in the legs to prevent clots A client on a 2-gram sodium diet states, "I never add salt to my food when I cook. I just need help selecting low-sodium foods." After receiving dietary education, the client creates sample menus. Which meal selection will cause the nurse to intervene? Soft-cooked egg, toast, jelly, skim milk Baked chicken, boiled potatoes, broccoli, coffee Fillet of sole, baked potato, fresh fruit cup (berries and melons) Cottage cheese, crackers, relish dish (celery, olives, sweet pickles) A client states, "I feel like my heart is jumping out of my chest, and it is skipping beats." The client passes a thallium stress test; however, the healthcare provider identifies one premature ventricular complex (PVC) and several premature atrial complexes (PACs) on the 24-hour follow-up Holter monitor. Which question is most important for the nurse to ask the client? "Do you eat foods high in vitamins?" "Do you have small children at home?" "How much caffeine do you consume each day?" "How many glasses of water do you drink per day?" A nurse is discussing discharge instructions with a patient who had a coronary artery bypass graft (CABG). The client states, "My spouse is afraid to have sex with me. When will it be safe to have sex again?" Which is the most appropriate response by the nurse? "You should wait at least 6 weeks to allow enough time for your chest incision to heal." "You will need to talk that over with your surgeon before you leave." "You can resume sexual activity when you feel you have recovered enough and when your chest no longer hurts." "You can resume sexual activity as soon as you can climb one flight of stairs without fatigue or discomfort." A client is seen in the clinic with sickle cell anemia. A nurse teaches the client about sickle cell anemia. Which information from the client indicates a correct understanding of the condition? "I have abnormal platelets." "I have abnormal hemoglobin." "I have abnormal hematocrit." "I have abnormal white blood cells." After sustaining multiple internal injuries when hit by a motor vehicle, a client has a sudden drop in blood pressure to 80/60 mm Hg. What does the nurse determine probably caused this response? Reduction in circulating blood volume Diminished vasomotor stimulation to arterial walls Vasodilation resulting from diminished vasoconstrictor tone Cardiac decompensation resulting from electrolyte imbalance A client with an inferior myocardial infarction has a heart rate of 120 beats per minute. Which goal achievements are priority? Increase left ventricular filling and improve cardiac output Decrease oxygen needs of the vital organs and prevent cardiac dysrhythmias Decrease the workload on the heart and promote maximum coronary artery filling Increase venous return to the right atrium and increase pulmonary arterial blood flow When assessing a client with heart failure, the nurse asks what aggravates the problem. Which activity should the nurse expect will cause the client the greatest distress? Getting up from bed in the morning Walking to visit the next-door neighbor Climbing a flight of stairs to the bedroom Leaving the table immediately after a meal A client’s arterial blood gas report indicates that pH is 7.25, Pco 2 is 60 mm Hg, and HCO 3 is 26 mEq/L (26 mmol/L). Which client should the nurse consider is most likely to exhibit these blood gas results? A 65-year-old with pulmonary fibrosis A 24-year-old with uncontrolled type 1 diabetes A 45-year-old who has been vomiting for 3 days A 54-year-old who takes sodium bicarbonate for indigestion A client with a long history of cardiovascular problems, including angina and hypertension, is scheduled to have a cardiac catheterization. During preprocedure teaching, what does the nurse explains to the client is the major purpose for catheterization? To obtain the pressures in the heart chambers To determine the existence of congenital heart disease To visualize the disease process in the coronary arteries To measure the oxygen content of various heart chambers A client is to be transferred from the coronary care unit to a progressive care unit. The client asks the nurse, "Are you sure I’m ready for this move?" What should the nurse determine that the client most likely is experiencing based on this statement? Fear Depression Dependency Ambivalence When developing a plan of care for a client who had a cardiac catheterization via a femoral insertion site, what should the nurse include? Ambulating the client 2 hours after the procedure Checking the vital signs every 15 minutes for 8 hours Keeping the client nothing by mouth for 4 hours after the procedure Maintaining the supine position for a minimum of 4 hours A nurse is taking the blood pressure of a client with hypertension. The first sound is heard at 140 mm Hg; the second sound is a swishing sound heard at 130 mm Hg; a tapping sound is heard at 100 mm Hg; a muffled sound is heard at 90 mm Hg; the sound disappears at 72 mm Hg. When recording just the systolic and diastolic readings, what is the diastolic pressure? 72 mm Hg 90 mm Hg 100 mm Hg 130 mm Hg A client has edema in the lower extremities during the day, which disappears at night. With which medical problem does the nurse conclude this clinical finding is consistent? Pulmonary edema Myocardial infarction Deep vein thrombosis Right ventricular heart failure The treatment regimen for a female diagnosed with Hodgkin disease, stage III, will start with nodal irradiation. Because the client and her husband have been trying to conceive a child, the client becomes visibly anxious when she learns that the radiation therapy includes the pelvic nodal area. The nurse refers the client to the primary healthcare provider when the client starts to question the treatment. What is the rationale for the nurse’s actions? Radiation used is not radical enough to destroy ovarian function. Intermittent radiation to the area does not cause permanent sterilization. Reproductive ability may be preserved through a variety of interventions. Ovarian function will be destroyed temporarily but will return in about six months. The nurse is caring for a client who is experiencing signs and symptoms of a cardiac dysrhythmia and is scheduled to wear a Holter monitor for 24 hours. What should the client be instructed to do during the test? Keep a diary of activities. Stay away from microwave ovens. Avoid taking any nitroglycerin that day. Take both blood pressure and pulse every 2 hours. A low-dose intravenous dopamine hydrochloride infusion drip is prescribed for a client in acute renal failure (ARF). Which method is mostappropriate for the nurse to administer this medication to the client? Peripherally inserted central catheter (PICC) line #20 angiocatheter in either antecubital area Large-gauge butterfly needle in hand Femoral line When two nurses are getting an older adult out of bed, the client reports feeling light-headed. The nurse identifies that the client’s pulse is stable and the client’s color has not changed. What should the nurses assist the client to do? Slide slowly to the floor to prevent a fall and injury. Sit on the edge of the bed while they hold the client upright. Bend forward because this will increase blood flow to the brain. Lie down quickly so the legs can be raised above the heart level. A client with heart failure has anxiety. Which effect of anxiety makes it particularly important for the nurse to reduce the anxiety of this client? Increases the cardiac workload Interferes with usual respirations Produces an elevation in temperature Decreases the amount of oxygen used Before a client has a cardiac catheterization, an electrocardiogram (ECG) is performed, and hypokalemia is suspected. The nurse expects that the diagnosis will be confirmed by which diagnostic test? Complete blood count Serum potassium level X-ray film of long bones Blood cultures times three The primary healthcare provider prescribes a transfusion of 2 units of packed red blood cells for a client. When administering blood, what is the priority nursing intervention? Make sure the client’s family has received education. Warm the blood to 98° F (36.7° C) to prevent chills. Infuse the blood at a slow rate during the first 15 minutes. Draw blood samples from the client after each unit is transfused. A client is experiencing hypovolemic shock with decreased tissue perfusion. Which information should the nurse consider when planning care? The body initially attempts to compensate by releasing more red blood cells. The body initially attempts to compensate by maintaining peripheral vasoconstriction. The body initially attempts to compensate by decreasing mineralocorticoid production. The body initially attempts to compensate by producing less antidiuretic hormone (ADH). A client with a dysrhythmia is admitted to telemetry for observation. In the morning the client asks for a cup of coffee. What is the nurse’s bestresponse? "Hot drinks such as coffee are not good for your heart." "Coffee is not permitted on the diet that was prescribed for you." "You cannot have coffee. I can bring you a cup of tea if you like." "Coffee has caffeine that can affect your heart. It should be avoided." Which client statement indicates an understanding of the nurse’s instructions concerning a Holter monitor? "The only times the monitor should be taken off are for showering and sleep." "The monitor will record my activities and symptoms if an abnormal rhythm occurs." "The results from the monitor will be used to determine the size and shape of my heart." "The monitor will record any abnormal heart rhythms while I go about my usual activities." A client is seen in the clinic with sickle cell anemia. The parents of the client ask how their child got sickle cell anemia. What is an accurate explanation? Sickle cell anemia is a random condition with no known cause. If one parent is a carrier and one is negative for the gene, the child will get the disease. If both parents are carriers, all of their offspring will probably get this disease, and they should consider sterilization. If both parents are carriers, the odds are one in four that an offspring will get the disease, and one in four that an offspring will be disease free. A client with newly diagnosed multiple myeloma asks, "How long do you think I have to live?" What is the most appropriate response by the nurse? "Let me ask your primary healthcare provider for you." "I can understand why you are worried." "Tell me about your concerns as of the moment." "It depends on whether the tumor has spread." A client is admitted to the unit with a crushed chest, abdominal trauma, a probable head injury, and multiple fractures. The nurse should provide what initial emergency care? Start an intravenous (IV) line, get blood for typing and crossmatching, and obtain a history Assess vital signs, obtain a history, and arrange for emergency x-ray films Conduct a thorough physical assessment, assess vital signs, and cover open wounds Assess vital signs, control accessible bleeding, and determine the presence of critical injuries A client has an open reduction and internal fixation (ORIF) of a fractured hip. The nurse monitors this client for signs and symptoms of a fat embolism. Which client assessment finding reflects this complication? Fever and chest pain Positive Homans sign Loss of sensation in the operative leg Tachycardia and petechiae over the chest The nurse provides discharge teaching to a client with a history of angina. The nurse instructs the client to call for emergency services immediatelyif the client’s pain exhibits which characteristic? Causes mild perspiration Occurs after moderate exercise Continues after rest and nitroglycerin Precipitates discomfort in the arms and jaw A client is experiencing a myocardial infarction. What should the nurse identify as the primary cause of the pain experienced by a client with a coronary occlusion? Arterial spasm Heart muscle ischemia Blocking of the coronary veins Irritation of nerve endings in the cardiac plexus A primary healthcare provider prescribes an antihypertensive medication. Which over-thecounter medication should the nurse teach the client to avoid because it has the potential to counteract the effect of the antihypertensive? Omeprazole Acetaminophen Docusate sodium Pseudoephedrine A client's blood pressure increases dramatically six hours after a femoral-popliteal bypass graft. Which priority concern motivates the nurse to inform the primary healthcare provider? Hypertension may cause the graft to occlude. Hypervolemia may be the cause of the hypertension. Extremely high blood pressure may cause a brain attack. Rapidly increasing blood pressure may rupture the graft. A nurse is performing external cardiac compression. Which action should the nurse take? Extend the fingers over the sternum and chest with the heels of each hand side by side. Place the fingers of one hand on the sternum and the fingers of the other hand on top of them. Interlock the fingers with the heel of one hand on the sternum and the heel of the other on top of it. Clench the hand into a fist and place the fleshy part of a clenched fist on the lower sternum. A nurse is monitoring a client admitted with a diagnosis of myocardial infarction (MI) for dysrhythmias. Which reason for increased incidence of dysrhythmias in this client should the nurse monitor? Metabolic alkalosis Myocardial hypoxia Decreased catecholamine secretion Increased parasympathetic nervous system stimulation After an acute coronary syndrome a client begins a supervised, progressive jogging regimen and asks the nurse how to tell whether it is helping. What is the best response by the nurse? "Intermittent claudication will be reduced." "Your breathing will become regular and shallow." "Perspiration will be less when you run, and you'll use less energy." "You will be able to run progressively longer distances before tiring." The nurse assesses a client receiving intravenous (IV) fluids. Which assessment finding should warrant the nurse calling the primary healthcare provider? Crackles in lungs Supple skin turgor Urine output of 240 mL over 8 hours Increase in blood pressure from 110/76 to 124/68 mm Hg A client with a history of heart disease has been receiving a calcium channel blocker and morphine sulfate for pain from abdominal surgery. When getting the client out of bed, the nurse first should have the client sit on the edge of the bed with feet on the floor. What untoward client response can be prevented by this nursing action? Abdominal pain Respiratory distress Sudden hemorrhage Postural hypotension Knee-length elastic support stockings are prescribed for a client with varicose veins. What should the nurse teach the client about the elastic stockings? The stockings should reach the middle of the knee. The stockings should be applied before getting out of bed. The stockings should be applied at the first sign of discomfort. The stockings may be substituted with loose elastic bandages. An older client tells the nurse, "My legs begin to hurt after walking the dog for several blocks. The pain goes away when I stop walking, but it comes back again when I resume walking." Which condition does the nurse consider as the most likely cause of the client’s pain? Spinal stenosis Buerger disease Rheumatoid arthritis Intermittent claudication A client with impaired peripheral pulses and signs of chronic hypoxia in a lower extremity is scheduled for a femoral angiogram. What would be appropriate for the nurse to include in the postprocedure plan of care? Elevate the foot of the bed. Perform urinary catheter care every 12 hours. Place in the high-Fowler position. Perform a neurovascular assessment every 2 hours. A client with a history of heart failure and atrial fibrillation reports a nine-pound (four kilogram) weight gain in the last two weeks. Which factor does the nurse consider as the most likely cause of this sudden weight gain? Fluid retention Urinary retention Renal insufficiency Abdominal distention The laboratory data for a client with prolonged vomiting reveal arterial blood gases of pH 7.51, Pco 2 of 50 mm Hg, HCO 3 of 58 mEq/L (59 mmol/L), and a serum potassium level of 3.8 mEq/L (3.8 mmol/L). The nurse concludes that the findings support what diagnosis? Hypocapnia Hyperkalemia Metabolic alkalosis Respiratory acidosis What are the clinical manifestations of myocardial infarction in women? Select all that apply. Anoxia Indigestion Unusual fatigue Sleep disturbances Tightness of the chest A child has been diagnosed with hemophilia type A after experiencing excessive bleeding from a minor trauma. How is hemophilia inherited? X-linked recessive trait Y-linked recessive trait X-linked dominant trait Y-linked dominant trait A client with peripheral arterial insufficiency tells the nurse that walking sometimes results in severe pain in the calf muscles. Which information should the nurse share with the client? This is called rest pain. This is called intermittent claudication. This is called phantom limb sensation. This is called Raynaud phenomenon. A client is admitted to the coronary care unit with atrial fibrillation and a rapid ventricular response. The nurse prepares for cardioversion. What nursing action is essential to prevent the potential danger of inducing ventricular fibrillation during cardioversion? Energy level is set at its maximum level. Synchronizer switch is in the "on" position. Skin electrodes are applied after the T wave. Alarm system of the cardiac monitor is functioning simultaneously. A client’s monitor shows a PQRST wave for each beat and indicates a rate of 120 beats/minute. The rhythm is regular. What does the nurse conclude that the client is experiencing? Atrial fibrillation Sinus tachycardia Ventricular fibrillation First-degree atrioventricular block Which client is at greatest risk for the development of a venous thrombosis? A 76-year-old female with a 100-pack-per-year smoking history and hypertension A 68-year-old male on bed rest following a left hip fracture A 59-year-old male who is an intravenous drug user with hyperlipidemia A 42-year-old female with Factor V Leiden mutation on warfarin A nurse is caring for a client with hypertension. Which assessment finding most significantly indicates that a client is hypertensive? Tachycardia Extended Korotkoff sound Sustained systolic pressure ranging from 110 to 120 mm Hg Diastolic blood pressure that remains higher than 90 mm Hg