rn cardiovascular hematologic and lymphatic systems eaq
rn cardiovascular hematologic and lymphatic systems eaqthe nurse assesses a client for orthostatic hypotension the results are lying heart rat
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RN Cardiovascular Hematologic and Lymphatic System
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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
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