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RN Cardiovascular Hematologic and Lymphatic System.
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RN Cardiovascular Hematologic and Lymphatic SystemsEAQ
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? - ANSWER: Synchronizer switch is in the "on" position.
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? - ANSWER:
Notify the primary healthcare provider of the client's refusal of blood products.
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? - ANSWER: "The diet prescribed for your spouse is a healthy
diet. It contains guidelines that many of us should follow."
A client is admitted to the hospital with a long history of hypertension. The nurse
should assess the client for which complication? - ANSWER: Kidney failure
A client is diagnosed with hypertension that is related to atherosclerosis. Which
information should the nurse consider when planning care for this client? - ANSWER:
Lipid plaque formation occurs within the arterial vessels.
After abdominal surgery a client suddenly reports numbness in the right leg and a
"funny feeling" in the toes. What should the nurse do first? - ANSWER: Instruct the
client to remain in bed.
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? - ANSWER: Hold the dose of digoxin, administer the potassium chloride,
and call the primary healthcare provider immediately.
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? - ANSWER: Hypokalemia
A client who is considering sclerotherapy asks the nurse to explain what causes
varicose veins. Which response by the nurse is best? - ANSWER: "The cause is
incompetent valves of superficial veins."
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 should be instructed to do during the test? - ANSWER: Keep a diary of
activities.
The nurse encourages a client with Raynaud disease to stop smoking. Which primary
goal is the nurse trying to achieve? - ANSWER: Prevent peripheral vasoconstriction
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? - ANSWER: "You can resume sexual activity as soon as you can climb one
flight of stairs without fatigue or discomfort."
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? - ANSWER: Rapidly increasing blood pressure may rupture the
graft.
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? - ANSWER: Sinus tachycardia
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? - ANSWER:
Active participation in providing self-care
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?
- ANSWER: Fear
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? - ANSWER: Take the client's blood pressure in
the other arm and then schedule a healthcare practitioner's appointment for as soon
as possible.
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? -
ANSWER: A low hemoglobin level causes reduced oxygen-carrying capacity.
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? - ANSWER: Practice relaxation techniques.
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