Exam (elaborations)
Med Surg ATI Cardiovascular and respiratory
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- Med Surg ATI Cardiovascular And Respiratory
Med Surg ATI Cardiovascular and respiratory
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Med Surg ATI Cardiovascular and respiratoryTest Questions And Answers
A nurse is caring for a client who is postoperative following vein ligation and
stripping for varicose veins. Which of the following actions should the nurse
take? - -Position the client supine with his legs elevated when in bed.
-A nurse is caring for a client who has an abdominal aortic aneurysm and is
scheduled for surgery. The client's vital signs are blood pressure 160/98 mm
Hg, heart rate 102/min, respirations 22/min, and SpO2 95%. Which of the
following actions should the nurse take?
Administer antihypertensive medication for blood pressure.
Monitor that urinary output is 20 mL/hr.
Withhold pain medication to prepare for surgery.
Take vital signs every 2 hr. - -The nurse should administer antihypertensive
medication for the elevated blood pressure because hypertension can cause
a sudden rupture of the aneurysm due to pressure on the arterial wall.
-A nurse is caring for a client who has hemophilia. The client reports pain
and swelling in a joint following an injury. Which of the following actions
should the nurse take?
Obtain blood samples to test platelet function.
Prepare for replacement of the missing clotting factor.
Administer aspirin for the client's pain.
Place the bleeding joint in the dependent position - -Prepare for replacement
of the missing clotting factor.
Hemophilia is a hereditary bleeding disorder in which blood clots slowly and
abnormal bleeding occurs. It is caused by a deficiency in the most common
clotting factor, factor VIII (hemophilia A). Aggressive factor replacement is
initiated to prevent hemarthrosis that can result in long-term loss of range of
motion in repeatedly affected joints.
-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
Jaundice with an enlarged liver
Petechiae and ecchymosis - -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 right-sided heart failure. Which of the
following findings should the nurse expect?
Decreased capillary refill
Dyspnea
Orthopnea
Dependent edema - -Dependent edema
Blood return from the venous system to the right atrium is impaired by a
weakened right heart. The subsequent systemic venous backup leads to
development of dependent edema.
-A nurse is caring for a client who has a demand pacemaker inserted with
the rate set at 72/min. Which of the following findings should the nurse
expect?
-Telemetry monitoring shows QRS complexes occurring at a rate of 74/min
with no pacing spikes.
-The client is experiencing premature ventricular complexes at 12/min.
-Telemetry monitoring shows pacing spikes with no QRS complexes
-The client is experiencing hiccups - -Telemetry monitoring shows QRS
complexes occurring at a rate of 74/min with no pacing spikes.
The nurse should not expect pacer spikes when the client's pulse is greater
than the set rate of 72/min, because the client's intrinsic rate overrides the
set rate of the pacemaker.
-A nurse is transfusing a unit of O-negative fresh frozen plasma to a client
whose blood type is B positive. Which of the following actions should the
nurse take?
Continue to monitor for manifestations of a transfusion reaction.
Remove the unit of plasma immediately and start an IV infusion of normal
saline solution.
Continue the transfusion and repeat the type and crossmatch.
Prepare to administer a dose of diphenhydramine IV - -Remove the unit of
plasma immediately and start an IV infusion of normal saline solution.
A client who receives FFP that is not compatible can experience a hemolytic
transfusion reaction. The nurse should stop the transfusion and infuse 0.9%
sodium chloride solution with new tubing.
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