Exam (elaborations)
EAQ NCLEX- Cardiovascular, Hematological, and Lymphatic
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QUESTIONS AND ANSWERS
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EAQ NCLEX: CARDIOVASCULAR,HEMATOLOGICAL, AND LYMPHATIC
EXAM GUIDE QUESTIONS AND
CORRECT ANSWERS
Which complica+on would the nurse consider in a client who just had a total
hip replacement and is experiencing restlessness and changes in menta+on?
- Bladder spasms
- Polycythemia vera
- Hypovolemic shock
- Pulmonary hypertension
These signs occur with hypovolemic shock because less blood is being
circulated to vital centers in the brain. A large loss of blood may occur during
and aDer orthopedic surgery. Urinary reten+on, not bladder spasms, may occur
aDer general anesthesia. Anemia and deep vein thrombosis, not an increase in
the total red blood cells (polycythemia vera), tend to occur aDer a total hip
replacement. Atelectasis and pneumonia are possible complica+ons of general
anesthesia, but pulmonary hypertension is not a postopera+ve complica+on.
Which physiological response occurs first when a client experiences sudden
hypovolemia caused by hemorrhage?
- Peripheral vasoconstric+on
- Eleva+on of serum cor+sol level
- Release of immature erythrocytes
- Increased an+diure+c hormone (ADH)
The ini+al response to hemorrhage is ac+va+on of the sympathe+c nervous
system, leading to increases in heart rate and peripheral vasoconstric+on,
,which shunts blood to essen+al core organs. The other responses also occur,
but more slowly. Cor+sol increases as part of the stress response, leading to
fluid reten+on, but this process occurs more slowly. Immature red blood cells
(erythrocytes) are released from the bone marrow, but this occurs more slowly
than vasoconstric+on. An increase in ADH causes fluid reten+on, but this
occurs more slowly.
Which behavior would the nurse expect a client to exhibit during the ini+al
stage of grieving aDer learning that a tumor is malignant and has metastasized
to several organs and that the illness is terminal?
- Crying uncontrollably
- Cri+cizing medical care
- Refusing to receive visitors
- Asking for a second opinion
Seeking other opinions to disprove the inevitable is a form of denial employed
by individuals who have illnesses with a poor prognosis. If the client is crying,
the client is aware of the magnitude of the situa+on and is past the stage of
denial. Cri+cism that is unjust oDen is characteris+c of the stage of anger.
Refusing to receive visitors is most common during the depression experienced
as one moves toward acceptance or during the acceptance stage.
Which physiological process causes temperature eleva+on aDer a client has
had a myocardial infarc+on?
- Tissue necrosis and inflamma+on
- Thrombosis followed by thrombolysis
- Sympathe+c nervous system s+mula+on
- Infec+ous process of myocardial muscle cells
The body's inflammatory response to myocardial necrosis causes an eleva+on
of temperature as well as leukocytosis within 24 to 48 hours aDer the event.
,Arterial thrombosis that causes myocardial infarc+on is followed by
thrombolysis, but does not cause elevated temperature. Sympathe+c ac+va+on
does commonly occur with stress associated with myocardial infarc+on but is
not the cause of fever. Myocardial infarc+on is not associated with an infec+ous
process.
Which waveform on an electrocardiogram (ECG) illustrates atrial
depolariza+on?
-A
-b
-c
-d
Op+on a reflects the P wave; it represents the electrical impulse star+ng at the
sinus node and spreading throughout the atria (atrial depolariza+on).
Waveform b reflects the QRS complex; it represents depolariza+on of the
ventricles. Op+on c reflects the T wave; it represents repolariza+on of the
ventricles. Waveform d reflects the U wave; it is believed to reflect late
ventricular repolariza+on or repolariza+on of the Purkinje fibers; it is
some+mes iden+fied in clients with hypokalemia.
Which explana+on would the nurse nurse give regarding purpose of early
ambula+on to a client who had surgery the previous day?
- Promote healing of the incision
- Decrease the incidence of urinary tract infec+ons
, - Allow nursing staff to change the bedding
- Keep blood from pooling in the legs to prevent clots
The muscular ac+on during ambula+on facilitates the return of venous blood to
the heart; this reduces venous stasis and minimizes the risk of postopera+ve
thrombophlebi+s. Protein and vitamin C promote wound healing. Walking is
not related to the preven+on of urinary tract infec+ons. Although nursing staff
oDen change the bed when clients are up ambula+ng, the purpose of early
ambula+on is the preven+on of client complica+ons, not making nursing
ac+ons more convenient for the staff.
Which type of shock is associated with a ruptured abdominal aneurysm?
- Vasogenic shock
- Neurogenic shock
- Cardiogenic shock
- Hypovolemic shock
When an abdominal aneurysm ruptures, hypovolemic shock ensues because
fluid volume deple+on occurs as the heart con+nues to pump blood out of the
ruptured vessel. Vasogenic shock results from humoral or toxic substances
ac+ng directly on the blood vessels, causing vasodila+on. Neurogenic shock
results from decreased neuromuscular tone, causing decreased
vasoconstric+on. Cardiogenic shock results from a decrease in cardiac output.
Which lymph nodes would the nurse expect to be affected first when a client is
diagnosed with Hodgkin disease?
- Cervical
- Axillary
- Inguinal
- Medias+nal
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