ATI Quiz: Medical-Surgical: Cardiovascular and Hematology – Flashcards

question
A nurse is preparing to transfuse a unit of blood to a client. The nurse must verify which factor?
answer
Expiration date and time.
question
A nurse is assessing a client who has fluid volume overload from cardiovascular disorder. Which of the following manifestations should the nurse expect? (SATA)
answer
1) Jugular vein distension R: The increase in venous pressure due to excessive circulating blood volume results in neck vein distention. 2) Moist crackles R: This is an indicator of pulmonary edema that can quickly lead to death 3) Increased heart rate R: Fluid volume excess, or hypervolemia, is an expansion of fluid volume in the extracellular fluid compartment. This results in hypertension and tachycardia
question
A nurse is caring for a client with right sided heart failure. Which of the findings should the nurse expect?
answer
Dependent edema R: 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.
question
A nurse is caring for an adult client with sickle cell disease who has a history of having received many transfusions. The nurse realizes that because of this history the client is at risk for
answer
iron toxicity
question
A nurse is caring for a client with hemophilia who has an active bleed in a joint.
answer
prepare for replacement of the missing factor
question
Anurse is caring for a client whose abdominal aortic aneurysm is extending
answer
back and abdominal pain
question
A nurse is instructing a client after a MI about lifestyle changes. A client returns for a follow up visit to the cardiac clinic after hospitalization for an acute MI. Which indicates an understanding of the teaching?
answer
Before taking my medication, I will count my radial pulse rate
question
A nurse is caring for a client 5 days following a MI. The client has a sudden onset of SOB. The nurse notes that the clientappears air hungry and is coughing frothy, pink sputum. When auscultating breath sounds the nurse expects to hear which bilateral sound?
answer
coarse crackles
question
A nurse is caring for a client experiencing an acute angina attack. Monitor for?
answer
Transient abnormal PMI
question
A nurse is caring for a client diagnosed with complete heart block who has a demand pacemaker inserted. The pacer is set for 72 beats/min. Which EKG pattern indicates to the nurse failure to captuer?
answer
Sharp spikes at 72/min; QRS complexes at 50 beats/min
question
A nurse is caring for a client with aplastic anemia. The nurse expects the client to have which of the following symptoms?
answer
Pancytopenia, fatigue, and pale mucous membranes
question
A nurse is caring for a client diagnosed with angina pectoris and is scheduled to undergo a percutaneous transluminal coronary angioplasty. The nurse explains to the client that PTCA is used to do which of the following?
answer
Dilate an obstructed coronary artery
question
A nurse is caring for a client with pericarditis. Which of the following manifestations should the nurse expect to find on assessment?
answer
Dyspnea with hiccups
question
A nurse is caring for a client following a vein ligation and stripping for varicose veins. Following surgery, the nurse should know to place the client in which of the following positions?
answer
Supine with the legs elevated at a 15 degree angle
question
A nurse is caring for a client with a cardiac contusion. The nurse understands that blunt chest trauma commonly results in damage to which of the following?
answer
Right ventricle
question
A nurse administered a transfusion of fresh frozen plasma to a client. Four hours later, the client has repeat laboratory work drawn. Which value should the nurse analyze to evaluate the client's response?
answer
Prothombin time R: The nurse should review the client's prothrombin time after the administration of FFP, which is plasma rich in clotting factors. FFP is administered to treat acute clotting disorders. The desired effect is a decrease in the prothrombin time.
question
A nurse is caring for a client with a history of congestive heart failure at risk for development of fluid volume excess. the nurse realizes that a late manifestation of fluid overload is which of the following?
answer
pitting edema of +3
question
A nurse is caring for a client with pernicious anemia. The nurse should know that to treat this condition, the client will require which of the following?
answer
Monthly injections of vitamin B12
question
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?
answer
Continue to monitor the client for manifestations of transfusion reaction. R: 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.
question
A nurse is monitoring a client who had a myocardial Infarction. For which of the following complications should the nurse monitor in the first 24 hr?
answer
Ventricular dysrhythmia R: After a MI, the electrical conduction system of the heart can be irritable and prone to dysrhythmias. Ischemic tissue caused by the infarction can also interfere with the normal conduction patterns of the heart's electrical system
question
A nurse is caring for a client with dyspnea who is diagnosed as having congestive heart failure related to mitral stenosis. The nurse is aware the cause of the dyspnea is due to which of the follwoing?
answer
Fluid accumulation in the lungs
question
A nurse is caring for a client on telemetry who has an irregular radial pulse. The progress notes say that the client has had atrial flutter. Which EKG pattern does the nurse recognize as corresponding to atrial flutter?
answer
An atrial rate of 300, with 80 QRS complex per min
question
A client reports to ta nurse that she is using several herbal dietary supplements inculing flaxseed oil. The nurse recognizes that the health benefit of this supplement si to provide increased dietary
answer
Omega-3 fatty acids
question
A nurse is caring for a client with suspected hypovolemic shock. Which solution is appropriate for the nurse to administer in this ccircumstance?
answer
0.9% sodium chloride
question
A nurse is preparing to infuse a blood transfusion using packed red blood cells (250 ml) to a client in 4 hrs. The blood set delivers 10 gtts per ml. What is the proper drip rate to use for the unit of packed cells? (round to the nearest whole number)
answer
10 gtts/min
question
A nurse is caring for a client who wants to know when the therapeutic results of epoetin alfa will take effect. The nurse bases her response on the knowledge that epoetin alfa will improve hemoglobin and hematocrit levels in which of the following time frames?
answer
2-4 weeks
question
A nurse is assessing a client in the clinic with a history of arteriosclerosis obliterans. When assessing the client's lower extremities and ankles, the nurse will expect to observe which manifestaions of this condition?
answer
Thin shiny skin with minimal body hair
question
A nurse is assessing a client admitted who has an abdominal aortic aneurysm. Which of the following manifestations should the nurse expect?
answer
Lower back discomfort R: Abdominal aortic aneurysm involves a widening, stretching, or ballooning of the aorta. Back and abdominal pain indicate that the aneurysm is extending downward and pressing on lumbar spinal nerve roots, causing pain.
question
A nurse is caring for a client with congestive heart failure whose electrocardiogram shows a flattening of the T wave. Which of the following lab results should the nurse anticipate with this EKG?
answer
Potassium 2.8 mEq/L
question
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?
answer
Administer antihypertensive medication for blood pressure R: 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.
question
A nurse is assessing for cardiac tamponade on a client who had a coronary artery bypass grafts. Which of the following actions should the nurse take?
answer
Auscultate blood pressure for pulsus paradoxus
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question
A nurse is preparing to transfuse a unit of blood to a client. The nurse must verify which factor?
answer
Expiration date and time.
question
A nurse is assessing a client who has fluid volume overload from cardiovascular disorder. Which of the following manifestations should the nurse expect? (SATA)
answer
1) Jugular vein distension R: The increase in venous pressure due to excessive circulating blood volume results in neck vein distention. 2) Moist crackles R: This is an indicator of pulmonary edema that can quickly lead to death 3) Increased heart rate R: Fluid volume excess, or hypervolemia, is an expansion of fluid volume in the extracellular fluid compartment. This results in hypertension and tachycardia
question
A nurse is caring for a client with right sided heart failure. Which of the findings should the nurse expect?
answer
Dependent edema R: 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.
question
A nurse is caring for an adult client with sickle cell disease who has a history of having received many transfusions. The nurse realizes that because of this history the client is at risk for
answer
iron toxicity
question
A nurse is caring for a client with hemophilia who has an active bleed in a joint.
answer
prepare for replacement of the missing factor
question
Anurse is caring for a client whose abdominal aortic aneurysm is extending
answer
back and abdominal pain
question
A nurse is instructing a client after a MI about lifestyle changes. A client returns for a follow up visit to the cardiac clinic after hospitalization for an acute MI. Which indicates an understanding of the teaching?
answer
Before taking my medication, I will count my radial pulse rate
question
A nurse is caring for a client 5 days following a MI. The client has a sudden onset of SOB. The nurse notes that the clientappears air hungry and is coughing frothy, pink sputum. When auscultating breath sounds the nurse expects to hear which bilateral sound?
answer
coarse crackles
question
A nurse is caring for a client experiencing an acute angina attack. Monitor for?
answer
Transient abnormal PMI
question
A nurse is caring for a client diagnosed with complete heart block who has a demand pacemaker inserted. The pacer is set for 72 beats/min. Which EKG pattern indicates to the nurse failure to captuer?
answer
Sharp spikes at 72/min; QRS complexes at 50 beats/min
question
A nurse is caring for a client with aplastic anemia. The nurse expects the client to have which of the following symptoms?
answer
Pancytopenia, fatigue, and pale mucous membranes
question
A nurse is caring for a client diagnosed with angina pectoris and is scheduled to undergo a percutaneous transluminal coronary angioplasty. The nurse explains to the client that PTCA is used to do which of the following?
answer
Dilate an obstructed coronary artery
question
A nurse is caring for a client with pericarditis. Which of the following manifestations should the nurse expect to find on assessment?
answer
Dyspnea with hiccups
question
A nurse is caring for a client following a vein ligation and stripping for varicose veins. Following surgery, the nurse should know to place the client in which of the following positions?
answer
Supine with the legs elevated at a 15 degree angle
question
A nurse is caring for a client with a cardiac contusion. The nurse understands that blunt chest trauma commonly results in damage to which of the following?
answer
Right ventricle
question
A nurse administered a transfusion of fresh frozen plasma to a client. Four hours later, the client has repeat laboratory work drawn. Which value should the nurse analyze to evaluate the client's response?
answer
Prothombin time R: The nurse should review the client's prothrombin time after the administration of FFP, which is plasma rich in clotting factors. FFP is administered to treat acute clotting disorders. The desired effect is a decrease in the prothrombin time.
question
A nurse is caring for a client with a history of congestive heart failure at risk for development of fluid volume excess. the nurse realizes that a late manifestation of fluid overload is which of the following?
answer
pitting edema of +3
question
A nurse is caring for a client with pernicious anemia. The nurse should know that to treat this condition, the client will require which of the following?
answer
Monthly injections of vitamin B12
question
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?
answer
Continue to monitor the client for manifestations of transfusion reaction. R: 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.
question
A nurse is monitoring a client who had a myocardial Infarction. For which of the following complications should the nurse monitor in the first 24 hr?
answer
Ventricular dysrhythmia R: After a MI, the electrical conduction system of the heart can be irritable and prone to dysrhythmias. Ischemic tissue caused by the infarction can also interfere with the normal conduction patterns of the heart's electrical system
question
A nurse is caring for a client with dyspnea who is diagnosed as having congestive heart failure related to mitral stenosis. The nurse is aware the cause of the dyspnea is due to which of the follwoing?
answer
Fluid accumulation in the lungs
question
A nurse is caring for a client on telemetry who has an irregular radial pulse. The progress notes say that the client has had atrial flutter. Which EKG pattern does the nurse recognize as corresponding to atrial flutter?
answer
An atrial rate of 300, with 80 QRS complex per min
question
A client reports to ta nurse that she is using several herbal dietary supplements inculing flaxseed oil. The nurse recognizes that the health benefit of this supplement si to provide increased dietary
answer
Omega-3 fatty acids
question
A nurse is caring for a client with suspected hypovolemic shock. Which solution is appropriate for the nurse to administer in this ccircumstance?
answer
0.9% sodium chloride
question
A nurse is preparing to infuse a blood transfusion using packed red blood cells (250 ml) to a client in 4 hrs. The blood set delivers 10 gtts per ml. What is the proper drip rate to use for the unit of packed cells? (round to the nearest whole number)
answer
10 gtts/min
question
A nurse is caring for a client who wants to know when the therapeutic results of epoetin alfa will take effect. The nurse bases her response on the knowledge that epoetin alfa will improve hemoglobin and hematocrit levels in which of the following time frames?
answer
2-4 weeks
question
A nurse is assessing a client in the clinic with a history of arteriosclerosis obliterans. When assessing the client's lower extremities and ankles, the nurse will expect to observe which manifestaions of this condition?
answer
Thin shiny skin with minimal body hair
question
A nurse is assessing a client admitted who has an abdominal aortic aneurysm. Which of the following manifestations should the nurse expect?
answer
Lower back discomfort R: Abdominal aortic aneurysm involves a widening, stretching, or ballooning of the aorta. Back and abdominal pain indicate that the aneurysm is extending downward and pressing on lumbar spinal nerve roots, causing pain.
question
A nurse is caring for a client with congestive heart failure whose electrocardiogram shows a flattening of the T wave. Which of the following lab results should the nurse anticipate with this EKG?
answer
Potassium 2.8 mEq/L
question
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?
answer
Administer antihypertensive medication for blood pressure R: 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.
question
A nurse is assessing for cardiac tamponade on a client who had a coronary artery bypass grafts. Which of the following actions should the nurse take?
answer
Auscultate blood pressure for pulsus paradoxus
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