Elsevier Adaptive Quizzing - Quiz performance - Cardiovascular, hematologic, and lymphatic systems_

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Elsevier Adaptive Quizzing - Quiz performance

Performance Exi t

Cardiovascular, hematologic, and lymphatic systems Due Apr 10, 202Э by 11:59 pm

Passed Э71 out of 470 questions answered correctly

Completed on Feb 10, 202Э 12:11 pm

Incorrect (99)

Which factor is the likely cause of the laboratory result when arterial blood gases done on a client who is being resuscitated after cardiac arrest show a low pH?

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Ketoacidosis Irregular heartbeat

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Lactic acid production Sodium bicarbonate administration

Rationale Cardiac arrest causes decreased tissue perfusion, which results in anaerobic metabolism and lactic acid production. Fat-forming ketoacids occur in diabetes. An irregular heartbeat does not cause acidosis. Sodium bicarbonate causes alkalosis, not acidosis.

STUDY TIP: Determine whether you are a "lark" or an "owl." Larks, day people, do best getting up early and studying during daylight hours.

Owls, night people, are more alert after dark and can remain up late at night studying, catching up on needed sleep during daylight hours. It is better to work with natural biorhythms than to try to conform to an arbitrary schedule. You will absorb material more quickly and retain it better if you use your most alert periods of each day for study. Of course, it is necessary to work around class and clinical schedules. Owls should attempt to register for afternoon or evening lectures and clinical sections; larks do better with morning lectures and day clinical sections.

How far would the nurse depress the lower sternum when performing cardiac compression on an adult client?

0.75 to 1 inch (2–2.5 cm) 0.5 to 0.75 inch (1.Э–2 cm) 1 to 1.4 inches (2.5–Э.6 cm) 2 to 2.4 inches (5–6 cm)

Rationale Current adult cardiopulmonary resuscitation (CPR) guidelines indicate that the sternum should be depressed at least 2 inches (5 cm) and not more than 2.4 inches (6

cm) to compress the heart adequately between the sternum and vertebrae.

In infants, the recommendation is that the sternum is compressed by approximately one-third of the anteroposterior diameter of the chest, which is about 1.5 inches (Э.8 cm). In children up to the age of puberty, compressions should be about one-third of the anteroposterior diameter of the chest, which is about 2 inches (5 cm). In postpubertal adolescents, recommended compression depth is at the adult range of 2 to 2.4 inches (5–6 cm).

Test-Taking Tip: When using this program, be sure to note if you guess at an answer. This will permit you to identify areas that need further review.

Also, it will help you see how correct your guessing can be.

Which modifiable risk factor would the nurse include in a community presentation on cardiovascular risk factors? Select all that apply. One, some, or all responses may be correct.

Some correct answers were not selected

Weight Inactivity Cholesterol Tobacco use Homocysteine

Rationale Modifiable risk factors are those a person can change. Modifiable risk factors for cardiovascular disease include maintaining a healthy weight, getting regular physical activity, keeping cholesterol levels within normal limits, refraining from using tobacco, and monitoring homocysteine levels to make sure they are within the normal range.

Which action would the nurse take when performing external cardiac compression?

Extend the fingers over the sternum and chest with the heels of each hand side by side.

Place the fingers of 1 hand on the sternum and the fingers of the other hand on top of them.

Interlock the fingers with the heel of 1 hand on the sternum and the heel of the other on top of it.

Clench the hand into a fist and place the fleshy part of a clenched fist on the lower sternum.

Rationale Interlocking the fingers with the heel of 1 hand on the sternum and the heel of the other on top of it provides the best leverage for depressing the sternum. Thus the heart is adequately compressed, and blood is forced into the arteries. Grasping the fingers keeps them off the chest and concentrates the energy expended in the heel of the hand while minimizing the possibility of fracturing ribs. Pressure spread over 2 hands may inadequately compress the heart and fracture the ribs.

Application of pressure by the fingers is less effective; this provides inadequate cardiac compression. Both hands must be used; pressure on the lower portion of the sternum may fracture the xiphoid process, which can injure vital underlying organs.

Test-Taking Tip: Do not read too much into the question or worry that it is a 'trick.' If you have nursing experience, ask yourself how a classmate who is inexperienced would answer this question from only the information provided in the textbooks or given in the lectures.

Which explanation would the nurse give about the purpose of the procedure when a client with angina is scheduled to have a cardiac catheterization?

To obtain the pressures in the heart chambers

To determine the existence of congenital heart disease

To visualize the disease process in the

coronary arteries To measure the oxygen content of various heart chambers

Rationale Angina usually is caused by narrowing of the coronary arteries; the lumen of the arteries can be assessed by cardiac catheterization. Although pressures can be obtained, they are not the priority for this client; this assessment is appropriate for those with valvular disease. Determining the existence of congenital heart disease is appropriate for infants and young adults with cardiac birth defects. Measuring the oxygen content of various heart chambers is appropriate for infants and young children with suspected septal defects.

Which laboratory result is important to communicate quickly to the health care provider?

Blood glucose 98 mg/dL (5.44 mmol/L) Hemoglobin 14.1 g/dL (141 mmol/L)

Potassium Э.0 mEq/L

(Э.0 mmol/L) White blood cell 9200/mm Э (9.2 × 10 9/L)

Rationale A potassium level of Э.0 mEq/L (Э.0 mmol/L) is indicative of hypokalemia, which needs to be quickly communicated to the provider so that potassium supplementation can be started. Normal values for an adult

are Э.5 to 5.0 mEq/L (Э.5–5.0 mmol/L). The blood glucose level is within the normal range of 70 to 100 mg/dL (Э.89–5.55 mmol/L).

Hemoglobin of 14.1 (141 mmol/L) is within normal values. White blood cell level of 9200 cells/mm Э is within the normal range of 4000 to 11,000 cells/mm Э (4 to 11 × 10 9 /L).

Test-Taking Tip: Choose the best answer for questions asking for a single answer. More than one answer may be correct, but one answer may contain more information or more important information than another answer.

Which condition unrelated to cardiac disease is the major cause of right ventricular failure?

Hypovolemic shock

Chronic

kidney disease Chronic obstructive pulmonary disease (COPD)

Systemic inflammatory response

syndrome (SIRS)

Rationale COPD causes destruction of capillary beds around the alveoli, interfering with blood flow through the lungs from the right side of the heart and causing pulmonary hypertension. As the heart continues to strain against this resistance, right ventricular failure eventually results. Hypovolemic shock will not cause stress on the right side of the heart. Chronic kidney disease and the resulting fluid retention cause stress on the left side of the heart and left ventricular failure. SIRS may be associated with septic shock and high output heart failure, but it does not cause right ventricular failure.

Which response would the nurse make when the spouse of a client who has been newly diagnosed with angina tells the nurse, "I guess I'm going to have to cook 2 meals, one for my spouse and one for myself."?

"A heart-healthy diet includes foods that most people would enjoy eating."

"As long as you decrease salt and avoid frying foods, no other changes are needed."

"Buy foods in small amounts to avoid wasting food when cooking 2 different meals."

"To help your spouse stay on the heart-healthy diet, you should avoid eating at the same time."

Rationale Heart-healthy diets are low in cholesterol, sodium, and fat, particularly saturated fats, and high in vegetables and fruits; this type of diet is advocated for all individuals.

Although low salt and avoiding frying foods are part of a heart-healthy diet, there are other components as well. Because a heart-healthy diet can be used by both the client and the spouse, there is no need to worry about wasting food. Eating is a social activity, and the spouses should be encouraged to share meals.

Test-Taking Tip: Try putting questions and answers in your own words to test your understanding.

Which confirmitory test would the nurse anticipate for a client with a tentative diagnosis of Hodgkin disease?

Bone scan Lymph node biopsy Computed tomography (CT) scan Radioactive iodine ( 1Э1I) uptake study

Rationale The diagnosis depends on the identification of characteristic histological features of an excised lymph node. A bone scan is a diagnostic device to assess bony metastasis of cancers. CT scans identify the extent of the disease in the abdominal and thoracic cavities. The 1Э1I uptake study is not indicated for Hodgkin disease; it is used for radiotherapy or diagnosis of thyroid diseases.

Which suggestion would be given by the nurse when a client asks how to avoid leg swelling when taking long plane flights?

Relax in a reclining position.

Sit upright with legs extended.

Walk around at least every hour.

Sit in any position that relieves pressure on the legs.

Rationale Muscle contraction associated with walking prevents pooling of blood in the extremities and dependent edema. Movement of the legs is required, not inactivity such as reclining in the airplane seat. Sitting upright with legs extended for long periods will decrease venous return and lead to leg swelling. Sitting in any position that relieves pressure on the legs does not include movement, which is essential to prevent leg swelling.

Test-Taking Tip: Relax during the last hour before an exam. Your brain needs some recovery time to function effectively.

Which instruction will the home health nurse give when teaching a client with arterial insuÆciency of both lower extremities?

'Maintain elevation of both legs.'

'Massage the legs when they are painful.'

'Apply a hot water bottle to

the legs.'

'Check pulses in the legs regularly.'

Rationale Altered quantity and quality of pulses are the earliest indications of increasingly limited circulation. Maintaining elevation of both legs prevents the use of gravity to carry arterial blood to the legs and feet.

Massaging the legs when painful can release an embolus into the circulation and cause tissue trauma. Altered sensation may limit sensitivity to heat, which can result in burns.

Which action would the nurse take when planning room placement for a client with squamous cell carcinoma of the tongue that is to be treated with interstitially implanted radon seeds?

Assign the client to any type of room.

Place the client in a

private room.

Assign the client to a semiprivate room.

Place the client with another client receiving the same type of therapy.

Rationale Radon seeds emit radiation; the client should be isolated in a private room to decrease radiation to others. Assigning the client to any type of room is inappropriate and unsafe because the treatment emits radiation. A semiprivate room is contraindicated because this will expose other clients to radiation. A room with clients receiving the same therapy is contraindicated because this will expose other clients to radiation.

Which action by a client who requires an above-the-knee amputation for peripheral arterial disease best indicates emotional readiness for the surgery?

Explains the goals of the procedure

Displays few signs of

anticipatory grief Participates in learning perioperative care Verbalizes acceptance of permanent dependency needs

Rationale Active participation in learning self-care indicates emotional acceptance of the need for surgery and planning for the future after surgery.

Explaining the goals of the procedure may indicate intellectual readiness but not necessarily emotional readiness.

A client who displays no signs of grief with a loss like amputation may be in denial. The client need not be dependent permanently; verbalizing acceptance of permanent dependency needs indicates the need for more teaching and emotional support.

Which response would the nurse give when a client with varicose veins asks the nurse, "What can I do to help myself?"?

"Limit walking to as little as possible."

"Reduce fluid intake to 1 L of liquid a day."

"Apply moisturizing lotion on your legs several times a day."

"Put on compression hose before getting out of bed in the morning."

Rationale Compression hose provides external pressure, thereby facilitating venous return and minimizing blood pooling in the veins. Because venous return is better at night when the legs are at the same level as the heart, the hose should be put on before getting out of bed in the morning and before the legs are in the dependent position. The client should engage in exercise such as walking or swimming because muscle contraction encourages venous return to the heart. Limiting fluid intake will not alter the leakage of fluid or blood into the interstitial space; this occurs in response to the increased hydrostatic pressure in the veins. Although applying moisturizing lotion may make the skin suppler, it will not treat enlarged and tortuous veins.

Which physiological response explains why elevation in body temperature occurs in clients who experience acute coronary syndrome?

Parasympathetic reflexes

Inflammatory

response Catecholamine release Peripheral vasoconstriction

Rationale Temperature may increase within the first 24 hours after acute coronary syndrome as a result of the inflammatory response to tissue destruction and persist as long as a week. Parasympathetic activity caused by vagal stimulation might cause bradycardia in clients with acute coronary syndrome. Catecholamine release associated with acute coronary syndrome might cause hypertension or dysrhythmias such as atrial or ventricular tachycardia and ventricular fibrillation. Peripheral vasoconstriction associated with acute coronary syndrome may cause prolonged capillary refill, decreased peripheral pulse quality, or cool skin.

Which distinguishing sign unique to a fat embolus will a nurse montor for in a client with a distal femoral shaft fracture who is at risk for developing a fat embolus?

Oliguria Dyspnea

Petechiae

Confusion

Rationale At the time of a fracture or orthopedic surgery, fat globules may move from the bone marrow into the bloodstream. Also, elevated catecholamines cause mobilization of fatty acids and the development of fat globules. In addition to obstructing vessels in the lung, brain, and kidneys with systemic embolization of small vessels from fat globules, petechiae are noted in the buccal membranes, conjunctival sacs, hard palate, chest, and anterior axillary folds; these adaptations only occur with a fat embolism.

Oliguria, dyspnea, and confusion are signs of an embolus but are not specific to a fat embolus.

A client with heart failure weighed 175 lb yesterday, and today's weight is 181 lb. How many milliliters of fluid has the client retained? Record your 4000 answer using a whole 2700 number.

mL

Rationale One liter of fluid equals 1000 mL; each liter of fluid is equal to 1 kg of weight. 175 lb equals 79.4 kg and 181 lb equals 82.1 kg.

82.1 kg – 79.4 kg = 2.7 kg = 2700 mL. Test-Taking Tip: When taking the NCLEX-RN® exam, an on-screen calculator will be available for you to determine your response, which you will then type in the provided space.

Which information will the nurse include when teaching an unlicensed health care worker about blood pressure (BP) measurement? Select all that apply. One, some, or all responses may be correct.

Some correct answers were not selected

Support the client's arm at heart level when taking BP. Have the client rest for 5 minutes before measuring BP. Choose a larger BP cuff size for thinner clients.

Deflate the BP cuff at a rate of 5 to 10 mm Hg per second. Automatic BP machines are preferable to manually taking BPs.

Rationale Recommendations for accurate BP measurement include having the client's arm supported at heart level and having the client rest quietly for at least 5 minutes before

taking the BP. Thinner clients will need a smaller BP cuff. The cuff should be deflated at a rate of 2 to Э mm Hg per second. Automatic BP machines may be inaccurate in clients with hypotension or who have dysrhythmias.

Test-Taking Tip: Avoid taking a wild guess at an answer. However, should you feel insecure about a question, eliminate the alternatives that you believe are incorrect, and reread the information given to make sure you understand the intent of the question. This approach increases your chances of randomly selecting the correct answer or getting a clearer understanding of what is being asked. Although there is no penalty for guessing, the subsequent question will be based, to an extent, on the response you give to the question at hand; that is, if you answer a question incorrectly, the computer will adapt the next question accordingly based on your knowledge and skill performance on the examination up to that point.

Which action will the nurse include when developing a plan of care for a client who had a cardiac catheterization via a femoral insertion site?

Ambulating the client 2 hours after the procedure

Checking the vital signs every 15

minutes for 8 hours Maintaining the supine position for a minimum of 4 hours Keeping the client nothing by mouth for 4 hours after the procedure

Rationale The supine position prevents hip flexion, decreasing the risk for clot disruption and bleeding at the catheter insertion site; if the head of the bed is elevated, it should not exceed 20 degrees. Hip flexion when

rising to ambulate traumatizes the catheter insertion site and should be avoided for at least 4 hours to promote healing. Checking the vital signs every 15 minutes for 8 hours will interfere with rest; the vital signs are measured every 15 minutes until stable, usually for 1 hour. The gastrointestinal system is not involved, and general anesthesia is not used.

Test-Taking Tip: Identify option components as correct or incorrect. This may help you

identify a wrong answer. Example: If you are being asked to identify a diet that is specific to a certain condition, your knowledge about that condition would help you choose the correct response (e.g., cholecystectomy = low-fat, high-protein, low-calorie diet).

Which information regarding palliative care as opposed to hospice care would the nurse provide during a home visit to a client with heart failure who asks about this option?

To receive palliative care, a provider must certify that you have 6 months or less to live.

The goal of palliative care is to humanize the end-of-life experience, allowing you to die with dignity.

The focus of palliative care is to enhance you and your family's quality of life despite your heart failure.

By making the choice to begin palliative care, you must no longer pursue life- extending or curative medical treatment.

Rationale Palliative care is specialized medical care for clients and families that focuses on quality of life. Hospice care requires that a provider certify that the client has 6 months or less to live. The goal of hospice care is to humanize the end-of-life experience, allowing the client to choose how they will die and where. Clients receiving palliative care can still opt for life-extending or curative treatment, while those receiving hospice services cannot.

Which action by an unlicensed health care worker who is assisting with postprocedure care requires that the nurse intervene when caring for a client who has had cardiac catheterization using the femoral approach?

Taking the pulse every 15 minutes Keeping the client's legs extended

Offering the client a sandwich and juice Assisting the client to stand to void

Rationale When the femoral artery is used for cardiac catheterization, the client is maintained on bed rest for several hours to avoid bleeding at the femoral site, so assisting the client to stand is not an appropriate action for the unlicensed health care worker. Pulse and blood pressure are done every 15 minutes in the first hour after the procedure. The client's legs are kept in the extended position after the procedure to prevent tension on the femoral site and decrease bleeding risk. Because clients are kept nothing by mouth (NPO) before the procedure, giving a client something to eat after the procedure is appropriate.

Which diet choice by a client who has heart failure indicates that the nurse's teaching about diet has been effective?

Select all that apply. One, some, or all responses may be correct.

Some correct answers were not selected

Lean steak Fruit salad Broiled chicken Smoked salmon Roasted potatoes Macaroni and cheese

Rationale The priority dietary change for clients with heart failure is a low-sodium diet. Lean steak, fruit salad, broiled chicken, and roasted potatoes are all low in sodium. Smoked meats such as smoked salmon are high in sodium.

Cheese is high in sodium.

Test-Taking Tip: Get a good night's sleep before an exam. Staying up all night to study before an exam rarely helps anyone. It usually interferes with the ability to concentrate.

Which action by the nurse is a priority when a client who is receiving a transfusion of packed red blood cells (PRBCs) after cardiac surgery experiences chest discomfort, chills, and anxiety?

Administer nitroglycerin.

Monitor the client's vital signs.

Stop the transfusion and administer normal saline.

Ask the client to describe the pain using a 0 to 10 scale.

Rationale The chest discomfort and anxiety may indicate an acute hemolytic reaction to the transfusion; the nurse's first action would be to stop the transfusion and administer normal saline to improve renal perfusion and prevent acute kidney injury secondary to hemolysis. Nitroglycerin may need to be administered if the client is experiencing angina, but the first action when a hemolytic reaction is suspected would be to stop the transfusion and infuse saline. Monitoring the vital signs is important, but it would be done after stopping the transfusion to prevent ongoing exposure to the PRBCs. Asking the client to further describe symptoms is needed but not until risk for hemolysis is decreased by stopping the transfusion.

Which change that occurs with aging increases the risk for hypothermia in older adults? Select all that apply. One, some, or all responses may be correct.

Some correct answers were not selected

Increased metabolic rate Increased shivering response

Decreased amount of body fat Diminished energy reserves Chronic medical conditions

Rationale Many older adults have decreases in body fat, diminished energy reserves, and chronic medical conditions that increase the risk for hypothermia when exposed to cold.

Metabolic rate slows with aging, which increases hypothermia risk. The shivering response to cold decreases with age, and this increases hypothermia risk.

Which clinical manifestation is more likely to occur in women with coronary artery disease compared with men?

Select all that apply. One, some, or all responses may be correct.

Severe fatigue Sense of unease Substernal chest pain Shortness of breath Pain radiating down the left arm

Rationale

Women with coronary artery disease are more likely than men to describe initial clinical manifestations of severe fatigue unrelieved with adequate rest, a sense of unease with no identified cause, and feeling "unable to catch my breath". Men are more likely to present with "classic" symptoms such as substernal chest pain and pain radiating down the left arm. However, it is important to remember that any individual client may present any of the symptoms listed above, and the nurse would assess all clients for all potential clinical manifestations of coronary artery disease.

Which risk factor is the highest priority when teaching a 68year-old client who has multiple risk factors for peripheral arterial disease, including client age, siblings with diabetes, a sedentary lifestyle, and family history of heart disease?

Older age Low activity level Blood glucose control Family history of cardiac disease

Rationale The client's low activity level is a modifiable risk factor and would be the focus of client teaching. Older age does increase risk for peripheral arterial disease, but it cannot be changed by the client. Blood glucose control may be a concern in the future for this client, but it is not currently a risk factor. Family history of cardiac disease does increase the client's risk for peripheral arterial disease, but family history is not a modifiable risk factor.

STUDY TIP: Establish your study priorities and the goals by which to achieve these priorities. Write them out and review the goals during each of your study periods to ensure focused preparation efforts.

Which result is most important to communicate to the primary health care provider when the nurse reviews laboratory results in a client who has positive testing for occult blood in the stool?

Iron level 100 mcg/dL (22 mcmol/L)

Hemoglobin level 8.5 g/dL (85 mmol/L) Э

Platelet count 160,000/mm

(160 × 10 9/L) Transferrin level Э00 mg/dL (Э g/L)

Rationale Intermittent or continuous loss of a small amount of blood over extended periods will lead to a decreased hemoglobin level; 8.5 g/dL (85 mmol/L) is below the expected hemoglobin range for men (14–18 g/dL; 140–180 mmol/L) and women (12–16 g/dL; 120–160 mmol/L). The low level indicates a need for further testing and intervention and would be reported rapidly to the health care provider. An iron level of 100 mcg/dL (22 mcmol/L) is within the expected range of 60 mcg/dL to 180 mcg/dL (14–Э2 mcmol/L). The platelet count is within the expected range of 150,000/mm Э to 400,000/mm Э (150–400 × 10 9/L). Transferrin level Э00 mg/dL (Э g/L) is within the expected range of 215 mg/dL to Э80 mg/dL (2.15–Э.80 g/L).

Which laboratory value would the nurse use to determine whether a client is receiving a therapeutic dose of intravenous heparin?

International normalized ratio (INR) is between 2 and Э

Prothrombin time (PT) is 2.5 times the

control value Activated partial thromboplastin time (APTT) is 70 seconds Activated clotting time (ACT) is in the range of 70 to 120 seconds

Rationale When a client is receiving intravenous heparin, the APTT should be 1.5 to 2 times the normal APTT of 40 seconds, or 60 to 80 seconds. INR and PT are used to evaluate therapeutic levels of warfarin. The ACT is not commonly used for monitoring of heparin, but ACT increases to a range of 150 to 200 seconds when heparin reaches therapeutic levels.

Which fluid therapy will the nurse prepare to infuse when a client with hypovolemic shock has a hematocrit value of 25%?

Lactated Ringer solution Human serum albumin 5%

Packed red blood cells High molecular weight dextran

Rationale Blood replacement is needed to increase the oxygen-carrying capacity of the blood; the expected hematocrit for women is Э7% to 47% and for men is 42% to 52%. The other three fluids will increase volume, but will not improve the oxygen-carrying capacity of the blood. Lactated Ringer solution does not increase the oxygen-carrying capacity of the blood.

Serum albumin helps maintain volume but does not affect the hematocrit level. Although dextran does expand blood volume, it decreases the hematocrit because it does not replace red blood cells.

Which topic will the nurse include in teaching for a client with Raynaud disease?

Tobacco avoidance

Dietary

salt reduction Need for increased exercise

Low-fat, low-

cholesterol diet

Rationale The symptoms of Raynaud disease are caused by sudden arterial vasoconstriction and tobacco use also causes arterial vasoconstriction, which will worsen symptoms. Dietary salt is not a factor in causing the sudden arterial spasm that leads to the symptoms of Raynaud disease. There is no

indication for increased exercise in Raynaud disease, although the nurse will teach the client to avoid exercising in cold temperatures.

Raynaud disease is not caused by atherosclerosis, and a low-fat, lowcholesterol diet will not help prevent symptoms.

Test-Taking Tip: Do not spend too much time on one question, because it can

compromise your overall performance. There is no deduction for incorrect answers, so you are not penalized for guessing. You cannot leave an answer blank; therefore, guess. Go for it! Remember: You do not have to get all the questions correct to pass.

Place the steps to obtaining an orthostatic blood pressure assessment in order.

1.

Explain procedure to client.

2.

Obtain correct-sized blood pressure cuff.

Э.

Have client in supine position for 5 minutes, and take blood pressure.

4.

Have client stand and take blood pressure immediately.

5.

Take blood pressure with client standing after Э minutes.

6.

Assist client to a sitting position.

7.

Obtain blood pressure in sitting position after waiting Э minutes.

8.

Document blood pressures, pulses, and client tolerance.

Rationale

Using the correct-sized sphygmomanometer and working stethoscope, rather than palpation, is important in obtaining accurate findings. Every procedure must be explained to the client. Obtaining equipment first demonstrates organization. Having

the client in the supine position for 5 minutes before obtaining the first reading ensures that the client has adapted to this position. The nurse then assists the client to the sitting position and determines whether there is any dizziness. Waiting Э minutes demonstrates that the client has adapted to the sitting position before obtaining the blood pressure.

Taking the blood pressure immediately upon standing will demonstrate orthostatic hypotension; repeating the procedure after Э minutes will show adaptation to change of position. Documenting the blood pressure in each of the positions, which arm was used to perform the procedure, symptoms if any, and interventions, provides pertinent information for the primary health care provider.

Orthostatic hypotension is a systolic drop of more than 15 mm Hg and an increase of more than 10 mm Hg diastolic. This is particularly significant because of increased risk of falling.

STUDY TIP: Focus your study time on the common health problems that nurses most frequently encounter.

Which nursing action is most important preoperatively for a client with an abdominal aortic aneurysm?

Administering supplemental oxygen

Maintaining a low blood

pressure Keeping the client in a supine position

Monitoring the femoral

and pedal pulses

Rationale Maintaining a low blood pressure reduces the risk of aortic rupture.

Administering supplemental oxygen may or may not be necessary.

Keeping the client in a supine position may or may not be necessary.

Monitoring pulses distal to the aneurysm will help identify whether an aneurysm has ruptured, but it will not prevent rupture.

Which clinical manifestation would the nurse expect when assessing a client who is diagnosed with cardiogenic shock?

Select all that apply. One, some, or all responses may be correct.

Some correct answers were not selected

Tachycardia Restlessness Warm, moist skin Decreased urinary output Bradypnea

Rationale The heart rate increases (tachycardia) and the respiratory rate increases (tachypnea, not bradypnea) in an attempt to meet the oxygen demands of the body. Restlessness occurs because of cerebral hypoxia. The urine output drops to less than Э0 mL/h because of decreased arterial perfusion to the kidneys and the compensatory mechanism of reabsorbing fluid to increase the circulating blood volume. The skin becomes cool and pale as blood shunts from the peripheral blood vessels to the vital organs.

Test-Taking Tip: The computerized NCLEX exam is an individualized testing experience in which the computer chooses your next question based on the ability and competency you have demonstrated on previous questions. The minimum number of questions will be 75 and the maximum 265. You must answer each question before the computer will present the next question, and you cannot go back to any previously answered questions. Remember that you do not have to answer all of the questions correctly to pass.

Which assessment finding will the nurse expect when caring for a client with peripheral arterial disease? Select all that apply.

One, some, or all responses may be correct.

Absence of hair on the toes Pink and moist ankle ulcers Pitting edema of the lower legs Reports of pain associated with exercising Increased pigmentation of the medial malleolus area

Rationale The absence of hair on the toes occurs because of diminished circulation. Reports of pain associated with exercising (intermittent claudication) are common because the increased need for oxygen leads to ischemia when the arterial flow is impaired. Pink and moist ulcers are associated with venous insuÆciency; arterial ulcers are pale and dry because of decreased blood flow. Pitting edema of the lower extremities is associated with venous insuÆciency. Increased pigmentation of the medial and lateral malleolus areas is associated with venous insuÆciency.

Which clinical finding would the nurse expect when assessing a client who has cardiogenic shock? Select all that apply. One, some, or all responses may be correct.

Some correct answers were not selected

Pallor Agitation Tachycardia

Narrow pulse pressure Decreased respirations

Rationale Pale skin (pallor), agitation, tachycardia, and narrow pulse pressure are signs of cardiogenic shock due to decreased cardiac output. Respiratory rate will increase with cardiogenic shock as a compensatory mechanism for poor tissue oxygenation.

Which dietary choice would the nurse teach for the client with peripheral arterial disease? Select all that apply. One, some, or all responses may be correct.

Limit salt intake.

Choose foods high in calcium. Eat whole-grain breads.

Use liquid vegetable oils.

Reduce fresh fruits and vegetables. Avoid processed meats.

Rationale Because peripheral arterial disease is caused by atherosclerosis, the nurse would teach the client heart-healthy diet principles such as limiting salt, eating more whole grains, using liquid rather than solid oils in cooking, and avoiding processed meats. High calcium intake does not prevent atherosclerosis. Intake of fresh fruits and vegetables would be increased because these will help lower atherosclerosis risk.

Test-Taking Tip: Answer every question. A question without an answer is always a wrong answer, so go ahead and guess.

Which finding would the nurse expect when assessing a client with peripheral arterial disease? Select all that apply. One, some, or all responses may be correct.

Pallor of feet Warm extremities Ulcers on the toes Thick, hardened skin Delayed capillary refill

Rationale Peripheral arterial disease affects arterial circulation and results in delayed and impaired circulation to the extremities. As a result, the extremities exhibit pallor, ulcers on the feet and toes, cool skin, and capillary refill longer than Э seconds. Warm extremities occur with venous disease.

Venous disease leads to thick, hardened skin on the legs.

Test-Taking Tip: The following are crucial requisites for doing well on the NCLEX exam: (1) A sound understanding of the subject; (2) The ability to follow explicitly the directions given at the beginning of the test; (Э) The ability to comprehend what is read; (4) The patience to read each question and set of options carefully before deciding how to answer the question; (5) The ability to use the computer correctly to record answers; (6) The determination to do well; (7) A degree of confidence.

Which clinical manifestation will the nurse expect when caring for a client with pulmonary edema? Select all that apply. One, some, or all responses may be correct.

Crackles Coughing Orthopnea

Yellow sputum Dependent edema

Rationale Fluid moves into the pulmonary interstitial space and then into the alveoli; this results in crackles, severe dyspnea, and coughing. Sitting upright while leaning forward with the arms supported (orthopnea) is an attempt to maximize thoracic expansion and limit the pressure of abdominal organs against the diaphragm. Yellow sputum indicates infection, not pulmonary edema. With pulmonary edema, the sputum may be frothy and blood-tinged. Pulmonary interstitial edema, not dependent edema, occurs.

Which response will the nurse make to explain the discoloration when a client with venous insuÆciency has questions about the brownish discoloration of the skin on the legs?

"The arterial blood supply is inadequate."

"There is delayed healing in the area after an injury."

"The production of melanin in the area

has increased."

"There is leakage of red blood cells [RBCs] through the vein wall."

Rationale Increased venous pressure alters the permeability of the veins, allowing extravasation (leakage out of vessels) of RBCs; lysis of RBCs causes brownish discoloration of the skin. Venous insuÆciency does not affect arterial circulation. Although healing may be delayed, the brownish

discoloration does not result from trauma. There is no increase in melanin production in the area with varicose veins.

Test-Taking Tip: Many times the correct answer is the longest alternative given, but do

not count on it. Item writers (those who write the questions) are also aware of this and attempt to avoid offering you such "helpful hints."

Which clinical manifestation would the nurse expect to find when assessing a client with varicose veins? Select all that apply. One, some, or all responses may be correct.

Some correct answers were not selected

Presence of ankle edema Increased leg fatigue Diminished peripheral pulses Report of leg fullness and pruritus Leg pain with activity that resolves with rest

Rationale The presence of ankle edema, increased leg fatigue, and a report of leg fullness and pruritus are all signs of varicose veins, due to poor venous return and increased venous pressure. Diminished peripheral pulses occur with decreased arterial blood flow. Intermittent claudication (as evidenced by leg pain with activity that resolves with rest) occurs with decreased arterial, not venous, perfusion.

Which clinical finding would the nurse expect when assessing a client with varicose veins?

Positive Homans sign Pallor of the affected extremity Prolonged capillary refill in the toes. Sensation of heaviness in lower legs

Rationale Because of dilation in the veins, decrease in venous return, and edema, the client may experience heaviness in the legs. Homans sign is calf pain when the ankle is dorsiflexed; usually it is related to venous thromboembolism. Pallor indicates decreased tissue perfusion that may be caused by decreased arterial blood flow.

Prolonged capillary refill is seen with decreased arterial perfusion to the feet.

Which clinical finding would the nurse expect when completing the admission assessment of a client with a large abdominal aortic aneurysm who is admitted for elective surgery?

Elevated heart rate Visible peristaltic waves

Radiating

abdominal pain Pulsating abdominal mass

Rationale With an abdominal aortic aneurysm, a pulsating midline mass can be palpated with each heartbeat. Signs of shock such as tachycardia would not be expected unless the aneurysm ruptures or dissects. Visible peristaltic waves are associated with intestinal obstruction. Radiating abdominal pain is not typical for an abdominal aortic aneurysm, but may be seen with enlargement or rupture of the aneurysm.

Test-Taking Tip: Keywords or phrases in the stem of the question such as flrst, primary, early, or best are important. Similarly, words such as only, alNays, never, and all in the alternatives are frequently evidence of a wrong response. As in

life, no real absolutes exist in nursing; however, every rule has its exceptions, so answer with care.

When both parents have sickle cell trait, what is the chance that a child will have sickle cell disease?

25%

50% 75% 100%

Rationale Sickle cell is an autosomal recessive genetic disorder. If both individuals have sickle cell traits, there is a 25% chance they will produce a child with the disease. Children will have a 50% chance of having sickle cell trait. A 75% chance of having offspring sickle cell trait or disease is not mathematically possible. A child born of parents who both have sickle cell disease will have 100% chance of having the disease.

Test-Taking Tip: Stay away from other nervous students before the test. Stop reviewing at least Э0 minutes before the test. Take a walk, go to the library and read a magazine, listen to music, or do something else that is relaxing. Go to the test room a few minutes before class time so that you are not rushed in settling down in your seat.

Tune out what others are saying. Crowd tension is contagious, so stay away from it.

Which clinical manifestation would the nurse expect to find in a client with hypokalemia? Select all that apply. One, some, or all responses may be correct.

Thirst Anorexia Leg cramps Rapid, thready pulse Dry mucous membranes

Rationale

The gastrointestinal manifestations associated with hypokalemia are caused by decreased neuromuscular irritability of the gastrointestinal tract; this results in anorexia, nausea, vomiting, and decreased peristalsis. Because of potassium's role in the sodium-potassium pump, hypokalemia results in altered neuromuscular functioning, which precipitates leg cramps. Thirst is associated with hypernatremia. Rapid, thready pulse is associated with dehydration and hyponatremia. Dry mucous membranes are associated with hypernatremia.

Which is the best action for the nurse to take when a client with hypertension tells the nurse, "I took the blood pressure pills for a few weeks, but I didn't feel any different, so I decided I'd only take them when I feel sick." ?

Educate the client about the complications associated with high blood pressure.

Ask the client questions to determine the current understanding of high blood pressure.

Emphasize the importance of taking blood pressure medications now to continue to feel well.

Show the client the current blood pressure and compare that with normal blood pressure levels.

Rationale Further assessment of the client's understanding of hypertension and treatment is important before the nurse can develop an effective plan to change the client's behavior. Education about complications of hypertension may be helpful, but first the nurse needs to know what the client already understands about the long-term effects of high blood pressure. An emphasis on taking medications now to ensure future health may be appropriate for this client, but further assessment is

needed before using this strategy. Many clients may respond to actually seeing the difference between their blood pressures and the expected normals, but more information about the client's knowledge is needed to know if this will be a useful strategy for this client.

Which action would the nurse take first when a client is admitted to the unit with a crushed chest, abdominal trauma, a probable head injury, and multiple fractures?

Establish an airway and stabilize the cervical spine.

Assess heart sounds and find carotid and femoral pulses.

Check for alertness, orientation, and pupil

reaction to light.

Remove clothing to enable

further assessment of injuries.

Rationale The initial actions after a traumatic injury are based on the ABCDE mnemonic: Airway/Cervical Spine, Breathing, Circulation, Disability, Exposure. The first action by the nurse would be to establish a patent airway and ensure that the cervical spine is stabilized. Assessment of heart sounds and pulses would be done after breath sounds and ventilation were assessed. Assessment of neurological status is done as part of the disability assessment after circulation is assessed. Removal of clothing to enable assessment of other injuries is part of the exposure assessment, after assessment for disability.

Test-Taking Tip: Key words or phrases in the stem of the question such as flrst, primary, early, or best are important. Similarly, words such as only, alNays, never, and all in the alternatives are frequently evidence of a wrong response. As in life, no real absolutes exist in nursing; however, every rule has its exceptions, so answer with care.

Which action would the nurse take to help alleviate the distress of a client with heart failure and pulmonary edema?

Encourage frequent coughing.

Elevate the client's lower extremities.

Prepare for modified postural drainage.

Place the client in the orthopneic position.

Rationale The orthopneic, or tripod position, allows maximum lung expansion because gravity reduces the pressure of the abdominal viscera on the diaphragm and lungs. Coughing is useful for clients who have excessive mucus in the airways, such as clients with pneumonia, but is not useful for clearing pulmonary edema. Elevation of the extremities should be prevented because it increases venous return, placing an increased workload on the heart. Positioning for postural drainage does not relieve acute dyspnea; furthermore, it increases venous return to the heart.

Test-Taking Tip: Being emotionally prepared for an examination is key to your success. Proper use of resources over an extended period of time ensures your understanding and increases your confidence about your nursing knowledge. Your lifelong dream of becoming a nurse is now within your reach! You are excited, yet anxious. This feeling is normal. A little anxiety can be good because it increases awareness of reality; but excessive anxiety has the opposite effect, acting as a barrier and keeping you from reaching your goal. Your attitude about yourself and your goals will help keep you focused, adding to your strength and inner conviction to achieve success.

Which action will the nurse take for a client with a suspected pulmonary embolus? Select all that apply. One, some, or all responses may be correct.

Some correct answers were not selected

Administer oxygen at high flow rates. Notify the Rapid Response Team.

Lower the head of the client's bed. Place the client on a cardiac monitor.

Anticipate rapid administration of warfarin.

Rationale Administration of oxygen at high flow rates (typically through a nonrebreather mask) will optimize the client's oxygen saturation. The Rapid Response Team will be notified immediately because clients with pulmonary embolus may rapidly develop severe hypoxemia and hypotension. Cardiac monitoring is needed because the client is at risk for dysrhythmias. The head of the bed will be raised to allow fuller lung expansion and improve oxygenation. Warfarin is a slow-acting anticoagulant and would not be given initially to a client with pulmonary embolism. Rather, the nurse will anticipate the need to administer rapidly acting anticoagulants such as fractionated or unfractionated heparin.

Which prescribed action has the highest priority when a client comes to the emergency department with moderate substernal chest pain that is unrelieved by rest and nitroglycerin?

Administer morphine sulfate.

Transfer to the coronary care unit.

Obtain a 12-lead electrocardiogram (ECG).

Have a blood specimen drawn for troponin studies.

Rationale Current guidelines state that an ECG should be done and reviewed by the health care provider within 10 minutes of the arrival of a client with possible acute coronary syndrome. The other actions are also essential.

Administration of morphine sulfate will be done to relieve pain, but the ECG has priority because the presence or absence of ECG changes will determine whether the client needs immediate interventions such as percutaneous coronary intervention or thrombolysis. The client will be transferred as

quickly as possible to the coronary care unit, but the ECG would be done in the emergency department. Obtaining blood for troponin should be done as quickly as possible, but the presence or absence of elevated troponin will not affect decision- making about the client's immediate care.

Which finding would be of most concern when the nurse is caring for a client who had a femoral-popliteal bypass graft 6 hours previously?

Blood pressure 192/98 mm Hg Sinus rhythm rate 100 beats/minute

Client report of

ongoing incisional pain Capillary refill of operative leg at 4 seconds

Rationale High blood pressure places pressure on the graft incisions and may cause rupture at the graft anastomosis. The health care provider would be notified so that actions to reduce blood pressure could be started. A heart rate at the upper limit of normal will be monitored, but no immediate action is needed. Ongoing incisional pain is not unusual a few hours after surgery; the nurse will assess and treat the pain as prescribed. Slightly longer than normal capillary refill will be monitored, but no other immediate action is needed.

Which action would the nurse take next when a client with a history of hypertension that is usually successfully treated with medications has a blood pressure of 160/100 mm Hg during a clinic appointment?

Teach the client about the need for a low sodium diet.

Ask the client when blood pressure medications were taken last.

Question the client about symptoms such as headache or chest pain.

Call for an ambulance to transport the client to the emergency department.

Rationale The nurse's initial action would be to determine if the client is having symptoms that might indicate acute complications such as stroke or acute coronary syndrome. The

client may need teaching about dietary sodium reduction, but more assessment is needed before the nurse implements teaching. Failure to take blood pressure medications is a common reason that clients have sudden increases in blood pressure, but it is more important to determine if the client is having complications caused by the elevated blood pressure. If the client is having symptoms of stroke or acute coronary syndrome, an ambulance would be called for transport to the hospital, but an elevated blood pressure alone is not an indicator of a need for emergency services.

Which clinical parameter will be most important for the nurse to assess when administering warmed intravenous fluids to a client with hypothermia?

Hematocrit Cardiac rhythm Intake and output Blood urea nitrogen

Rationale Because dysrhythmias can occur during rewarming and may need treatment, ongoing cardiac monitoring is essential. Hematocrit may increase with hypothermia and would be expected to improve with administration of warm fluids, but changes in hematocrit during rewarming are expected.

Intake and output would be monitored during intravenous infusion, but are not as important to monitor as cardiac rhythm. Renal failure may occur as a complication of hypothermia and blood urea nitrogen would be monitored, but is not as important to monitor as cardiac rhythm.

Which response would be given by the nurse when a client admitted for mitral valve surgery tells the nurse, "I am not worried at all about the surgery!"?

"You really don't need to hide your anxieties." "You sure came to the right place for a valve job."

"I'm glad to see you're handling the situation well."

"I think you may still have questions about the surgery."

Rationale "I think you may still have questions about the surgery," is open-ended and encourages the client to ask any questions and address concerns. The response, "You really don't need to hide your anxieties," fails to acknowledge what the client has said and puts the client on the defensive.

The response, "You sure came to the right place for a valve job," cuts off further communication. The response, "I'm glad to see you're handling the situation well," may discourage the client from asking questions and cut off further communication.

How would the nurse document this rhythm for a client who has just arrived in the emergency department?

Atrial flutter Atrial fibrillation Second-degree heart block

Supraventricular

tachycardia

Rationale The rhythm strip shows the sawtooth atrial waves at a rate of about Э00 that are characteristic of atrial flutter. Not every atrial impulse is conducted to the ventricles

and the QRS rate is 75 to 80. Atrial fibrillation is characterized by the presence of low amplitude fibrillatory waves originating in the atria, with irregularly irregular QRS waves. With second-degree heart block, P waves would appear normal, but not every P wave would be followed by a QRS. Supraventricular tachycardia would have P waves at a rate of 150 to 220 and each P wave would be followed by a QRS. Test-Taking Tip: Answer every question. A question without an answer is always a wrong answer, so go ahead and guess.

Which finding by the nurse who is caring for a client who had a left pneumonectomy would be immediately communicated to the health care provider?

Absent left sided breath sounds Client report of 9 out of 10 incisional pain

Blood pressure of

162/90 mm Hg Crackles heard throughout the right lung

Rationale Because fluid overload can occur after pneumonectomy because of the loss of a large vascular bed, the crackles need to be reported immediately; the nurse would anticipate actions such as decreasing intravenous infusion rates and administrating a diuretic.

Absent left-sided breath sounds are expected after left pneumonectomy.

Severe incisional pain indicates a need for the administration of prescribed analgesics but is not life-threatening. Elevated blood pressure will be reported to the health care provider, but is not unusual when clients experience pain or stress during the postoperative period.

Test-Taking Tip: When using this program, be sure to note if you guess at an answer. This will permit you to identify areas that need further review.

Also, it will help you see how correct your guessing can be.

Which finding requires the most rapid action when the nurse is assessing a client with laryngeal cancer who has had radical neck surgery?

Crackles at both lung bases Blood pressure 102/54 mm Hg

Client report of

severe neck pain Rapid oozing of blood at neck incision

Rationale Rapid oozing of blood at the neck incision may indicate carotid artery rupture, which can occur because of the proximity of the carotid artery to the surgical area and the possibility that age or the disease process has weakened the carotid artery. The nurse would apply pressure to the site and have the surgeon notified immediately, anticipating the need to give intravenous fluids and transport the client rapidly to surgery. The other assessment findings also require action but are not indicative of life-threatening complications. Bibasilar crackles in a postoperative client are common because of poor deep breathing during and after surgery. The nurse would assist the client to cough and deep breathe, but no other action is needed. The blood pressure requires ongoing monitoring, but no other immediate action. The client would be medicated for pain after the nurse has ensured that bleeding has stopped and that the client is hemodynamically stable.

Which assessment finding is most important to report to the health care provider when caring for a client who has pancytopenia after treatment for Hodgkin disease?

Fatigue

Hematocrit Э2% Occult blood in stool Temperature 100.8°F (Э8.2°C)

Rationale Bone marrow depression lowers levels of white blood cells, red blood cells, and platelets. Because infection is the most common cause of morbidity and death in clients with cancer, the elevated temperature needs to be reported quickly so that diagnosis and treatment of infection can be initiated. Fatigue may occur with anemia but does not need rapid intervention. A low hematocrit will be reported, but Э2% is not dangerously low and no immediate action is needed. Occult blood in stools may occur because of low platelet levels but is not life threatening.

Test-Taking Tip: Become familiar with reading questions on a computer screen. Familiarity reduces anxiety and decreases errors.

Which action would the nurse take first when caring for a client who has just returned to the intensive care unit after open-heart surgery?

Elevate the head of the bed to Э0 degrees.

Suction the client through the endotracheal tube.

Check the pulse

oximeter for oxygen saturation.

Auscultate the client's heart and lung sounds.

Rationale Assessing oxygen saturation is a priority because hypoxemia may indicate post- operative complications such as bleeding or a displaced endotracheal tube. In addition, inadequate oxygenation can cause complications such as dysrhythmias. The head of the bed is usually elevated, but this would be

done after ensuring that blood pressure is adequate to perfuse the brain with the head elevated. The client may need suctioning, but breath sounds would be assessed first, because unnecessary suctioning should be avoided.

The heart and lung sounds will be assessed, but ensuring adequate oxygen saturation is the priority.

Which finding is most important to communicate to the health care provider when the nurse is caring for a client who has had a femoropopliteal bypass for peripheral arterial disease?

Pain at the incisional site

Nonpalpable

popliteal pulse Erythema of the incision Pallor of the lower leg

Rationale Pallor of the lower leg suggests decreased blood flow through the bypass graft and should be reported immediately to the health care provider, because intervention may be needed. The other findings would also be reported, but are expected during the postoperative period.

Incisional pain is common after surgery and would be treated with prescribed analgesics. Because the graft bypasses the popliteal area, the popliteal pulse may not be palpable. Erythema of the incision is expected as part of the inflammatory process that leads to wound healing.

Which finding by the nurse is most important to communicate to the health care provider when assessing a client who has aortic stenosis and is scheduled for aortic valve replacement?

Loud systolic murmur

Multiple

dental caries Heartburn when lying down

Paroxysmal

nocturnal dyspnea

Rationale

Multiple dental caries increase the risk for endocarditis in clients with valvular disease, and caries should be treated before surgery. A loud systolic murmur is typical for aortic stenosis. Heartburn will be treated with medications such as histamine blockers or protein pump inhibitors but is not a reason to postpone surgery. Paroxysmal nocturnal dyspnea is a common symptom of severe aortic stenosis.

Which response is best when the home care nurse calls to make an appointment for the initial visit with a client who has heart failure and the client reports that many family members are visiting today and requests that the nurse wait a week for the appointment?

Reschedule the initial assessment visit to be done in a week as requested.

Check with the health care provider about how urgently the client needs to be seen.

Inform the client that the assessment visit is needed before any services can be offered.

Tell the client that it might be helpful to talk with family members during the initial visit.

Rationale Because family members may offer useful information about the client and it can be helpful to observe family interactions, the best response by the nurse will be to try to do the visit as scheduled. Waiting a week before visiting the client may result in worsening of the client's heart failure before the nurse has an opportunity to intervene. Checking with the health care provider about how urgently the client needs to be seen would result in the loss of assessment data available by interviewing and observing the client's family members. Although the assessment visit provides the basis for interventions and services that can be offered to

the client, this response fails to recognize the client's preference and concerns.

Which action would the nurse take next after observing this rhythm in a client who came to the emergency department after experiencing 'skipped heartbeats'?

Obtain the client's blood pressure.

Ask the client about

caffeine intake.

Review the client's home medications.

Question the client

about alcohol use.

Rationale The cardiac monitor shows sinus rhythm with unifocal premature ventricular contractions (PVCs). The nurse's first action would be to determine whether the client is hemodynamically stable by assessing blood pressure. Stimulants such as caffeine can cause PVCs, and the nurse would ask about caffeine use after determining that the client is hemodynamically stable and does not need immediate treatment for the PVCs. The client's home medications may provide information about possible causes of the PVCs, but these will be reviewed by the nurse after assessing for hemodynamic effects of the PVCs. Alcohol use can cause PVCs, so the

nurse will ask the client about alcohol use after assessing for hemodynamic stability.

Which intervention would the nurse implement for an 8-yearold child who is admitted for a sickle cell pain crisis?

Limiting fluids until the crisis ends

Administering prescribed analgesics Applying cold compresses to painful joints Performing range-of-motion exercises of affected joints

Rationale The priority is pain management; severe pain requires analgesics. Increased hydration is necessary to promote hemodilution, improve circulation, and prevent more sickling. Cold will constrict blood vessels, further depleting oxygenation to affected parts; warmth is preferable. There is too much swelling and pain in the joints during a crisis for the implementation of range-of-motion exercises.

Test-Taking Tip: Do not read too much into the question or worry that it is a 'trick.' If you have nursing experience, ask yourself how a classmate who is inexperienced would answer this question from only the information provided in the textbooks or given in the lectures.

Which action would the nurse take first in a client with an abdominal aortic aneurysm who is suddenly pale and reports feeling light-headed and having abdominal pain?

Assess the respiratory rate for hyperventilation.

Check the blood

pressure for hypotension.

Administer the prescribed morphine for pain.

Inspect the abdomen for distension and firmness.

Rationale

The history of abdominal aortic aneurysm, with new symptoms of pallor, lightheadedness, and abdominal pain, suggests bleeding or dissection of the aneurysm. The nurse would first check blood pressure and report hypotension immediately to the health care provider, anticipating the need to give intravenous

fluids and prepare the client for emergency surgery. The other actions are also appropriate after the nurse has obtained the blood pressure.

Hyperventilation may cause lightheadedness. Treatment of pain is appropriate if the blood pressure is stable, but morphine would further lower blood pressure if the client is hypotensive.

Inspection of the abdomen would help confirm a diagnosis of bleeding or dissection but would not be first action.

Which intervention would reflect an organizational-level approach to help prevent development of chronic obstructive pulmonary disease (COPD)?

Collaborate with local employers to develop smoke and tobacco free workplaces.

Support local advertisement of free quit lines and access to free nicotine replacement therapies.

Advocate to local and state policymakers to increase restrictions on the sale of tobacco products.

Create a local coalition of relevant organizations and other community entities to support a smoke free community.

Rationale According to the social-ecologic model, organizational-level interventions target policies, rules, and regulations at community organizations such as worksites that enable or thwart certain behaviors. Advertisements for individual level resources to quit smoking targets the individual level.

Advocating for stricter legislation related to the sale of tobacco products reflects the policy level. Developing a network of community organizations and entities to support smoke free communities reflects a community level intervention.

Which finding would be of most concern when the nurse is caring for a client who has just arrived in the intensive care unit after coronary artery bypass graft surgery?

Blood pressure 152/92 mm Hg Blood glucose 120 mg/dL (6.68 mmol/L)

Atrial fibrillation, rate 112

beats/minute 100 mL of blood in the chest drainage system

Rationale Atrial fibrillation is common after cardiac surgery and can adversely affect cardiac output and blood pressure. The nurse would discuss the dysrhythmia with the health care provider and anticipate a prescription for an antidysrhythmic medication. An elevated blood pressure immediately after surgery is common because of the stress response; the nurse would continue to monitor the blood pressure but no other immediate action is needed. Mild elevations in blood glucose are expected with stress and would not adversely affect wound healing or other client outcomes. The nurse would continue to monitor the glucose, but no other immediate action is needed.

Moderate bleeding in the immediate postoperative period after cardiac surgery is common. The nurse would continue to monitor the chest drainage system and expect that bleeding would decrease, but no other immediate action is needed.

Which conclusion would be made by the nurse caring for a client with osteomyelitis receiving antibiotic therapy through a central line whose laboratory results reveal that the trough level is higher than the peak level after trough blood levels

were obtained immediately before a prescribed dose of antibiotics was administered and peak levels were obtained Э0 minutes after the infusion was completed?

The dose should be increased.

The dose is in excess of the client's needs.

There was an adequate administration of the antibiotic.

There was a problem with the obtaining of blood specimens.

Rationale Peak levels will always be higher than trough levels; therefore this result indicates that there has been some mix-up while drawing the samples.

Increasing the dose would be an appropriate action if the trough level was too low. Concluding that the dose is in excess of the client's needs would be appropriate if the trough level was too high; however, the trough level still should never exceed the peak level. There is not enough information provided to determine whether there was adequate antibiotic administration.

Which nursing concern is a priority when a 6-year-old child with sickle cell disease is admitted with a vasoocclusive crisis (pain episode)? Select all that apply. One, some, or all responses may be correct.

Nutritio n Hydratio n Pain management Prevention of infection Oxygen supplementation

Rationale

The triad of treatment for a client experiencing a sickle cell crisis is hydration, pain management, and oxygenation. Hydration will provide more circulating volume for the sickle cells. Pain management is typically the primary reason this client presents for treatment; the pain becomes unbearable. Supplemental oxygen will provide more oxygen molecules to attach to the red cells, providing more oxygen to the tissue and joints. Other interventions such as nutrition and keeping the client safe from infection should be addressed but are not priorities.

Test-Taking Tip: Study wisely, not hard. Use study strategies to save time and be able to get a good night's sleep the night before your exam.

Cramming is not smart, and it is hard work that increases stress while reducing learning. When you cram, your mind is more likely to go blank during a test. When you cram, the information is in your short-term memory, so you will need to relearn it before a comprehensive exam.

Relearning takes more time. The stress caused by cramming may interfere with your sleep. Your brain needs sleep to function at its best.

Which is the best action for the nurse to take when a client with hypertension tells the nurse, "I took the blood pressure pills for a few weeks, but I didn't feel any different, so I decided I'd only take them when I feel sick." ?

Educate the client about the complications associated with high blood pressure.

Ask the client questions to determine the current understanding of high blood pressure.

Emphasize the importance of taking blood pressure medications now to continue to feel well.

Show the client the current blood pressure and compare that with normal blood pressure levels.

Rationale Further assessment of the client's understanding of hypertension and treatment is important before the nurse can develop an effective plan to change the client's behavior. Education about complications of hypertension may be helpful, but first the nurse needs to know what the client already understands about the long-term effects of high blood pressure. An emphasis on taking medications now to ensure future

health may be appropriate for this client, but further assessment is needed before using this strategy. Many clients may respond to actually seeing the difference between their blood pressures and the expected normals, but more information about the client's knowledge is needed to know if this will be a useful strategy for this client.

Which action would the nurse take first when a client is admitted to the unit with a crushed chest, abdominal trauma, a probable head injury, and multiple fractures?

Establish an airway and stabilize the cervical spine.

Assess heart sounds and find carotid and femoral pulses.

Check for alertness, orientation, and pupil

reaction to light.

Remove clothing to enable

further assessment of injuries.

Rationale The initial actions after a traumatic injury are based on the ABCDE mnemonic: Airway/Cervical Spine, Breathing, Circulation, Disability, Exposure. The first action by the nurse would be to establish a patent airway and ensure that the cervical spine is stabilized. Assessment of heart sounds and pulses would be done after breath sounds and ventilation were assessed. Assessment of neurological status is done as part of the disability assessment after circulation is assessed. Removal of clothing to enable assessment of other injuries is part of the exposure assessment, after assessment for disability.

Test-Taking Tip: Key words or phrases in the stem of the question such as flrst, primary, early, or best are important. Similarly, words such as only, alNays, never, and all in the alternatives are frequently evidence of a wrong response. As in life, no real absolutes exist in nursing; however, every rule has its exceptions, so answer with care.

Which action will the nurse take for a client with a suspected pulmonary embolus? Select all that apply. One, some, or all responses may be correct.

Administer oxygen at high flow rates. Notify the Rapid Response Team.

Lower the head of the client's bed. Place the client on a cardiac monitor.

Anticipate rapid administration of warfarin.

Rationale Administration of oxygen at high flow rates (typically through a nonrebreather mask) will optimize the client's oxygen saturation. The Rapid Response Team will be notified immediately because clients with pulmonary embolus may rapidly develop severe hypoxemia and hypotension. Cardiac monitoring is needed because the client is at risk for dysrhythmias. The head of the bed will be raised to allow fuller lung expansion and improve oxygenation. Warfarin is a slow-acting anticoagulant and would not be given initially to a client with pulmonary embolism. Rather, the nurse will anticipate the need to administer rapidly acting anticoagulants such as fractionated or unfractionated heparin.

Which action by the nurse is the priority when a client who had abdominal surgery 24 hours ago develops pain, redness, and swelling in the left calf?

Elevate the legs.

Document the findings.

Notify the health care provider.

Give the prescribed pain medication.

Rationale

The history and clinical findings are consistent with venous thrombosis, and the nurse would notify the health care provider rapidly so that diagnostic testing and interventions can be implemented. The legs would be elevated, but this is not the highest priority because further diagnosis and treatment are needed. The findings would be documented, but this can be done after notification of the health care

provider. Pain medication administration is important, but will not help in further diagnosis and treatment of the venous thrombosis.

Test-Taking Tip: Look for options that are similar in nature. If all are correct, either the question is poor or all options are incorrect, the latter of which is more likely. Example: If the ansNer you are seeking is directed to a speciflc treatment and all but one option deal Nith signs and symptoms, you Nould be correct in choosing the treatment-speciflc option.

Which symptom requires the most rapid action by the nurse when caring for a client with known peripheral arterial disease who calls the clinic and tells the nurse about experiencing several symptoms?

Anxiety Chest pain Weak pulse quality Cool and pale lower legs

Rationale Because atherosclerosis is a systemic disease, clients with peripheral arterial disease are likely to have coronary artery disease as well. The client's chest pain may indicate acute coronary syndrome, and the nurse should notify the health care provider or have the client activate the emergency response system immediately. Anxiety can have many causes, and the nurse could further assess the client or assist the client to schedule an appointment.

Weak pulse quality is expected with peripheral arterial disease; the client's disease may be progressing, but no rapid action is needed. Cool and pale lower extremities are expected with peripheral arterial disease; the

client may need further evaluation for progression of disease but this is not urgent.

Which information will the nurse include when teaching a client with intermittent claudication in the lower legs?

Assess the feet daily for injuries.

Use compression hose during the day.

Avoid exercising if exercise causes leg pain. Keep the feet elevated when sitting or lying.

Rationale Because decreased blood flow to the feet hinders healing of any breaks in the skin, the client should monitor the feet daily. Compression hose would decrease blood flow further and should be avoided. Exercise programs to improve collateral blood flow in intermittent claudication involve exercising until ischemic pain develops, then resting and repeating the exercise. Blood flow to the feet will be further decreased when the feet are elevated. The client would be taught to keep the feet in a dependent position to improve perfusion.

STUDY TIP: Focus your study time on the common health problems that nurses most frequently encounter.

Which action would the home health nurse take when caring for a client with a pink and moist left leg venous stasis ulcer?

Teach the client to keep the left leg in a dependent position to improve blood flow.

Monitor for increases in bruising or bleeding caused by use of anticoagulant medications.

Clean the wound with normal saline and apply prescribed hydrocolloid dressings weekly.

Educate the client about the need for vascular surgery to improve blood flow to the wound.

Rationale

For noninfected venous stasis ulcers, typical care includes cleaning with normal saline and applying a hydrocolloid dressing, which is left in place for at least Э to 5 days to promote a moist environment for wound healing. Because venous stasis ulcers are associated with edema, not with poor arterial blood flow to the wound, clients are taught to keep the leg elevated for 20 minutes at least 4 to 5 times daily to reduce swelling. Anticoagulant medications are not prescribed for venous stasis ulcers, although they are prescribed for clients who have had venous thrombosis. Vascular surgery is used for arterial ulcers, but it is not effective for venous stasis ulcers.

How would the nurse interpret the rhythm when a client's rhythm strip shows that the P and QRS waves are consistent, with a P wave preceding every QRS complex and a PR interval of 0.26 seconds?

Complete heart block

Normal sinus

rhythm First degree atrioventricular (AV) block

Second degree AV block

Rationale In first degree AV block, P and QRS waves are consistent in shape. A P wave precedes every QRS complex, and the PR interval is greater than 0.20 seconds. In third degree AV block or complete heart bock, the QRS has no relationship with P waves. Normal sinus rhythm reflects normal conduction of the sinus impulse through the atria and ventricles; PR interval is 0.12 to 0.20 seconds, and every QRS is preceded by a P wave. In second degree AV block, 1 or more P waves are not conducted to the ventricles and therefore not followed by a QRS.

Which rhythm is the client experiencing when the cardiac monitor shows sudden bursts of a regular heart rhythm with a rate of 220 beats/minute, normal QRS duration, and P waves that are diÆcult to see?

Sinus tachycardia Atrial fibrillation Ventricular tachycardia (VT) Paroxysmal supraventricular tachycardia (PSVT)

Rationale PSVT occurs above the ventricles, and it has an abrupt onset and cessation.

Sinus tachycardia results when the sinoatrial node fires faster than 100 beats/minute. Onset is gradual rather than abrupt. PR interval is 0.12 to 0.20 seconds. P and QRS waves are consistent in shape. Atrial fibrillation is irregular and does not start and stop suddenly. VT occurs at a rate greater than 100 beats/minute, but the rate is usually around 150 beats/minute and may be up to 250 beats/minute. Depolarization of the ventricles is abnormal and produces a widened QRS complex.

Which topic will the nurse include when teaching a group of clients about risk factors for heart disease? Select all that apply.

One, some, or all responses may be correct.

Obesity Hypertension Diabetes insipidus Asian-American ancestry

Increased high-density lipoprotein (HDL)

Rationale Obesity and hypertension increase the risk for coronary artery disease.

Diabetes insipidus does not increase coronary artery disease risk, although diabetes mellitus is a risk factor. Coronary artery disease risk is not higher in Asian Americans. Increased levels of low-density lipoprotein increase the risk for heart disease, but high HDL decreases coronary artery disease risk.

Test-Taking Tip: Be alert for details about what you are being asked to do.

In this question type, you are asked to select all options that apply to a given situation or client. All options likely relate to the situation, but only some of the options may relate directly to the situation.

Which action would the nurse take first when the occupational health nurse is working at a construction site and observes a worker who collapses and is pulseless?

Ask someone to activate the emergency response system immediately.

Begin chest compressions that depress the sternum at least 2 inches (5 cm).

Apply the pads for the automatic external defibrillator (AED) that is readily available.

Use a chin lift and head tilt technique and ventilate using a bagvalve-mask system.

Rationale Current guidelines recommend that the emergency response system be activated as soon as respiratory or cardiac arrest is suspected. If the client is pulseless and an AED is available, it should be used next, because early defibrillation is associated with more successful resuscitation. Chest compressions would be used in a pulseless client if an AED was not readily

available or if defibrillation was unsuccessful. Ventilation is started after Э0 chest compressions.

Which information would the nurse include when teaching a client about dietary guidelines to reduce heart disease risk?

Eat small, frequent meals.

Decrease the amount of proteins.

Increase complex

carbohydrates.

Avoid

monounsaturated fats.

Rationale The fiber component of complex carbohydrates helps bind and eliminate dietary cholesterol and fosters growth of intestinal microorganisms to break down bile salts and release the cholesterol component for excretion. It is what the client eats, not the amount at each meal that is important. Proteins need not be decreased in a heart healthy diet.

Although no more than 25% to Э5% of daily calories should be from fats, monosaturated fats are considered heart healthy.

Which information will the nurse include in preprocedure teaching when a client is scheduled for a cardiac catheterization through a femoral artery access?

Plan to ambulate shortly after the procedure.

Need for conscious sedation before the procedure.

Expect to experience a feeling of warmth during the procedure.

Prepare to be in a semi-Fowler position for 12 hours after the procedure.

Rationale A warm flushing sensation that lasts approximately Э0 seconds will occur when the contrast medium is injected. The supine position will be maintained for 4 to 6 hours after the procedure; ambulation may dislodge clots at the catheter insertion site,

resulting in bleeding. Medication is given for mild sedation; clients are drowsy but awake enough to follow instructions. The semi-Fowler position flexes the legs, which may result in bleeding at the femoral insertion site and should be avoided.

STUDY TIP: Do not change your pattern of study. It obviously has contributed to your being here, so it worked. If you have studied alone, continue to study alone. If you have studied in a group, form a study group.

When discharging a client who has had insertion of a coronary artery stent, for which signs and symptoms will a nurse instruct the client to seek immediate medical attention? Select all that apply. One, some, or all responses may be correct.

Some correct answers were not selected

Dyspnea with vigorous exertion Unexplainable profuse diaphoresis Indigestion not relieved by antacids Fatigue the day after a rigorous walk Acute chest pain after rigorous exercise Continued chest pain after nitroglycerin use

Rationale Unexplainable profuse diaphoresis, indigestion not relieved by antacids, acute chest pain after rigorous exercise, and continued chest pain after use of nitroglycerin are clinical indicators of inadequate oxygen to the heart. The client should be instructed to seek immediate medical

intervention. Dyspnea on vigorous exertion and fatigue the day after a rigorous walk are expected.

Which type of shock would the nurse suspect when a client is admitted to the emergency department after a motor vehicle accident with abdominal pain, a blood pressure decrease from 120/76 mm Hg to 60/40 mm Hg, and a heart rate increase from 82 beats/minute to 121 beats/minute?

Septic shock Cardiogenic shock Hemorrhagic shock

Neurogenic

shock

Rationale With a history of a traumatic injury and abdominal pain associated with assessment findings of hypotension and tachycardia, the most likely type of shock is hemorrhagic. A client with septic shock would have tachycardia and hypotension, but symptoms would also include fever and warm, flushed skin. Cardiogenic shock might also present with tachycardia and hypotension, but the client would report chest discomfort and dyspnea. Neurogenic shock presents with hypotension and bradycardia.

Test-Taking Tip: After you have eliminated one or more choices, you may discover that two of the options are very similar. This can be very helpful, because it may mean that one of these look-alike answers is the best choice and the other is a very good distractor. Test both of these options against the stem. Ask yourself which one completes the incomplete statement grammatically and which one answers the question more fully and completely. The option that best completes or answers the stem is the

one you should choose. Here, too, pause for a few seconds, give your brain time to reflect, and recall may occur.

Which action by the nurse will be most effective in determining whether fluid overload is improving when caring for a client who was admitted with heart failure?

Weighing the client Monitoring the intake and output Assessing the extent of pitting edema Asking the client about subjective symptoms

Rationale Because 1 liter of fluid weighs approximately 2.2 pounds (1 kg), daily weights are the best way to monitor fluid volume status. Although monitoring the intake and output is important to assess fluid balance, it does not account for intake and output that cannot be measured.

Assessing the extent of pitting edema is effective in determining localized, not generalized, edema; it is more subjective than is weighing the client.

Subjective symptoms such as dyspnea may vary for other reasons than fluid balance status.

Test-Taking Tip: Study wisely, not hard. Use study strategies to save time and be able to get a good night's sleep the night before your exam.

Cramming is not smart, and it is hard work that increases stress while reducing learning. When you cram, your mind is more likely to go blank during a test. When you cram, the information is in your short-term memory so you will need to relearn it before a comprehensive exam.

Relearning takes more time. The stress caused by cramming may interfere with your sleep. Your brain needs sleep to function at its best.

Which topic would be included when teaching a client with heart failure who will be discharged with a new prescription

for digoxin? Select all that apply. One, some, or all responses may be correct.

Some correct answers were not selected

Take your radial pulse daily and write it down.

Avoid foods that are high in potassium such as bananas and potatoes. Notify the health care provider if you develop any vision changes.

Call the health care provider if your pulse is irregular or less than 60 beats/minute.

Eat at least 1 serving of green leafy vegetables daily.

Rationale Clients taking digoxin should be taught how to take a radial pulse and how to document pulse rate and bring results to all medical appointments. Vision changes may indicate digoxin toxicity and should be reported to the health care provider. Pulse irregularity or a rate less than 60 beats/minute may indicate digoxin toxicity, and clients should report these changes to the health care provider. Hypokalemia may increase the risk for digoxin toxicity, and clients are advised to eat high-potassium foods such as bananas and potatoes. Green leafy vegetables contain large quantities of vitamin K, but this does not affect digoxin at all.

Which response by the nurse is best when a client who has peripheral arterial disease of the lower extremities tells the nurse, "I walk so slowly that no one wants to walk with me,"?

"Many people enjoy walking alone."

"You will be able to walk faster eventually."

"It is important that you keep walking to improve circulation."

"Perhaps you might consider a supervised exercise training program."

Rationale

Supervised exercise training programs for peripheral arterial disease include exercise and walking programs that encourage new growth of vessels around the obstructed artery; this may improve peripheral perfusion and the ability to walk. These programs

also involve interaction with a therapist and other clients, which may improve motivation. Although many people may enjoy walking alone, this client's statement indicates a preference for walking with others.

An assurance that walking speed will improve does not address the client's current concern. Because the client did not indicate lack of understanding of the purpose of a walking program, there is no need to explain the rationale for continuing to walk.

Which action would be taken first when a staff nurse is instructed by the charge nurse to give the scheduled warfarin dose to a client whose current international normalized ratio (INR) is 6?

Refuse to give the unsafe medication dose.

Remind the charge nurse of the

INR result.

Ask the hospital pharmacist to talk with the nurse manager.

Ask the health care provider whether to

give the medication.

Rationale Because the INR is at an unsafe level, warfarin would not be given.

Professional communication would include first clarifying concerns with the charge nurse, by discussing the abnormal INR result and reasons for not administering another dose of warfarin. Although the nurse could refuse to give the medication as the first action, this is not likely to foster professional communication or workplace relationships.

Direct communication with coworkers about concerns is more professional and fosters better relationships than having a third party (such as the pharmacist) address concerns. Because the INR is prolonged and the warfarin would be unsafe to give, the nurse does not need to ask the

health care provider about giving the warfarin but would notify the provider about the INR result.

Which topic would the nurse include in preoperative teaching when a client is scheduled for an emergency splenectomy after a traumatic injury?

Probability of wound dehiscence Safety aspects of this type of surgery

Expectation of

postoperative bleeding Presence of abdominal drains for several days

Rationale Drains usually are inserted into the splenic bed to facilitate the removal of fluid that can lead to abscess formation. The risk for wound dehiscence is no greater than for any other abdominal surgery. Discussion of safety aspects of this type of surgery is the role of the health care provider. Bleeding may occur after splenectomy, but the nurse would not teach that bleeding is "expected."

Which statement indicates the client requires further teaching after the nurse teaches a client with varicose veins about prevention of venous thromboembolism (VTE)?

"I must increase my fluid intake."

"Elastic stockings should be worn every day."

"I will try to keep my legs lower

than my heart."

"Frequent daily walks will help prevent clot formation."

Rationale To prevent VTE in clients at risk, the legs are elevated above the level of the heart as frequently as possible to promote venous return and prevent venous stasis. The other client statements indicate a good understanding of the nurse's instructions. A high

fluid intake decreases blood viscosity and decreases the risk for venous stasis. Compression stockings help improve venous return, decreasing venous stasis and risk for VTE. Use of the large muscles in the legs when walking improves venous return and prevents venous stasis and VTE.

Which lifestyle factor, that may have contributed to the ankle swelling, would a nurse ask about when questioning a client with heart failure and new onset ankle edema? Select all that apply. One, some, or all responses may be correct.

Some correct answers were not selected Intake of salty

foods Dietary fat intake Medication compliance Family stresses Recent travel

Rationale Fluid retention in heart failure may be caused by increased salt intake, with associated water retention. Poor adherence to medication used to treat heart failure, such as angiotensin-converting enzyme inhibitors and diuretics, may also cause fluid retention. Recent travel may cause fluid retention because of changes in environmental temperature, effects of airplane travel on fluid retention, or changes in dietary sodium intake.

Increased or decreased dietary fat intake will not cause fluid retention.

Stress is not a contributor to fluid retention.

Which clinical indicator will the nurse monitor to evaluate the effectiveness of treatment for a client with exacerbation of left ventricular failure? Select all that apply. One, some, or all responses may be correct.

Lung sounds Heart sounds Heart rate Peripheral edema Dyspnea on exertion Jugular vein distension

Rationale Left ventricular failure is characterized by the development of pulmonary congestion, SЭ and S4 gallops, tachycardia, and shortness of breath. The nurse will assess for improvement in these parameters to determine if treatment is effective. Because peripheral edema is a clinical manifestation of right ventricular failure, it is not an indicator of improvement in this client. Jugular vein distention is caused by right ventricular failure.

Which finding by the nurse will be of most concern when a client has venous insuÆciency?

Bilateral discoloration

brown

lower

leg

Calf pain when the

feet

are

dorsiflexed

Severe

edema from ankles to calves Thickened and dry skin on lower legs

Rationale Calf pain when the feet are dorsiflexed, which is referred to as Homans sign, is a symptom of possible venous thrombosis and would require further diagnostic testing and treatment. Bilateral brown lower leg discoloration is a common symptom of chronic edema caused by venous insuÆciency and would be expected in this client.

Severe edema is a common and expected symptom of venous insuÆciency and may require actions such as leg elevation, but is not as concerning as a positive Homans sign. Thick and dry skin is common in chronic venous insuÆciency and the nurse will plan to use a lubricating ointment, but it is not as big a concern as a possible venous thrombosis.

Which information would the nurse include when teaching a client about resumption of sexual activity after having a myocardial infarction?

Choose only familiar sexual positions.

Select familiar settings for

sexual activity.

Avoid use of nitroglycerin before sexual activity.

Wait for 4 to 6 weeks before resuming sexual activity.

Rationale An unfamiliar environment increases stress, which increases cardiac workload.

It is advantageous to experiment with positions and find one that is relaxing and permits unrestricted breathing. Because sexual activity raises cardiac workload and may cause angina, some clients benefit from prophylactic use of sublingual nitroglycerin before sexual activity.

Resumption of sexual activity is based on how well the client is tolerating other physical activity such as walking or stair-climbing, not on a specific time frame.

Test-Taking Tip: A psychological technique used to boost your test-taking confidence is to look into a mirror whenever you pass one and say out loud, 'I know the material, and I'll do well on the test.' Try it; many students have found that it works because it reduces test anxiety.

Which action would the nurse take to prevent venous thrombus formation in a postoperative client? Select all that apply. One, some, or all responses may be correct.

Encourage an increase in oral fluid intake.

Massage the client's extremities with lotion. Instruct the client to avoid crossing the legs. Remind the client to dorsiflex the feet frequently.

Help the client use prescribed pneumatic sequential stockings. Plan discharge teaching about the need to avoid taking aspirin.

Rationale Actions such as increasing fluid intake, avoiding crossing the legs, frequent dorsiflexion of the feet, and using pneumatic sequential stockings when in bed all help decrease venous thrombus risk. Massage of the legs is avoided because it can dislodge any developing venous thrombus and cause a pulmonary embolus. Because aspirin helps prevent venous thrombosis, it does not have to be avoided after discharge.

Which response would the nurse give when the spouse of a client with chest pain repeatedly expresses concern about the client's pallor?

"Paleness is not always a sign that something is wrong."

"Skin color really varies quite a bit from

person to person."

"We will be drawing blood to check your spouse for anemia."

"Tell me why you are concerned about your

spouse's paleness."

Rationale

Because the spouse has repeatedly expressed concern about the client's skin color, asking about why the spouse is concerned recognizes that this is something of high importance for the spouse and shows that the nurse is listening to the concerns. In addition, it gives the spouse a chance to share information that may be useful to the care of the client, such as usual skin color and any history of anemia or other relevant diagnoses.

The statement that paleness is not always a sign that something is wrong is true, but it discourages further sharing of information or concerns by the spouse. It is true that skin color varies from person to person, but this response fails to recognize that the spouse knows this specific client well and has valuable information to share. In telling the spouse that blood will be drawn to check for anemia, the nurse makes a possible false assumption that the spouse is concerned about anemia.

Which instruction will the home health nurse include when teaching a client with peripheral artery disease? Select all that apply. One, some, or all responses may be correct.

Some correct answers were not selected

"Avoid crossing your legs." "Inspect your feet daily." "Change positions slowly."

"Do not use compression stockings." "Avoid green leafy vegetables in your diet."

Rationale Crossing the legs and using compression stockings will restrict blood flow, so these actions should be avoided in clients with peripheral artery

disease. Inspection of the feet is done daily to detect injury, infection, or skin breakdown. Changing position slowly is not necessary for clients with peripheral artery disease, although it is recommended for those on medications that cause orthostatic hypotension. Dark green leafy vegetables are avoided by clients who take warfarin.

After the nurse has taught self-care management to a client admitted with sickle cell crisis, which client action indicates a need for more education?

Removes restrictive socks Raises the knee position of the bed Asks that the room to be kept at 74°F (2Э°C) Chooses noncaffeinated beverages to stay hydrated

Rationale Self-care for sickle cell crisis would include actions that promote blood flow through the systemic circulation. The client should not raise the knee position of the bed because that restricts blood flow to and from the lower extremities. Removal of restrictive socks promotes blood flow.

Keeping the room warm avoids constriction of blood vessels. Hydrating with noncaffeinated drinks decreases blood viscosity and promotes blood flow.

Which action woudl the be the nurse's priority before administration of packed red blood cells to a client?

Obtaining the client's current vital signs Assuring that there is a large-bore infusion cannula

Monitoring the hemoglobin and

hematocrit levels Determining proper typing and crossmatching of blood

Rationale

Determining proper typing and crossmatching of blood is necessary to prevent an acute immunological reaction if the donated blood is not compatible with the client's blood. Although important, obtaining the client's baseline vital signs is not the highest

priority. Ideally, blood should be infused through a large-bore cannula, but smaller gauge cannulas may be used when necessary. The nurse should be aware of the hemoglobin and hematocrit levels, but blood can be safely infused even if the nurse does not know the exact levels.

STUDY TIP: Answer every question. A question without an answer is the same as a wrong answer. Go ahead and guess. You have studied for the test and you know the material well. You are not making a random guess based on no information. You are guessing based on what you have learned and your best assessment of the question.

Which client statement indicates an understanding of the nurse's instructions concerning a Holter monitor?

'The only times the monitor should be taken off are for showering and sleep.'

'The monitor will record my activities and symptoms if an abnormal rhythm occurs.'

'The results from the monitor will be used to determine the size and shape of my heart.'

'The monitor will record any abnormal heart rhythms while I go about my usual activities.'

Rationale The cardiac rhythm is monitored, and rhythm disturbances documented; disturbances are stored, printed, and then analyzed in relation to the client's activity/symptom diary. The monitor must remain in place constantly for accurate recordings. The client must keep a record of activities and symptoms while the monitor records cardiac rhythm disturbances, and then an analysis of correlations between the two is made. A chest radiograph, not a Holter monitor, will reveal the size and contour of the heart.

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