A nursing student wants to know why clients with chronic obstructive pulmonary disease tend to be polycythemic. What response by the nurse instructor is best?
a. It is due to side effects of medications for bronchodilation.
b. It is from overactive bone marrow in response to chronic disease.
c. It combats the anemia caused by an increased metabolic rate.
d. It compensates for tissue hypoxia caused by lung disease.
A nurse assesses a client who had a myocardial infarction and is hypotensive. Which additional assessment finding should the nurse expect?
a. Heart rate of 120 beats/min
b. Cool, clammy skin
c. Oxygen saturation of 90%
d. Respiratory rate of 8 breaths/min
A nurse assesses a client in an outpatient clinic. Which statement alerts the nurse to the possibility of left-sided heart failure?
a.“I have been drinking more water than usual.”
b.“I am awakened by the need to urinate at night.”
c.“I must stop halfway up the stairs to catch my breath.”
d.“I have experienced blurred vision on several occasions.”
A nurse assesses clients on a cardiac unit. Which client should the nurse identify as being at greatest risk for the development of left-sided heart failure?
a. A 36-year-old woman with aortic stenosis
b. A 42-year-old man with pulmonary hypertension
c. A 59-year-old woman who smokes cigarettes daily
d. A 70-year-old man who had a cerebral vascular accident
A client is receiving rivaroxaban (Xarelto) and asks the nurse to explain how it works. What response by the nurse is best?
a. “It inhibits thrombin.”
b. “It inhibits fibrinogen.”
c. “It thins your blood.”
d. “It works against vitamin K.”
A client undergoing hemodynamic monitoring after a myocardial infarction has a right atrial pressure of 0.5 mm Hg. What action by the nurse is most appropriate?
a. Level the transducer at the phlebostatic axis.
b. Lay the client in the supine position.
c. Prepare to administer diuretics.
d. Prepare to administer a fluid bolus.
A nurse assesses a client with atrial fibrillation. Which manifestation should alert the nurse to the possibility of a serious complication from this condition?
a. Sinus tachycardia
b. Speech alterations
d. Dyspnea with activity
A client has been diagnosed with hypertension but does not take the antihypertensive medications because of a lack of symptoms. What response by the nurse is best?
a.“Do you have trouble affording your medications?”
b.“Most people with hypertension do not have symptoms.”
c.“You are lucky; most people get severe morning headaches.”
d.“You need to take your medicine or you will get kidney failure.”
A client received tissue plasminogen activator (t-PA) after a myocardial infarction and now is on an intravenous infusion of heparin. The client’s spouse asks why the client needs this medication. What response by the nurse is best?
a.“The t-PA didn’t dissolve the entire coronary clot.”
b.“The heparin keeps that artery from getting blocked again.”
c.“Heparin keeps the blood as thin as possible for a longer time.”
d.“The heparin prevents a stroke from occurring as the t-PA wears off.”
The nurse is reviewing the lipid panel of a male client who has atherosclerosis. Which finding is most concerning?
a. Cholesterol: 126 mg/dL
b. High-density lipoprotein cholesterol (HDL-C): 48 mg/dL
c. Low-density lipoprotein cholesterol (LDL-C): 122 mg/dL
d. Triglycerides: 198 mg/dL
A hospitalized client has a platelet count of 58,000/mm3. What action by the nurse is best?
a. Encourage high-protein foods.
b. Institute neutropenic precautions.
c. Limit visitors to healthy adults.
d. Place the client on safety precautions.
A client is in the hospital after suffering a myocardial infarction and has bathroom privileges. The nurse assists the client to the bathroom and notes the client’s O2 saturation to be 95%, pulse 88 beats/min, and respiratory rate 16 breaths/min after returning to bed. What action by the nurse is best?
a. Administer oxygen at 2 L/min.
b. Allow continued bathroom privileges.
c. Obtain a bedside commode.
d. Suggest the client use a bedpan
A nurse is working with a client who takes atorvastatin (Lipitor). The client’s recent laboratory results include a blood urea nitrogen (BUN) of 33 mg/dL and creatinine of 2.8 mg/dL. What action by the nurse is best?
a. Ask if the client eats grapefruit.
b. Assess the client for dehydration.
c. Facilitate admission to the hospital.
d. Obtain a random urinalysis.
While assessing a client on a cardiac unit, a nurse identifies the presence of an S3 gallop. Which action should the nurse take next?
a. Assess for symptoms of left-sided heart failure.
b. Document this as a normal finding.
c. Call the health care provider immediately.
d. Transfer the client to the intensive care unit.
The nurse is evaluating a 3-day diet history with a client who has an elevated lipid panel. What meal selection indicates the client is managing this condition well with diet?
a. A 4-ounce steak, French fries, iceberg lettuce
b. Baked chicken breast, broccoli, tomatoes
c. Fried catfish, cornbread, peas
d. Spaghetti with meat sauce, garlic bread
A client is in shock and the nurse prepares to administer insulin for a blood glucose reading of 208 mg/dL. The spouse asks why the client needs insulin as the client is not a diabetic. What response by the nurse is best?
a. “High glucose is common in shock and needs to be treated.”
b. “Some of the medications we are giving are to raise blood sugar.”
c. “The IV solution has lots of glucose, which raises blood sugar.”
d. “The stress of this illness has made your spouse a diabetic.”
The nurse gets the hand-off report on four clients. Which client should the nurse assess first?
a. Client with a blood pressure change of 128/74 to 110/88 mm Hg
b. Client with oxygen saturation unchanged at 94%
c. Client with a pulse change of 100 to 88 beats/min
d. Client with urine output of 40 mL/hr for the last 2 hours
A nurse cares for a client with right-sided heart failure. The client asks, “Why do I need to weigh myself every day?” How should the nurse respond?
a. “Weight is the best indication that you are gaining or losing fluid.”
b. “Daily weights will help us make sure that you’re eating properly.”
c. “The hospital requires that all inpatients be weighed daily.”
d. “You need to lose weight to decrease the incidence of heart failure.”
A nurse cares for a client who has a heart rate averaging 56 beats/min with no adverse symptoms. Which activity modification should the nurse suggest to avoid further slowing of the heart rate?
a. “Make certain that your bath water is warm.”
b.“Avoid straining while having a bowel movement.”
c.“Limit your intake of caffeinated drinks to one a day.”
d.“Avoid strenuous exercise such as running.”
A nurse is caring for a client after surgery. The client’s respiratory rate has increased from 12 to 18 breaths/min and the pulse rate increased from 86 to 98 beats/min since they were last assessed 4 hours ago. What action by the nurse is best?
a. Ask if the client needs pain medication.
b. Assess the client’s tissue perfusion further.
c. Document the findings in the client’s chart.
d. Increase the rate of the client’s IV infusion.
An emergency room nurse obtains the health history of a client. Which statement by the client should alert the nurse to the occurrence of heart failure?
a. “I get short of breath when I climb stairs.”
b. “I see halos floating around my head.”
c. “I have trouble remembering things.”
d. “I have lost weight over the past month.”
The health care provider tells the nurse that a client is to be started on a platelet inhibitor. About what drug does the nurse plan to teach the client?
a. Clopidogrel (Plavix)
b. Enoxaparin (Lovenox)
c. Reteplase (Retavase)
d. Warfarin (Coumadin)
A nurse assesses a client’s electrocardiograph tracing and observes that not all QRS complexes are preceded by a P wave. How should the nurse interpret this observation?
a. The client has hyperkalemia causing irregular QRS complexes.
b. Ventricular tachycardia is overriding the normal atrial rhythm.
c. The client’s chest leads are not making sufficient contact with the skin.
d. Ventricular and atrial depolarizations are initiated from different sites.
A nurse caring for a client with sickle cell disease (SCD) reviews the client’s laboratory work. Which finding should the nurse report to the provider?
a. Creatinine: 2.9 mg/dL
b. Hematocrit: 30%
c. Sodium: 147 mEq/L
d. White blood cell count: 12,000/mm3
A nurse assesses clients on a medical-surgical unit. Which client should the nurse identify as having the greatest risk for cardiovascular disease?
a. An 86-year-old man with a history of asthma
b. A 32-year-old Asian-American man with colorectal cancer
c. A 45-year-old American Indian woman with diabetes mellitus
d. A 53-year-old postmenopausal woman who is on hormone therapy
A student nurse is assessing the peripheral vascular system of an older adult. What action by the student would cause the faculty member to intervene?
a. Assessing blood pressure in both upper extremities
b. Auscultating the carotid arteries for any bruits
c. Classifying capillary refill of 4 seconds as normal
d. Palpating both carotid arteries at the same time
A nurse assesses a client after administering a prescribed beta blocker. Which assessment should the nurse expect to find?
a. Blood pressure increased from 98/42 mm Hg to 132/60 mm Hg
b. Respiratory rate decreased from 25 breaths/min to 14 breaths/min
c. Oxygen saturation increased from 88% to 96%
d. Pulse decreased from 100 beats/min to 80 beats/min
A nurse evaluates prescriptions for a client with chronic atrial fibrillation. Which medication should the nurse expect to find on this client’s medication administration record to prevent a common complication of this condition?
a. Sotalol (Betapace)
b. Warfarin (Coumadin)
c. Atropine (Sal-Tropine)
d. Lidocaine (Xylocaine)
A nurse assesses an older adult client who has multiple chronic diseases. The client’s heart rate is 48 beats/min. Which action should the nurse take first?
a. Document the finding in the chart.
b. Initiate external pacing.
c. Assess the client’s medications.
d. Administer 1 mg of atropine.
A client presents to the emergency department in sickle cell crisis. What intervention by the nurse takes priority?
a. Administer oxygen.
b. Apply an oximetry probe.
c. Give pain medication.
d. Start an IV line.
A nurse assesses a client admitted to the cardiac unit. Which statement by the client alerts the nurse to the possibility of right-sided heart failure?
a.“I sleep with four pillows at night.”
b.“My shoes fit really tight lately.”
c.“I wake up coughing every night.”
d.“I have trouble catching my breath.”
A nursing student is caring for a client who had a myocardial infarction. The student is confused because the client states nothing is wrong and yet listens attentively while the student provides education on lifestyle changes and healthy menu choices. What response by the faculty member is best?
a.“Continue to educate the client on possible healthy changes.”
b.“Emphasize complications that can occur with noncompliance.”
c.“Tell the client that denial is normal and will soon go away.”
d.“You need to make sure the client understands this illness.”
A client is receiving an infusion of tissue plasminogen activator (t-PA). The nurse assesses the client to be disoriented to person, place, and time. What action by the nurse is best?
a. Assess the client’s pupillary responses.
b. Request a neurologic consultation.
c. Stop the infusion and call the provider.
d. Take and document a full set of vital signs.
A client in sickle cell crisis is dehydrated and in the emergency department. The nurse plans to start an IV. Which fluid choice is best?
a.0.45% normal saline
b.0.9% normal saline
c. Dextrose 50% (D50)
d. Lactated Ringer’s solution
A student is caring for a client who suffered massive blood loss after trauma. How does the student correlate the blood loss with the client’s mean arterial pressure (MAP)?
a. It causes vasoconstriction and increased MAP.
b. Lower blood volume lowers MAP.
c. There is no direct correlation to MAP.
d. It raises cardiac output and MAP.
A client has a serum ferritin level of 8 ng/mL and microcytic red blood cells. What action by the nurse is best?
a. Encourage high-protein Foods.
b. Perform a Hemoccult test on the client’s stools.
c. Offer Frequent oral care.
d. Prepare to administer cobalamin (vitamin B12).
A nurse is assessing clients on a medical-surgical unit. Which client should the nurse identify as being at greatest risk for atrial fibrillation?
a. A 45-year-old who takes an aspirin daily
b. A 50-year-old who is post coronary artery bypass graft surgery
c. A 78-year-old who had a carotid endarterectomy
d. An 80-year-old with chronic obstructive pulmonary disease
A client hospitalized with sickle cell crisis frequently asks for opioid pain medications, often shortly after receiving a dose. The nurses on the unit believe the client is drug seeking. When the client requests pain medication, what action by the nurse is best?
a. Give the client pain medication if it is time for another dose.
b. Instruct the client not to request pain medication too early.
c. Request the provider leave a prescription for a placebo.
d. Tell the client it is too early to have more pain medication.
A nurse is caring for a client after surgery who is restless and apprehensive. The unlicensed assistive personnel (UAP) reports the vital signs and the nurse sees they are only slightly different from previous readings. What action does the nurse delegate next to the UAP?
a. Assess the client for pain or discomfort.
b. Measure urine output from the catheter.
c. Reposition the client to the unaffected side.
d. Stay with the client and reassure him or her.
A nurse is assessing a dark-skinned client for pallor. What action is best?
a. Assess the conjunctiva of the eye.
b. Have the client open the hand widely.
c. Look at the roof of the client’s mouth.
d. Palpate for areas of mild swelling.
Expert Solution Preview
As a medical professor in charge of creating assignments and evaluating student performance, I am responsible for providing accurate and comprehensive answers to medical college students. In this assignment, I will address a range of questions related to various cardiovascular conditions and medications.
Answer for Question 1:
The best response by the nurse instructor is option d. It compensates for tissue hypoxia caused by lung disease. Clients with chronic obstructive pulmonary disease (COPD) often experience lung disease, which results in impaired gas exchange and tissue hypoxia. Increased red blood cell production (polycythemia) is the body’s compensatory mechanism to increase oxygen-carrying capacity and combat tissue hypoxia.
Answer for Question 2:
The nurse should expect the additional assessment finding of option a. Heart rate of 120 beats/min. Hypotension after a myocardial infarction can cause compensatory mechanisms, including an increased heart rate (tachycardia), to maintain cardiac output.
Answer for Question 3:
The statement that alerts the nurse to the possibility of left-sided heart failure is option c. “I must stop halfway up the stairs to catch my breath.” Left-sided heart failure results in the backflow of blood into the pulmonary circulation, leading to pulmonary congestion and fluid accumulation in the lungs. This can cause shortness of breath and fatigue, particularly with physical activity.
Answer for Question 4:
The nurse should identify the client mentioned in option a. A 36-year-old woman with aortic stenosis as being at greatest risk for the development of left-sided heart failure. Aortic stenosis is a condition that results in increased resistance to blood flow from the left ventricle, leading to left ventricular hypertrophy and eventually, heart failure.
Answer for Question 5:
The best response by the nurse is option a. “It inhibits thrombin.” Rivaroxaban (Xarelto) is a direct oral anticoagulant that works by inhibiting thrombin, an enzyme involved in blood clot formation.
Answer for Question 6:
The most appropriate action by the nurse is option a. Level the transducer at the phlebostatic axis. The phlebostatic axis, located at the fourth intercostal space in the midaxillary line, is the reference point for accurate measurement of central venous pressures. Leveling the transducer ensures accurate pressure readings.
Answer for Question 7:
The manifestation that should alert the nurse to the possibility of a serious complication from atrial fibrillation is option b. Speech alterations. Atrial fibrillation increases the risk of stroke due to the formation of blood clots in the atria. Speech alterations can be a sign of a stroke or transient ischemic attack (TIA).
Answer for Question 8:
The best response by the nurse is option b. “Most people with hypertension do not have symptoms.” Hypertension is often referred to as the “silent killer” because it typically does not cause noticeable symptoms. It is important to educate the client about the importance of medication adherence to prevent complications related to long-term, uncontrolled hypertension.
Answer for Question 9:
The best response by the nurse is option d. “The heparin prevents a stroke from occurring as the t-PA wears off.” Tissue plasminogen activator (t-PA) is used to dissolve blood clots in the coronary artery during a myocardial infarction. Heparin is given afterwards to prevent re-formation of the clot and reduce the risk of stroke.
Answer for Question 10:
The most concerning finding in the lipid panel of a male client with atherosclerosis is option c. Low-density lipoprotein cholesterol (LDL-C): 122 mg/dL. Elevated LDL cholesterol levels are a major risk factor for the development of atherosclerosis and cardiovascular disease.
Answer for Question 11:
The best action by the nurse is option d. Place the client on safety precautions. A platelet count of 58,000/mm3 indicates thrombocytopenia, a low platelet count. Safety precautions, such as fall prevention measures, are necessary to prevent bleeding complications.
Answer for Question 12:
The best action by the nurse is option a. Administer oxygen at 2 L/min. The oxygen saturation of 95% after the client returns to bed indicates decreased oxygen levels. Administering supplemental oxygen can help improve oxygenation and prevent post-activity hypoxia.
Answer for Question 13:
The best action by the nurse is option c. Facilitate admission to the hospital. The elevated blood urea nitrogen (BUN) and creatinine levels indicate impaired kidney function. Further evaluation and management in a hospital setting may be required.
Answer for Question 14:
The best action by the nurse is option a. Assess for symptoms of left-sided heart failure. The presence of an S3 gallop can indicate heart failure, specifically left ventricular dysfunction. Assessing for symptoms such as shortness of breath, fatigue, and fluid retention can help confirm the diagnosis.
Answer for Question 15:
The meal selection that indicates the client is managing an elevated lipid panel well with diet is option b. Baked chicken breast, broccoli, tomatoes. This meal selection includes lean protein (chicken breast) and vegetables, which are low in saturated and trans fats, and high in fiber. These dietary choices help manage elevated lipid levels.
Answer for Question 16:
The best response by the nurse is option a. “High glucose is common in shock and needs to be treated.” During shock, the body may release stress hormones that can cause hyperglycemia. Treating high glucose levels is important to prevent further complications and support the body’s response to shock.
Answer for Question 17:
The nurse should assess the client mentioned in option c. Client with a pulse change of 100 to 88 beats/min first. A change in pulse rate can indicate a cardiac or circulatory issue that requires immediate assessment and potential intervention.
Answer for Question 18:
The nurse should respond to the client’s question with option a. “Weight is the best indication that you are gaining or losing fluid.” Daily weight measurement is crucial in clients with right-sided heart failure because weight gain can indicate fluid retention, an important sign of worsening heart failure.
Answer for Question 19:
The nurse should suggest the activity modification mentioned in option b. “Avoid straining while having a bowel movement.” Straining during bowel movements can stimulate the vagus nerve, leading to vagal stimulation and potentially further slowing of the heart rate.
Answer for Question 20:
The best action by the nurse is option a. Ask if the client needs pain medication. The increased respiratory rate and pulse rate in the client may indicate pain or discomfort. Assessing for pain and providing appropriate pain management is important for the client’s comfort and well-being.
Answer for Question 21:
The statement that should alert the nurse to the occurrence of heart failure is option a. “I get short of breath when I climb stairs.” Shortness of breath with exertion (dyspnea on exertion) is a common symptom of heart failure, indicating reduced cardiac function and impaired oxygen delivery.
Answer for Question 22:
The nurse plans to teach the client about the drug mentioned in option a. Clopidogrel (Plavix). Clopidogrel is an antiplatelet medication that inhibits the aggregation of platelets, preventing clot formation. It is commonly prescribed for clients at risk of cardiovascular events.
Answer for Question 23:
The nurse should interpret the observation mentioned in option d. Ventricular and atrial depolarizations are initiated from different sites. Not all QRS complexes preceded by a P wave on an electrocardiograph tracing indicate a lack of atrial depolarization. This can occur when the atrial and ventricular depolarizations are not synchronized, suggesting an interruption in the normal conduction pathway.
Answer for Question 24:
The finding that the nurse should report to the provider is option d. White blood cell count: 12,000/mm3. Sickle cell disease (SCD) increases the risk of infection and inflammation, which can elevate the white blood cell count. However, it is essential to notify the healthcare provider for further evaluation and potential treatment.
Answer for Question 25:
The client with the greatest risk for cardiovascular disease is the client mentioned in option c. A 45-year-old American Indian woman with diabetes mellitus. Diabetes mellitus is a significant risk factor for the development of cardiovascular disease.