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Medical-Surgical: Cardiovascular and Hematology

Terms in this set (108)

ST-segment elevation during an acute myocardial infarction indicates necrosis. This ECG change reects a clot at the site of injury. Therefore, the client requires immediate revascularization of the artery
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The client who has sickle cell anemia and is in crisis will have an elevated bilirubin because hemolysis of the abnormal red blood cells occurs.
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The expected reference range of Hgb is 14 to 18 g/dL for men and 12 to 16 g/dL for women. Therefore, a client who has an Hgb level of 6.5 g/dL has anemia. Typical manifestations of a low Hgb level include fatigue, headaches, pallor, dizziness, and tachycardia
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The nurse should identify that swelling of the ankle is a manifestation of venous insufciency due to poor venous return. Other manifestations can include brown pigmentations and cellulitis.
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The nurse should identify that nausea is an associated manifestation of an MI. Manifestations of an MI include chest pain and pain in the jaw, shoulder, or abdomen.
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An aortic aneurysm is a weak spot in the wall of the aorta that allows the aorta to expand and increase in diameter. Sudden, increasing lower abdominal and back pain indicates that the aneurysm is extending downward and pressing on the lumbar sacral nerve roots.
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The rst action the nurse should take when using the airway, breathing, and circulation (ABC) approach to client care is to keep the client NPO due to the risk of aspiration as a result of the stroke. The client should be screened for the ability to swallow and should not receive anything by mouth until this has been completed. A client who has experienced a cerebrovascular accident is at risk of dysphagia, which increases the risk of life-threating aspiration.
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A client who is in sickle cell crisis needs ample hydration (IV, oral, or both) to shorten the duration of painful episodes. The nurse should plan to offer the client water, juice, or the client's favorite beverage, as long as it does not contain caffeine.
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"I can have yogurt as a dessert."
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The nurse should monitor the client for ototoxicity, and the client should report any manifestations of hearing impairment while on the loop diuretic. The nurse should use caution when a loop diuretic is used in conjunction with other ototoxic medications such as aminoglycoside antibiotics.
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Evidence-based practice indicates that the most common manifestation of acute MI is substernal chest pain that does not subside with rest or with nitroglycerin. Therefore, nurses should make pain management with morphine a priority to reduce myocardial oxygen demand and increase oxygenation.
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The increased venous pressure due to excessive circulating blood volume results in neck vein distension. Moist crackles are an indicator of pulmonary edema that can quickly lead to death. Fluid volume excess, or hypervolemia, is an expansion of uid volume in the extracellular uid compartment that results in an increased heart rate and bounding pulses
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Manifestations of hypokalemia include muscle weakness and cramps, confusion, and drowsiness. Hypokalemia can also result in life-threatening dysrhythmias.
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The nurse should inform the client of ways to decrease the risk of recurrence of infective endocarditis. The client should notify the provider prior to undergoing invasive or dental procedures due to the need for prophylactic antibiotic therapy to reduce the risk of a streptococcal infection.
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The primary dietary alteration for a client who has heart failure is sodium restriction. A turkey sandwich with whole wheat bread has a relatively low sodium content.
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The nurse should check and document the client's vital signs prior to a blood transfusion to obtain a baseline for comparison. Monitoring the client's vital signs helps the nurse identify adverse reactions to the packed RBCs and identify if the client is tolerating the volume of the prescribed blood product. Additionally, 2 nurses should check the blood type and Rh of the packed RBCs and compare
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A client who has pernicious anemia is decient in vitamin B12 due to a deciency in an intrinsic factor normally supplied by the gastric mucosa that is essential for the absorption of vitamin B12.
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The QRS complexes are of unusually great amplitude in height and depth for clients who have PVCs
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The nurse should plan to measure the client's abdominal girth daily to monitor for manifestations of internal bleeding. A client who has a reduced platelet count is at risk for bleeding due to delayed clotting.
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The nurse should monitor the client for hyperkalemia because chronic respiratory acidosis can result in high potassium levels due to potassium shifting out of the cells into the extracellular uid.
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The nurse should review the client's prothrombin time after the administration of FFP, which is plasma rich in clotting factors. FFP is administered to treat acute clotting disorders. The desired effect is a decrease in the prothrombin time
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The nurse should elevate the client's legs above his heart to promote venous return by gravity. During discharge teaching, the nurse should reinforce the importance of periodic positioning of the legs above the heart.
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The nurse should enforce uid restrictions to help reduce uid retention in the lungs and lower extremities.
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The nurse should identify that chicken breast is low in cholesterol and all vegetables, including corn, are cholesterol-free; therefore, this food selection by the client indicates an understanding of the teaching.
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Vitamin C deciency produces signs and symptoms of scurvy, such as delayed wound healing and capillary fragility.
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Platelets help maintain hemostasis and coagulation by plugging disruptions in the integrity of blood vessels. When a blood vessel is injured, platelets collect at the edge of the break and, by adhering to each other, plug the injured area and limit blood loss
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Pernicious anemia is caused by a lack of intrinsic factor needed to absorb vitamin B12 from the gastrointestinal tract. The nurse should recommend weekly injections of vitamin B12 for a client who has pernicious anemia. These may be decreased to monthly.
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Older adult clients are more prone to complications from poor tissue perfusion following acute MI because peripheral vascular resistance increases with aging. This results from calcication and loss of elasticity of the blood vessels.
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Hemophilia is a hereditary bleeding disorder in which blood clots slowly and abnormal bleeding occurs. It is caused by a deciency in the most common clotting factor, factor VIII (hemophilia A). Aggressive factor replacement is initiated to prevent hemarthrosis that can result in long-term loss of range-of-motion in repeatedly affected joints.
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The nurse should expect the client to have an increased hematocrit level due to hemoconcentration caused by reduced plasma uid volume.
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The nurse should identify that paresthesias (tingling sensations) in the hands and feet is an expected nding of pernicious anemia. Other manifestations include weight loss and fatigue.
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A platelet count below 100,000/mm^3 indicates thrombocytopenia, which puts the client at an increased risk of bleeding. By applying pressure to the site for 10 minutes, the nurse promotes coagulation and prevents additional blood loss.
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The nurse should encourage the client to increase her consumption of iron-rich foods, including meat, sh, poultry, and dried beans and peas. A 1-cup serving of lentils contains 3.6 mg of iron
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The nurse should identify that an AV stula is commonly located in the client's forearm. It is the surgical connection of an artery and vein to provide access for hemodialysis. The nurse should assess the client's forearm by listening for a bruit over the vascular access site.
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Abdominal aortic aneurysm involves a widening, stretching, or ballooning of the aorta. Back and abdominal pain indicate that the aneurysm is extending downward and pressing on lumbar spinal nerve roots, causing pain.
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According to evidence-based practice, the nurse should identify that dysrhythmias, specically ventricular brillation, are the most common cause of death following MI. Therefore, nurses should monitor clients' ECGs carefully for dysrhythmias and report and treat them immediately
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Nausea, vomiting, and epigastric distress are common manifestations of MI, as well as diaphoresis (sweating), dizziness, fatigue, and anxiety and feelings of doom and fear
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The client can help prevent infection by eating thoroughly cooked foods. Fresh fruit, vegetables, eggs, meat, and sh can harbor microorganisms that cooking would destroy, so the client should avoid raw foods.
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The superior and inferior vena cava carry deoxygenated blood to the right atrium.
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The client who has aplastic anemia will have manifestations of petechiae and ecchymosis. Dyspnea on exertion also can be present. In aplastic anemia, all three major blood components (red blood cells, white blood cells, and platelets) are reduced or absent, which is known as pancytopenia. Manifestations usually develop gradually.
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A client who has peripheral arterial disease can display dry, scaly, pale, or mottled skin with minimal body hair because of narrowing of the arteries in the legs and feet. This causes a decrease in blood ow to the distal extremities, which can lead to tissue damage. Common manifestations are intermittent claudication (leg pain with exercise), cold or numb feet at rest, loss of hair on the lower legs, and weakened pulses.
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The nurse should apply compression stockings on the client's lower extremities to promote blood return and decrease venous stasis.
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This statement implies that the client has most likely stopped adding salt to food. Sodium restriction is an aspect of the treatment plan and indicates dietary adherence by the client
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Elevated ST segments can indicate hyperkalemia and pericarditis.
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The nurse should instruct the client to check his heart rate each day and to document the rate in a log to support future discussions with the provider. The nurse should instruct the client to notify the provider if the heart rate is below the prescribed parameters.
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The nurse should identify that low back pain is a manifestation of a hemolytic transfusion reaction. Other manifestations include headaches, chest pain, tachypnea, tachycardia, and dark urine
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The client should avoid lifting the arm or shoulder on the side of the pacemaker because dislodgement of the pacer leads can occur.
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Fibrinolysis is a process that breaks a clot down over time in the body. It is a treatment option for clots that are not immediately life threatening.
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The client should avoid coffee, alcohol, and caffeine on the day of the test. These can affect the client's heart rate and blood pressure during the test.
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Solutions of 0.9% sodium chloride, as well as lactated Ringer's solution, are used for uidvolume replacement. Sodium chloride, a crystalloid, is a physiologically isotonic solution that replaces lost volume in the bloodstream and is the only solution to use when infusing blood products
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The nurse should instruct the client to use and hold a cellular phone to the opposite ear from the pacemaker. This will avoid interference of the generator inside the pacemaker.
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The nurse should identify that furosemide can cause a loss of potassium, sodium, calcium, and magnesium. Manifestations of hypokalemia can include shallow respirations, muscle weakness, lethargy, and ectopic heartbeats.
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Fish oil contains omega-3 fatty acids, which can help lower the risk of cardiovascular disease and stroke by decreasing triglyceride levels.
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To help prevent a recurrence of sickle cell crisis, the client should avoid overexertion from especially strenuous activities.
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The nurse should verify the information on the label of the packed RBCs with another nurse. The nurse should also verify the information on the label with the provider's order, the blood administration form from the blood bank, and the client armband and blood bracelet.
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The nurse should apply the urgent vs. nonurgent priority-setting framework when caring for this client. Using this framework, the nurse should consider urgent needs to be the priority because they pose more of a threat to the client. The nurse might also need to use Maslow's hierarchy of needs, the ABC priority-setting framework, and/or nursing knowledge to identify which nding is the most urgent. The nurse should stop the infusion of blood because the client has manifestations of an allergic reaction.
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The nurse should administer 0.9% sodium chloride with blood products because this solution does not cause clotting or hemolysis of the blood cells.
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After obtaining the AED, the nurse should apply 2 large adhesive debrillator pads on the client's anterior chest wall to enable the machine to analyze the rhythm and deliver the shock appropriately if indicated. One pad should be applied to the upper right chest area above the client's nipple and to the right of the sternum, and the second pad should be applied to the left lower chest area below the client's nipple and pectoral muscle. The pads should be applied without interrupting CPR.
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The nurse should apply the least invasive priority-setting framework, which assigns priority to nursing interventions that are least invasive to the client, as long as those interventions do not jeopardize client safety. Since witnessing the informed consent is the least invasive action, it should be performed rst. Unless the situation is an emergency, informed consent should be obtained prior to initiating a blood transfusion for a client.
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A weight gain of 1 kg in 1 day alerts the nurse that the client might be retaining uid and is at risk of uid volume overload. This is an indication that the client's heart failure is worsening.
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The nurse should check to determine that the packed RBCs are less than 1 week old; if the blood is older, the RBCs become fragile, break easily, and release potassium into the bloodstream. Additionally, the nurse should seek verication from 2 RNs before the packed RBCs are hung by an RN. Verication involves comparing the packed RBCs label against the medical record, against the client's complete name and identication number, and against the blood group name and number. If there is any discrepancy, the h ld t i f th bl d d h ld
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The nurse should observe the P wave, which represents atrial depolarization, to determine if the rhythm is originating from the sinoatrial (SA) node and is, therefore, a sinus rhythm. The P wave should be regular and accompany every QRS complex.
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The nurse should administer antihypertensive medication for the elevated blood pressure because hypertension can cause a sudden rupture of the aneurysm due to pressure on the arterial wall.
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The nurse should elevate the client's affected leg when the client is in bed to reduce inammation
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A client who had a recent myocardial infarction is at risk for left-sided heart failure. Crackles are breath sounds caused by the movement of air through airways partially or intermittently occluded with uid. These sounds are associated with heart failure and frothy sputum, are heard at the end of inspiration, and are not cleared by coughing.
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Acute confusion is a manifestation of myocardial infarction in clients age 65 or older. Other manifestations can include nausea, vomiting, dyspnea, diaphoresis, anxiety, dizziness, palpitations, and fatigue.
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Coronary artery disease is a primary risk factor for the development of heart failure. Other risk factors for heart failure include hypertension, cardiomyopathy, tobacco use, family history, and hyperthyroidism.
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The nurses should expect the client's provider to prescribe vitamin B12 to a client who has pernicious anemia.
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To solve using ratio and proportion and desired over have: STEP 1: What is the unit of measurement the nurse should calculate? gtt/min STEP 2: What is the volume the nurse should infuse? 250 mL STEP 3: What is the total infusion time? 4 hr STEP 4: Should the nurse convert the units of measurement? Yes (hr does not equal min) 1 hr/60 min = 4 hr/X min X = 240 min STEP 5: Set up an equation and solve for X. 10 Back Next Check Answer Volume (mL)/Time (min) x drop factor (gtt/mL) = X gtt/min 250 mL/240 min x 10 gtt/mL = X gtt/min X = 10.4 gtt/min STEP 6: Round if necessary: 10.4 gtt/min = 10 gtt/min STEP 7: Reassess to determine whether the amount to administer makes sense. If the prescription is for packed cells (250 mL) X 10 gtt/mL to infuse over 240 min, the nurse should set the manual IV infusion to deliver packed cells (250 mL) to infuse at 10 gtt/min. To solve using dimensional analysis: STEP 1: What is the unit of measurement the nurse should calculate? gtt/min STEP 2: What is the quantity of the drop factor that is available? 10 gtt/mL STEP 3: What is the total infusion time? 4 hr STEP 4: What is the volume the nurse should infuse? 250 mL STEP 5: Should the nurse convert the units of measurement? Yes (hr does not equal min)
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The client should remove the skin from poultry before eating because the skin contains the greatest amount of fat.
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Progressive loss of hair is common with aging. However, thinning or absence of hair on the extremities indicates poor arterial circulation to that area. The nurse should look for further indications of arterial insufciency and report these ndings to the provider.
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A common adverse effect of epoetin alfa is hypertension because of the rise in the production of erythrocytes and other blood cell types. Epoetin alfa is a synthetic version of human erythropoietin. Epoetin alfa is used to treat anemia associated with kidney disease or medication therapy. It increases and maintains the red blood cell level.
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Clients who have polycythemia vera should elevate their legs when seated to avoid venous pooling with subsequent clot formation.
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Left-sided heart failure precipitates pulmonary congestion and edema, causing crackles in the lungs.
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The formation of large amounts of microemboli in the circulation depletes the body's platelets and clotting factors. As a result, uncontrollable bleeding can occur as manifested by bleeding at the venipuncture site, petechiae on the arms and chest, and abdominal distension due to internal bleeding
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The client who has cardiac tamponade will have pulsus paradoxus when the systolic blood pressure is at least 10 mmHg higher on expiration than on inspiration. This occurs because of the sudden decrease in cardiac output from the uid compressing the atria and ventricles
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The nurse should apply the safety and risk reduction priority-setting framework, which assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the risk posing the greatest threat is the highest priority. The nurse should use Maslow's hierarchy of needs, the ABC priority-setting framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client. For this client, a life-threatening event such as circulatory collapse is possible. Therefore, the nurse should stop the infusion to prevent any further administration of blood.
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The appearance of ventricular dysrhythmias following thrombolytic therapy is a sign of reperfusion of the coronary artery.
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The nurse should plan to initiate an aspirin regimen or another antiplatelet agent. The antiplatelet medication maintains the patency of the stent by reducing platelet aggregation.
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A beta blocker will induce bradycardia. The client should take her pulse rate for 1 minute before self-administration.
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Blood return from the venous system to the right atrium is impaired by a weakened right heart. The subsequent systemic venous backup leads to the development of dependent edema.
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The nurse should identify that fresh fruits contain little to no sodium and are a good snack for a client who has hypertension.
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The nurse should identify that a client who has hypertension, diabetes mellitus, or hyperlipidemia is at risk of coronary artery disease (CAD). Hypertension can be controlled by diet and exercise, along with medication if needed. Diabetes can cause damage to large and small blood vessels, which leads to poor perfusion, cell death, and organ damage. Diabetes mellitus can be managed by monitoring glucose levels and implementing diet and exercise. Hyperlipidemia can be controlled with diet
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When a client has an elevated reading at a hypertension screening, the nurse should encourage the client to see the provider for further evaluation within 2 months. To help facilitate this process, the nurse should give the client a written record of the BP at the screening to share with the provider.
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A decreased albumin level can be an indication of long-term protein depletion. Other potential conditions that result in decreased albumin levels include burns, wound drainage, and impaired hepatic function.
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After a myocardial infarction, the electrical conduction system of the heart can be irritable and prone to dysrhythmias. Ischemic tissue caused by the infarction can also interfere with the normal conduction patterns of the heart's electrical system.
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The rst action the nurse should take using the nursing process is to collect data about the client's calf to check for swelling, redness, and warmth that can indicate deep-vein thrombophlebitis
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A client who is a vegetarian might require additional iron because of the limited availability of iron in vegetable sources. During pregnancy, maternal blood volume increases, and the fetus requires iron. Therefore, the RDA of iron for clients who are pregnant is increased to 27 mg/day. Toddlers who are overweight might get most of their calories from milk and from foods that are not considered healthy, which places toddlers at risk of iron-deciency anemia
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A client who has unstable angina will have chest pain even while resting because of insufcient blood ow to the coronary arteries and decreased oxygen supply. Chest pain at rest is a condition called variant (Prinzmetal's) angina, caused by an artery spasm.
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The nurse should encourage the client to increase consumption of foods rich in vitamin B12 such as dairy products, animal proteins, poultry, shellsh, and eggs.
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An elevated LDL level increases a client's risk for atherosclerosis. The client's desirable LDL level is below 130 mg/dL.
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Sodium reduction helps control blood pressure. Grilled chicken salad and fresh tomatoes are fresh food items that are likely to be low in sodium. However, the client should make sure the food preparer has not added salt generously to the mea
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The client should keep the legs elevated while in bed to promote venous return to the heart and prevent venous pooling
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The nurse should identify that prolonged arterial insufciency from PVD can contribute to the formation of ulcerations of the client's toes. Severe arterial disease is identied through assessment of the quality of the client's posterior tibial pulses by comparing the pulses on both feet
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Palpate the blood pressure and inate the cuff above the systolic pressure Deate the cuff slowly and listen for the rst audible sounds Identify the rst BP sounds audible on expiration and then on inspiration Subtractthe inspiratory pressure from the expiratory pressure
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The nurse should encourage the client to increase her consumption of iron-rich foods, including meat, sh, and poultry. A 3 oz serving of beef liver contains 4.17 mg of iron.
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The client who has pericarditis will experience dyspnea, hiccups, and a nonproductive cough. These manifestations can indicate heart failure from pericardial compression due to constrictive pericarditis or cardiac tamponade.
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The nurse should identify that a client who has heart failure will have an elevated human B-type natriuretic peptide (BNP) level of >100 pg/mL. Endogenous BNP is released into the client's bloodstream due to decreased cardiac output, a process called natriuresis.
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Depending on the provider's prescription, the client should remain at or with the head of the bed elevated to no more than 30°for 2 to 6 hours after the procedure. The amount of time depends on the type of closure device the provider uses. The client will receive a mild sedative for relaxation and comfort
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Erythropoietin stimulates the production of RBCs and is used to treat anemia associated with chronic renal failure.
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The nurse should expect a client who is experiencing third spacing resulting from a major burn to have an elevated hematocrit level as blood volume is reduced by vascular dehydration
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Deep-vein thrombosis can cause hardening along the affected blood vessel and prominence of supercial veins. Additionally, deep-vein thrombosis causes pain or tenderness in the calf and an increased circumference of the leg due to swelling.
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Variant or Prinzmetal's angina causes ECG changes that reect coronary artery spasms, resulting in less oxygen supplying the myocardium.
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The nurse should prepare the client to expect a painful, pulling sensation when the provider aspirates the marrow and some discomfort from the rotation of the needle into the bone.
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The nurse should administer oxygen to the client during a sickle cell crisis. Hypoxia increases sickling and client discomfort.
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The nurse should apply direct pressure to the nose for 10 minutes to control epistaxis. If after 10 minutes the epistaxis continues, the client might require nasal packing or other interventions.
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In response to tissue hypoxia, the kidneys release erythropoietin, which stimulates the production of erythrocytes (RBCs) in the bone marrow.
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Epistaxis is a manifestation of elevated blood pressure. Hypertension is often asymptomatic, but when it is severely elevated, it can also cause headaches, dizziness, facial ushing, and fainting.
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