The nurse is assessing a 48-year-old client with a history of smoking during a
routine clinic visit. The client, who exercises regularly, reports having pain in the calf
during exercise that disappears at rest. Which of the following findings requires further
1. Heart rate 57 bpm.
2. SpO2 of 94% on room air.
3. Blood pressure 134/82.
4. Ankle-brachial index of 0.65.
An Ankle-Brachial Index of 0.65 suggests moderate arterial vascular disease in
a client who is experiencing intermittent claudication. A Doppler ultrasound is
indicated for further evaluation. The bradycardic heart rate is acceptable in an athletic
client with a normal blood pressure. The SpO2 is acceptable; the client has a smoking
An overweight client taking warfarin (Coumadin) has dry skin due to decreased
arterial blood flow. What should the nurse instruct the client to do? Select all that apply.
1. Apply lanolin or petroleum jelly to intact skin.
2. Follow a reduced-calorie, reduced-fat diet.
3. Inspect the involved areas daily for new ulcerations.
4. Instruct the client to limit activities of daily living (ADLs).
5.Use an electric razor to shave
Maintaining skin integrity is important in preventing chronic ulcers and
infections. The client should be taught to inspect the skin on a daily basis. The client
should reduce weight to promote circulation; a diet lower in calories and fat is
appropriate. Because the client is receiving Coumadin, the client is at risk for bleeding
from cuts. To decrease the risk of cuts, the nurse should suggest that the client use an
electric razor. The client with decreased arterial blood flow should be encouraged to
participate in ADLs. In fact, the client should be encouraged to consult an exercise
physiologist for an exercise program that enhances the aerobic capacity of the body.
A client with peripheral vascular disease has undergone a right femoral-popliteal
bypass graft. The blood pressure has decreased from 124/80 to 94/62. What
should the nurse assess first?
1. IV fluid solution.
2. Pedal pulses.
3. Nasal cannula flow rate.
4. Capillary refill
With each set of vital signs, the nurse should assess the dorsalis pedis and
posterior tibial pulses. The nurse needs to ensure adequate perfusion to the lower
extremity with the drop in blood pressure. IV fluids, nasal cannula setting, and capillary
refill are important to assess; however, priority is to determine the cause of drop in
blood pressure and that adequate perfusion through the new graft is maintained.
The nurse is caring for a client with peripheral artery disease who has recently
been prescribed clopidogrel (Plavix). The nurse understands that more teaching is
necessary when the client states which of the following:
1. "I should not be surprised if I bruise easier or if my gums bleed a little when
brushing my teeth."
2. "It doesn't really matter if I take this medicine with or without food, whatever
works best for my stomach."
3. "I should stop taking Plavix if it makes me feel weak and dizzy."
4. "The doctor prescribed this medicine to make my platelets less likely to stick together and help prevent clots from forming."
Weakness, dizziness, and headache are common adverse effects of Plavix and
the client should report these to the physician if they are problematic; in order to
decrease risk of clot formation, Plavix must be taken regularly and should not be
stopped or taken intermittently. The main adverse effect of Plavix is bleeding, which
often occurs as increased bruising or bleeding when brushing teeth. Plavix is well
absorbed, and while food may help decrease potential gastrointestinal upset, Plavix may
be taken with or without food. Plavix is an antiplatelet agent used to prevent clot
formation in clients who have experienced or are at risk for myocardial infarction,
ischemic stroke, peripheral artery disease, or acute coronary syndrome.
A client is receiving Cilostazol (Pletal) for peripheral arterial disease causing
intermittent claudication. The nurse determines this medication is effective when the
client reports which of the following?
1. "I am having fewer aches and pains."
2. "I do not have headaches anymore."
3. "I am able to walk further without leg pain."
4. "My toes are turning grayish black in color."
Cilostazol is indicated for management of intermittent claudication. Symptoms
usually improve within 2 to 4 weeks of therapy. Intermittent claudication prevents
clients from walking for long periods of time. Cilostazol inhibits platelet aggregation
induced by various stimuli and improving blood flow to the muscles and allowing the
client to walk long distances without pain. Peripheral arterial disease causes pain
mainly of the leg muscles. "Aches and pains" does not specify exactly where the pain is
occurring. Headaches may occur as a side effect of this drug, and the client should
report this information to the health care provider. Peripheral arterial disease causes
decreased blood supply to the peripheral tissues and may cause gangrene of the toes; the
drug is effective when the toes are warm to the touch and the color of the toes is similar
to the color of the body.
The client admitted with peripheral vascular disease (PVD) asks the nurse why
her legs hurt when she walks. The nurse bases a response on the knowledge that the
main characteristic of PVD is:
1. Decreased blood flow.
2. Increased blood flow.
3. Slow blood flow.
4. Thrombus formation.
Decreased blood flow is a common characteristic of all PVD. When the
demand for oxygen to the working muscles becomes greater than the supply, pain is the
outcome. Slow blood flow throughout the circulatory system may suggest pump failure.
Thrombus formation can result from stasis or damage to the intima of the vessels.
The nurse is planning care for a client who is diagnosed with peripheral vascular
disease (PVD) and has a history of heart failure. The nurse should develop a plan of
care that is based on the fact that the client may have a low tolerance for exercise
1. Decreased blood flow.
2. Increased blood flow.
3. Decreased pain.
4. Increased blood viscosity.
A client with PVD and heart failure will experience decreased blood flow. In
this situation, low exercise tolerance (oxygen demand becomes greater than the oxygen
supply) may be related to less blood being ejected from the left ventricle into the
systemic circulation. Decreased blood supply to the tissues results in pain. Increased
blood viscosity may be a component, but it is of much less importance than the disease
When assessing the lower extremities of a client with peripheral vascular
disease (PVD), the nurse notes bilateral ankle edema. The edema is related to:
1. Competent venous valves.
2. Decreased blood volume.
3. Increase in muscular activity.
4. Increased venous pressure.
In PVD, decreased blood flow can result in increased venous pressure. The
increase in venous pressure results in an increase in capillary hydrostatic pressure,
which causes a net filtration of fluid out of the capillaries into the interstitial space,
resulting in edema. Valves often become incompetent with PVD. Blood volume is not
decreased in this condition. Decreased muscular action would contribute to the
formation of edema in the lower extremities.
The nurse is obtaining the pulse of a client who has had a femoral-popliteal
bypass surgery 6 hours ago. (See below) Which assessment provides the most accurate
information about the client's postoperative status?
1. radial pulse
2. femoral pulse
3. apical pulse
4. dorsalis pedis pulse
The presence of a strong dorsalis pedis pulse indicates that there is circulation to
the extremity distal to the surgery indicating that the graft between the femoral and
popliteal artery is allowing blood to circulate effectively. Answer 1 shows the nurse
obtaining the radial pulse; answer 2 shows the femoral pulse, which is proximal to the
surgery site and will not indicate circulation distal to the surgery site. Answer 3 shows
the nurse obtaining an apical pulse.
The nurse is teaching a client about risk factors associated with atherosclerosis
and how to reduce the risk. Which of the following is a risk factor that the client is not
able to modify?
3. Exercise level.
4. Dietary preferences
Age is a nonmodifiable risk factor for atherosclerosis. The nurse instructs the
client to manage modifiable risk factors such as comorbid diseases (eg, diabetes),
activity level, and diet. Controlling serum blood glucose levels, engaging in regular
aerobic activity, and choosing a diet low in saturated fats can reduce the risk of
The nurse is assessing the lower extremities of the client with peripheral
vascular disease (PVD). During the assessment, the nurse should expect to find which of
the following clinical manifestations of PVD? Select all that apply.
1. Hairy legs.
2. Mottled skin.
3. Pink skin.
5. Moist skin.
Reduction of blood flow to a specific area results in decreased oxygen and
nutrients. As a result, the skin may appear mottled. The skin will also be cool to the
touch. Loss of hair and dry skin are other signs that the nurse may observe in a client
with PVD of the lower extremities.
The nurse is unable to palpate the client's left pedal pulses. Which of the
following actions should the nurse take next?
1. Auscultate the pulses with a stethoscope.
2. Call the physician.
3. Use a Doppler ultrasound device.
4. Inspect the lower left extremity
When pedal pulses are not palpable, the nurse should obtain a Doppler
ultrasound device. Auscultation is not likely to be helpful if the pulse isn't palpable.
Inspection of the lower extremity can be done simultaneously when palpating, but the
nurse should first try to locate a pulse by Doppler. Calling the physician may be
necessary if there is a change in the client's condition.
Which of the following lipid abnormalities is a risk factor for the development
of atherosclerosis and peripheral vascular disease?
1. Low concentration of triglycerides.
2. High levels of high-density lipid (HDL) cholesterol.
3. High levels of low-density lipid (LDL) cholesterol.
4. Low levels of LDL cholesterol.
An increased LDL cholesterol concentration has been documented as a risk
factor for the development of atherosclerosis. LDL cholesterol is not broken down in
the liver but is deposited into the intima of the blood vessels. Low triglyceride levels
are desirable. High HDL and low LDL levels are beneficial and are known to be
protective for the cardiovascular system.
When assessing an individual with peripheral vascular disease, which clinical
manifestation would indicate complete arterial obstruction in the lower left leg?
1. Aching pain in the left calf.
2. Burning pain in the left calf.
3. Numbness and tingling in the left leg.
4. Coldness of the left foot and ankle
Coldness in the left foot and ankle is consistent with complete arterial
obstruction. Other expected findings would include paralysis and pallor. Aching pain, a
burning sensation, or numbness and tingling are earlier signs of tissue hypoxia and
ischemia and are commonly associated with incomplete obstruction.
A client with peripheral vascular disease returns to the surgical care unit after
having femoral-popliteal bypass grafting. Indicate in which order the nurse should
conduct assessment of this client.
1. Postoperative pain.
2. Peripheral pulses.
3. Urine output.
4. Incision site.
Because assessment of the presence and quality of the pedal pulses in the affected
extremity is essential after surgery to make sure that the bypass graft is functioning, this
step should be done first. The nurse should next ensure that the dressing is intact, and
then that the client has adequate urine output. Lastly, the nurse should determine the
client's level of pain.
A client with heart failure has bilateral +4 edema of the right ankle that extends
up to midcalf. The client is sitting in a chair with the legs in a dependent position.
Which of the following goals is the priority?
1. Decrease venous congestion.
2. Maintain normal respirations.
3. Maintain body temperature.
4. Prevent injury to lower extremities.
Decreasing venous congestion in the extremities is a desired outcome for
clients with heart failure. The nurse should elevate the client's legs above the level of
the heart to achieve this goal. The client is not demonstrating difficulty breathing or
being cold. The nurse should prevent injury to the swollen extremity; however, this is
not the priority.
The nurse is assessing an older Caucasian male who has a history of peripheral
vascular disease. The nurse observes that the man's left great toe is black. The
discoloration is probably a result of:
The term gangrene refers to blackened, decomposing tissue that is devoid of
circulation. Chronic ischemia and death of the tissue can lead to gangrene in the affected
extremity. Injury, edema, and decreased circulation lead to infection, gangrene, and
tissue death. Atrophy is the shrinking of tissue, and contraction is joint stiffening
secondary to disuse. The term rubor denotes a reddish color of the skin
A client has peripheral vascular disease (PVD) of the lower extremities. The
client tells the nurse, "I've really tried to manage my condition well." Which of the
following routines should the nurse evaluate as having been appropriate for this client?
1. Resting with the legs elevated above the level of the heart.
2. Walking slowly but steadily for 30 minutes twice a day.
3. Minimizing activity.
4. Wearing antiembolism stockings at all times when out of bed
Slow, steady walking is a recommended activity for clients with peripheral
vascular disease because it stimulates the development of collateral circulation. The
client with PVD should not remain inactive. Elevating the legs above the heart or
wearing antiembolism stockings is a strategy for alleviating venous congestion and may
worsen peripheral arterial disease
A client is scheduled for an arteriogram. The nurse should explain to the client
that the arteriogram will confirm the diagnosis of occlusive arterial disease by:
1. Showing the location of the obstruction and the collateral circulation.
2. Scanning the affected extremity and identifying the areas of volume changes.
3. Using ultrasound to estimate the velocity changes in the blood vessels.
4. Determining how long the client can walk.
An arteriogram involves injecting a radiopaque contrast agent directly into the
vascular system to visualize the vessels. It usually involves computed tomographic
scanning. The velocity of the blood flow can be estimated by duplex ultrasound. The
client's ankle-brachial index is determined, and then the client is requested to walk. The
normal response is little or no drop in ankle systolic pressure after exercise.
A client is scheduled to have an arteriogram. During the arteriogram, the client
reports having nausea, tingling, and dyspnea. The nurse's immediate action should be
1. Administer epinephrine.
2. Inform the physician.
3. Administer oxygen.
4. Inform the client that the procedure is almost over.
.Clients may have an immediate or a delayed reaction to the radiopaque dye.
The physician should be notified immediately because the symptoms suggest an allergic
reaction. Treatment may involve administering oxygen and epinephrine. Explaining that
the procedure is over does not address the current symptoms
Which of the following is an expected outcome when a client is receiving an IV
administration of furosemide?
1. Increased blood pressure.
2. Increased urine output.
3. Decreased pain.
4. Decreased premature ventricular contractions.
Furosemide is a loop diuretic that acts to increase urine output. Furosemide
does not increase blood pressure, decrease pain, or decrease arrhythmias.
A client has had a pulmonary artery catheter inserted. In performing
hemodynamic monitoring with the catheter, the nurse will wedge the catheter to gain
information about which of the following?
1. Cardiac output.
2. Right atrial blood flow.
3. Left end-diastolic pressure.
4. Cardiac index
When wedged, the catheter is "pointing" indirectly at the left end-diastolic
pressure. The pulmonary artery wedge pressure is measured when the tip of the catheter
is slowing inflated and allowed to wedge into a branch of the pulmonary artery. Once
the balloon is wedged, the catheter reads the pressure in front of the balloon. During
diastole, the mitral valve is open, reflecting left ventricular end diastolic pressure.
Cardiac output is the amount of blood ejected by the heart in 1 minute and is determined
through thermodilution and not wedge pressure. Cardiac index is calculated by dividing
the client's cardiac output by the client's body surface area, and is considered a more
accurate reflection of the individual client's cardiac output. Right atrial blood pressure
is not measured with the pulmonary artery catheter.
After a myocardial infarction, the hospitalized client is taught to move the legs
while resting in bed. The expected outcome of this exercise is to:
1. Prepare the client for ambulation.
2. Promote urinary and intestinal elimination.
3. Prevent thrombophlebitis and blood clot formation.
4. Decrease the likelihood of pressure ulcer formation.
Encouraging the client to move the legs while in bed is a preventive strategy
taught to all clients who are hospitalized and on bed rest to promote venous return. The
muscular action aids in venous return and prevents venous stasis in the lower
extremities. These exercises are not intended to prepare the client for ambulation. These
exercises are not associated with promoting urinary and intestinal elimination. These
exercises are not performed to decrease the risk of pressure ulcer formation
Which of the following is the most appropriate diet for a client during the acute
phase of myocardial infarction?
1. Liquids as desired.
2. Small, easily digested meals.
3. Three regular meals per day.
4. Nothing by mouth
Recommended dietary principles in the acute phase of MI include avoiding
large meals because small, easily digested foods are better tolerated. Fluids are given
according to the client's needs, and sodium restrictions may be prescribed, especially
for clients with manifestations of heart failure. Cholesterol restrictions may be
prescribed as well. Clients are not prescribed diets of liquids only or restricted to
nothing by mouth unless their condition is very unstable.
The nurse is caring for a client who recently experienced a myocardial
infarction and has been started on clopidogrel (Plavix). The nurse should develop a
teaching plan that includes which of the following points? Select all that apply.
1. The client should report unexpected bleeding or bleeding that lasts a long time.
2. The client should take Plavix with food.
3. The client may bruise more easily and may experience bleeding gums.
4. Plavix works by preventing platelets from sticking together and forming a clot.
5. The client should drink a glass of water after taking Plavix.
Plavix is generally well absorbed and may be taken with or without
food; it should be taken at the same time every day and, while food may help prevent
potential GI upset, food has no effect on absorption of the drug. Bleeding is the most
common adverse effect of Plavix; the client must understand the importance of reporting
any unexpected, prolonged, or excessive bleeding including blood in urine or stool.
Increased bruising and bleeding gums are possible side effects of Plavix; the client
should be aware of this possibility. Plavix is an antiplatelet agent used to prevent clot
formation in clients that have experienced or are at risk for myocardial infarction,
ischemic stroke, peripheral artery disease, or acute coronary syndrome. It is not
necessary to drink a glass of water after taking Plavix.
Which client is at greatest risk for coronary artery disease?
1. A 32-year-old female with mitral valve prolapse who quit smoking 10 years ago.
2. A 43-year-old male with a family history of CAD and cholesterol level of 158
3. A 56-year-old male with an HDL of 60 (3.3 mmol/L) who takes atorvastatin.
4. A 65-year-old female who is obese with an LDL of 188 (10.4 mmol/L).
The woman who is 65 years old, overweight, and has an elevated LDL is at
greatest risk. Total cholesterol greater than 200 (11.1 mmol/L), LDL greater than 100
(5.5 mmol/L), HDL less than 40 (2.2 mmol/L) in men, HDL less than 50 (2.8 mmol/L) in
women, men 45 years and older, women 55 years and older, smoking and obesity
increase the risk of CAD. Atorvastatin reduces LDL and decreases risk of CAD. The
combination of postmenopausal, obesity, and high LDL places this client at greatest risk.
. A middle-aged adult with a family history of CAD has the following: total
cholesterol 198 (11 mmol/L); LDL cholesterol 120 (6.7 mmol/L); HDL cholesterol 58
(3.2 mmol/L); triglycerides 148 (8.2 mmol/L); blood sugar 102 (5.7 mmol/L); and Creactive
protein (CRP) 4.2. The health care provider prescribes a statin medication and
aspirin. The client asks the nurse why these medications are needed. Which is the best
response by the nurse?
1. "The labs indicate severe hyperlipidemia and the medications will lower your
LDL, along with a low-fat diet."
2. "The triglycerides are elevated and will not return to normal without these
3. "The CRP is elevated indicating inflammation seen in cardiovascular disease,
which can be lowered by the medications prescribed."
4. "These medications will reduce the risk of type 2 diabetes."
CRP is a marker of inflammation and is elevated in the presence of
cardiovascular disease. The high sensitivity CRP (hs-CRP) is the blood test for greater
accuracy in measuring the CRP to evaluate cardiovascular risk. The family history,
postmenopausal age, LDL above optimum levels, and elevated CRP place the client at
risk of CAD. Statin medications can decrease LDL, whereas statins and aspirin can
reduce CRP and decrease the risk of MI and stroke. The blood sugar is within normal
The client has been managing angina episodes with nitroglycerin. Which of the
following indicate the drug is effective?
1. Decreased chest pain.
2. Increased blood pressure.
3. Decreased blood pressure.
4. Decreased heart rate
Nitroglycerin acts to decrease myocardial oxygen consumption. Vasodilation
makes it easier for the heart to eject blood, resulting in decreased oxygen needs.
Decreased oxygen demand reduces pain caused by heart muscle not receiving sufficient
oxygen. While blood pressure may decrease ever so slightly due to the vasodilation
effects of nitroglycerine, it is only secondary and not related to the angina the patient is
experiencing. Increased blood pressure would mean the heart would work harder,
increasing oxygen demand and thus angina. Decreased heart rate is not an effect of
If a client displays risk factors for coronary artery disease, such as smoking
cigarettes, eating a diet high in saturated fat, or leading a sedentary lifestyle, techniques
of behavior modification may be used to help the client change the behavior. The nurse
can best reinforce new adaptive behaviors by:
1. Explaining how the risk factor behavior leads to poor health.
2. Withholding praise until the new behavior is well established.
3. Rewarding the client whenever the acceptable behavior is performed.
4. Instilling mild fear into the client to extinguish the behavior.
A basic principle of behavior modification is that behavior that is learned and
continued is behavior that has been rewarded. Other reinforcement techniques have not
been found to be as effective as reward.
Alteplase recombinant, or tissue plasminogen activator (t-PA), a thrombolytic
enzyme, is administered during the first 6 hours after onset of myocardial infarction
1. Control chest pain.
2. Reduce coronary artery vasospasm.
3. Control the arrhythmias associated with MI.
4. Revascularize the blocked coronary artery.
The thrombolytic agent t-PA, administered intravenously, lyses the clot
blocking the coronary artery. The drug is most effective when administered within the
first 6 hours after onset of MI. The drug does not reduce coronary artery vasospasm;
nitrates are used to promote vasodilation. Arrhythmias are managed by antiarrhythmic
drugs. Surgical approaches are used to open the coronary artery and re-establish a
blood supply to the area.
After the administration of t-PA, the nurse should:
1. Observe the client for chest pain.
2. Monitor for fever.
3. Review the 12-lead electrocardiogram (ECG).
4. Auscultate breath sounds
Although monitoring the 12-lead ECG and monitoring breath sounds are
important, observing the client for chest pain is the nursing assessment priority because
closure of the previously obstructed coronary artery may recur. Clients who receive t-
PA frequently receive heparin to prevent closure of the artery after administration of t-
PA. Careful assessment for signs of bleeding and monitoring of partial thromboplastin
time are essential to detect complications. Administration of t-PA should not cause
When monitoring a client who is receiving tissue plasminogen activator (t-PA),
the nurse should have resuscitation equipment available because reperfusion of the
cardiac tissue can result in which of the following?
1. Cardiac arrhythmias.
Cardiac arrhythmias are commonly observed with administration of t-PA.
Cardiac arrhythmias are associated with reperfusion of the cardiac tissue. Hypotension
is commonly observed with administration of t-PA. Seizures and hypothermia are not
generally associated with reperfusion of the cardiac tissue.
Prior to administering tissue plasminogen activator (t-PA), the nurse should
assess the client for which of the following contradictions to administering the drug?
1. Age greater than 60 years.
2. History of cerebral hemorrhage.
3. History of heart failure.
4. Cigarette smoking.
A history of cerebral hemorrhage is a contraindication to administration of t-
PA because the risk of hemorrhage may be further increased. Age greater than 60 years,
history of heart failure, and cigarette smoking are not contraindications.
A client has driven himself to the emergency department. He is 50 years old,
has a history of hypertension, and informs the nurse that his father died from a heart
attack at age 60. The client has indigestion. The nurse connects him to an
electrocardiogram monitor and begins administering oxygen at 2 L/min per nasal
cannula. The nurse's next action should be to:
1. Call for the physician.
2. Start an IV infusion.
3. Obtain a portable chest radiograph.
4. Draw blood for laboratory studies
Advanced cardiac life support recommends that at least one or two IV lines
be inserted in one or both of the antecubital spaces. Calling the physician, obtaining a
portable chest radiograph, and drawing blood for the laboratory are important but
secondary to starting the IV line.
Crackles heard on lung auscultation indicate which of the following?
3. Airway narrowing.
Crackles are auscultated over fluid-filled alveoli. Crackles heard on lung
auscultation do not have to be associated with cyanosis. Bronchospasm and airway
narrowing generally are associated with wheezing sounds.
A 68-year-old client on day 2 after hip surgery has no cardiac history but
reports having chest heaviness. The first nursing action should be to:
1. Inquire about the onset, duration, severity, and precipitating factors of the
2. Administer oxygen via nasal cannula.
3. Offer pain medication for the chest heaviness.
4. Inform the physician of the chest heaviness.
1 Further assessment is needed in this situation. It is premature to initiate other
actions until further data have been gathered. Inquiring about the onset, duration,
location, severity, and precipitating factors of the chest heaviness will provide pertinent
information to convey to the physician.
The nurse is assessing an older adult with a pacemaker who leads a sedentary
lifestyle. The client reports being unable to perform activities that require physical
exertion. The nurse should further assess the client for which of the following?
1. Left ventricular atrophy.
2. Irregular heartbeats.
3. Peripheral vascular occlusion.
4. Pacemaker placement
In older adults who are less active and do not exercise the heart muscle,
atrophy can result. Disuse or deconditioning can lead to abnormal changes in the
myocardium of the older adult. As a result, under sudden emotional or physical stress,
the left ventricle is less able to respond to the increased demands on the myocardial
muscle. Decreased cardiac output, cardiac hypertrophy, and heart failure are examples
of the chronic conditions that may develop in response to inactivity, rather than in
response to the aging process. Irregular heartbeats are generally not associated with an
older sedentary adult's lifestyle. Peripheral vascular occlusion or pacemaker placement
should not affect response to stress.
. Following diagnosis of angina pectoris, a client reports being unable to walk up
two flights of stairs without pain. Which of the following measures would most likely
help the client prevent this problem?
1. Climb the steps early in the day.
2. Rest for at least an hour before climbing the stairs.
3. Take a nitroglycerin tablet before climbing the stairs.
4. Lie down after climbing the stairs.
Nitroglycerin may be used prophylactically before stressful physical
activities such as stair climbing to help the client remain pain free. Climbing the stairs
early in the day would have no impact on decreasing pain episodes. Resting before or
after an activity is not as likely to help prevent an activity-related pain episode.
The client who experiences angina has been told to follow a low-cholesterol
diet. Which of the following meals would be best?
1. Hamburger, salad, and milkshake.
2. Baked liver, green beans, and coffee.
3. Spaghetti with tomato sauce, salad, and coffee.
4. Fried chicken, green beans, and skim milk
Pasta, tomato sauce, salad, and coffee would be the best selection for the
client following a low-cholesterol diet. Hamburgers, milkshakes, liver, and fried foods
tend to be high in cholesterol.
The nurse should caution the client with diabetes mellitus who is taking a
sulfonylurea that alcoholic beverages should be avoided while taking these drugs
because they can cause which of the following?
4.Disulfiram (Antabuse)-like symptoms
A client with diabetes who takes any first- or second-generation sulfonylurea
should be advised to avoid alcohol intake. Sulfonylureas in combination with alcohol
can cause serious disulfiram (Antabuse)-like reactions, including flushing, angina,
palpitations, and vertigo. Serious reactions, such as seizures and possibly death, may
also occur. Hypokalemia, hyperkalemia, and hypocalcemia do not result from taking
sulfonylureas in combination with alcohol.
Which of the following conditions is the most significant risk factor for the
development of type 2 diabetes mellitus?
1. Cigarette smoking.
2. High-cholesterol diet.
The most important factor predisposing to the development of type 2 diabetes
mellitus is obesity. Insulin resistance increases with obesity. Cigarette smoking is not a
predisposing factor, but it is a risk factor that increases complications of diabetes
mellitus. A high-cholesterol diet does not necessarily predispose to diabetes mellitus,
but it may contribute to obesity and hyperlipidemia. Hypertension is not a predisposing
factor, but it is a risk factor for developing complications of diabetes mellitus.
Which of the following indicates a potential complication of diabetes mellitus?
1. Inflamed, painful joints.
2. Blood pressure of 160/100 mm Hg.
3. Stooped appearance.
4. Hemoglobin of 9 g/dL (90 g/L).
The client with diabetes mellitus is especially prone to hypertension due to
atherosclerotic changes, which leads to problems of the microvascular and
macrovascular systems. This can result in complications in the heart, brain, and kidneys.
Heart disease and stroke are twice as common among people with diabetes mellitus as
among people without the disease. Painful, inflamed joints accompany rheumatoid
arthritis. A stooped appearance accompanies osteoporosis with narrowing of the
vertebral column. A low hemoglobin concentration accompanies anemia, especially
iron deficiency anemia and anemia of chronic disease.
The nurse is teaching the client about home blood glucose monitoring. Which of
the following blood glucose measurements indicates hypoglycemia?
1. 59 mg/dL (3.3 mmol/L).
2. 75 mg/dL (4.2 mmol/L).
3. 108 mg/dL (6 mmol/L).
4. 119 mg/dL (6.6 mmol/L).
Although some individual variation exists, when the blood glucose level
decreases to less than 70 mg/dL (3.9 mmol/L), the client experiences or is at risk for
hypoglycemia. Hypoglycemia can occur in both type 1 and type 2 diabetes mellitus,
although it is more common when the client is taking insulin. The nurse should instruct
the client on the prevention, detection, and treatment of hypoglycemia.
Assessment of the diabetic client for common complications should include
examination of the:
2. Lymph glands.
Diabetic retinopathy, cataracts, and glaucoma are common complications in
diabetics, necessitating eye assessment and examination. The feet should also be
examined at each client encounter, monitoring for thickening, fissures, or breaks in the
skin; ulcers; and thickened nails. Although assessments of the abdomen, pharynx, and
lymph glands are included in a thorough examination, they are not pertinent to common
The client with type 1 diabetes mellitus is taught to take isophane insulin
suspension NPH (Humulin N) at 5 PM each day. The client should be instructed that the
greatest risk of hypoglycemia will occur at about what time?
1. 11 AM, shortly before lunch.
2. 1 PM, shortly after lunch.
3. 6 PM, shortly after dinner.
4.1 AM, while sleeping
The client with diabetes mellitus who is taking NPH insulin (Humulin N) in
the evening is most likely to become hypoglycemic shortly after midnight because this
insulin peaks in 6 to 8 hours. The client should eat a bedtime snack to help prevent
hypoglycemia while sleeping.
A nurse is teaching a client with type 1 diabetes mellitus who jogs daily about
the preferred sites for insulin absorption. What is the most appropriate site for a client
4. Iliac crest.
If the client engages in an activity or exercise that focuses on one area of the
body, that area may cause inconsistent absorption of insulin. A good regimen for a
jogger is to inject the abdomen for 1 week and then rotate to the buttock. A jogger may
have inconsistent absorption in the legs or arms with strenuous running. The iliac crest
is not an appropriate site due to a lack of loose skin and subcutaneous tissue in that area.
A client with diabetes is taking insulin lispro (Humalog) injections. The nurse
should advise the client to eat:
1. Within 10 to 15 minutes after the injection.
2. 1 hour after the injection.
3. At any time, because timing of meals with lispro injections is unnecessary.
4. 2 hours before the injection.
Insulin lispro (Humalog) begins to act within 10 to 15 minutes and lasts
approximately 4 hours. A major advantage of Humalog is that the client can eat almost
immediately after the insulin is administered. The client needs to be instructed regarding
the onset, peak, and duration of all insulin, as meals need to be timed with these
parameters. Waiting 1 hour to eat may precipitate hypoglycemia. Eating 2 hours before
the insulin lispro could cause hyperglycemia if the client does not have circulating
insulin to metabolize the carbohydrate.
The best indicator that the client has learned how to give an insulin self injection
correctly is when the client can:
1. Perform the procedure safely and correctly.
2. Critique the nurse's performance of the procedure.
3. Explain all steps of the procedure correctly.
4. Correctly answer a posttest about the procedure
The nurse should judge that learning has occurred from the evidence of a
change in the client's behavior. A client who performs a procedure safely and correctly
demonstrates that he has acquired a skill. Evaluation of this skill acquisition requires
performance of that skill by the client with observation by the nurse. The client must
also demonstrate cognitive understanding, as shown by the ability to critique the nurse's
performance. Explaining the steps demonstrates acquisition of knowledge at the
cognitive level only. A posttest does not indicate the degree to which the client has
learned a psychomotor skill.
The nurse is instructing the client on insulin administration. The client is performing a
return demonstration for preparing the insulin. The client's morning dose of insulin is 10
units of regular and 22 units of NPH. The nurse checks the dose accuracy with the client.
The nurse determines that the client has prepared the correct dose when the syringe
reads how many units?
Angiotensin-converting enzyme (ACE) inhibitors may be prescribed for the
client with diabetes mellitus to reduce vascular changes and possibly prevent or delay
1. Chronic obstructive pulmonary disease (COPD).
2. Pancreatic cancer.
3. Renal failure.
4. Cerebrovascular accident.
Renal failure frequently results from the vascular changes associated with
diabetes mellitus. ACE inhibitors increase renal blood flow and are effective in
decreasing diabetic nephropathy. Chronic obstructive pulmonary disease is not a
complication of diabetes, nor is it prevented by ACE inhibitors. Pancreatic cancer is
neither prevented by ACE inhibitors nor considered a complication of diabetes.
Cerebrovascular accident is not directly prevented by ACE inhibitors, although
management of hypertension will decrease vascular disease.
The nurse should teach the diabetic client that which of the following is the
most common symptom of hypoglycemia?
3. Kussmaul's respirations.
The four most commonly reported signs and symptoms of hypoglycemia are
nervousness, weakness, perspiration, and confusion. Other signs and symptoms include
hunger, incoherent speech, tachycardia, and blurred vision. Anorexia and Kussmaul's
respirations are clinical manifestations of hyperglycemia or ketoacidosis. Bradycardia
is not associated with hypoglycemia; tachycardia is.
The nurse is assessing the client's use of medications. Which of the following
medications may cause a complication with the treatment plan of a client with diabetes?
4. Angiotensin-converting enzyme (ACE) inhibitors
Steroids can cause hyperglycemia because of their effects on carbohydrate
metabolism, making diabetic control more difficult. Aspirin is not known to affect
glucose metabolism. Sulfonylureas are oral hypoglycemic agents used in the treatment of
diabetes mellitus. ACE inhibitors are not known to affect glucose metabolism.
A client with type 1 diabetes mellitus has influenza. The nurse should instruct
the client to:
1. Increase the frequency of self-monitoring (blood glucose testing).
2. Reduce food intake to diminish nausea.
3. Discontinue that dose of insulin if unable to eat.
4. Take half of the normal dose of insulin
1 Colds and influenza present special challenges to the client with diabetes
mellitus because the body's need for insulin increases during illness. Therefore, the
client must take the prescribed insulin dose, increase the frequency of blood glucose
testing, and maintain an adequate fluid intake to counteract the dehydrating effect of
hyperglycemia. Clear fluids, juices, and Gatorade are encouraged. Not taking insulin
when sick, or taking half the normal dose, may cause the client to develop ketoacidosis.
Which of the following is a priority goal for the diabetic client who is taking
insulin and has nausea and vomiting from a viral illness or influenza?
1. Obtaining adequate food intake.
2. Managing own health.
3. Relieving pain.
4. Increasing activity.
The priority goal for the client with diabetes mellitus who is experiencing
vomiting with influenza is to obtain adequate nutrition. The diabetic client should eat
small, frequent meals of 50 g of carbohydrate or food equal to 200 cal every 3 to 4
hours. If the client cannot eat the carbohydrates or take fluids, the health care provider
should be called or the client should go to the emergency department. The diabetic
client is in danger of complications with dehydration, electrolyte imbalance, and
ketoacidosis. Increasing the client's health management skills is important to lifestyle
behaviors, but it is not a priority during this acute illness of influenza. Pain relief may
be a need for this client, but it is not the priority at this time; neither is increasing
activity during the illness.
A client with diabetes begins to cry and says, "I just cannot stand the thought of
having to give myself a shot every day." Which of the following would be the best
response by the nurse?
1. "If you do not give yourself your insulin shots, you will die."
2. "We can teach your daughter to give the shots so you will not have to do it."
3. "I can arrange to have a home care nurse give you the shots every day."
4. "What is it about giving yourself the insulin shots that bothers you?"
The best response is to allow the client to verbalize her fears about giving
herself a shot each day. Tactics that increase fear are not effective in changing behavior.
If possible, the client needs to be responsible for her own care, including giving selfinjections.
It is unlikely that the client's insurance company will pay for home-care
visits if the client is capable of self-administration.
A client is to have a transsphenoidal hypophysectomy to remove a large,
invasive pituitary tumor. The nurse should instruct the client that the surgery will be
performed through an incision in the:
1. Back of the mouth.
3. Sinus channel below the right eye.
4.Upper gingival mucosa in the space between the upper gums and lip.
With transsphenoidal hypophysectomy, the sella turcica is entered from
below, through the sphenoid sinus. There is no external incision; the incision is made
between the upper lip and gums.
To help minimize the risk of postoperative respiratory complications after a
hypophysectomy, during preoperative teaching, the nurse should instruct the client how
1. Use incentive spirometry.
2. Turn in bed.
3. Take deep breaths.
Deep breathing is the best choice for helping prevent atelectasis. The client
should be placed in the semi-Fowler's position (or as prescribed) and taught deep
breathing, sighing, mouth breathing, and how to avoid coughing. Blow bottles are not
effective in preventing atelectasis because they do not promote sustained alveolar
inflation to maximal lung capacity. Frequent position changes help loosen lung
secretions, but deep breathing is most important in preventing atelectasis. Coughing is
contraindicated because it increases intracranial pressure and can cause cerebrospinal
fluid to leak from the point at which the sella turcica was entered.
Following a transsphenoidal hypophysectomy, the nurse should assess the client
1. Cerebrospinal fluid (CSF) leak.
2. Fluctuating blood glucose levels.
3. Cushing's syndrome.
4. Cardiac arrhythmias
A major focus of nursing care after transsphenoidal hypophysectomy is the
prevention of and monitoring for a CSF leak. CSF leakage can occur if the patch or
incision is disrupted. The nurse should monitor for signs of infection, including elevated
temperature, increased white blood cell count, rhinorrhea, nuchal rigidity, and persistent
headache. Hypoglycemia and adrenocortical insufficiency may occur. Monitoring for
fluctuating blood glucose levels is not related specifically to transsphenoidal
hypophysectomy. The client will be given IV fluids postoperatively to supply
carbohydrates. Cushing's disease results from adrenocortical excess, not insufficiency.
Monitoring for cardiac arrhythmias is important, but arrhythmias are not anticipated
following a transsphenoidal hypophysectomy.
A male client expresses concern about how a hypophysectomy will affect his
sexual function. Which of the following statements provides the most accurate
information about the physiologic effects of hypophysectomy?
1. Removing the source of excess hormone should restore the client's libido,
erectile function, and fertility.
2. Potency will be restored, but the client will remain infertile.
3. Fertility will be restored, but impotence and decreased libido will persist.
4. Exogenous hormones will be needed to restore erectile function after the
adenoma is removed.
The client's sexual problems are directly related to the excessive prolactin
level. Removing the source of excessive hormone secretion should allow the client to
return gradually to a normal physiologic pattern. Fertility will return, and erectile
function and sexual desire will return to baseline as hormone levels return to normal.
The nurse instructs the unlicensed nursing personnel (UAP) on how to provide
oral hygiene for clients who cannot perform this task for themselves. Which of the
following techniques should the nurse tell the UAP to incorporate into the client's daily
1. Assess the oral cavity each time mouth care is given and record observations.
2. Use a soft toothbrush to brush the client's teeth after each meal.
3. Swab the client's tongue, gums, and lips with a soft foam applicator every 2
4. Rinse the client's mouth with mouthwash several times a day.
A soft toothbrush should be used to brush the client's teeth after every meal
and more often as needed. Mechanical cleaning is necessary to maintain oral health,
stimulate gingiva, and remove plaque. Assessing the oral cavity and recording
observations is the responsibility of the nurse, not the nursing assistant. Swabbing with
a safe foam applicator does not provide enough friction to clean the mouth. Mouthwash
can be a drying irritant and is not recommended for frequent use.
The nurse is developing standards of care for a client with gastroesophageal
reflux disease and wants to review current evidence for practice. Which one of the
following resources will provide the most helpful information?
1. A review in the Cochrane Library.
2. A literature search in a database, such as the Cumulative Index to Nursing and
Allied Health Literature (CINAHL).
3. An online nursing textbook.
4. The policy and procedure manual at the health care agency.
. The Cochrane Library provides systematic reviews of health care
interventions and will provide the best resource for evidence for nursing care. CINAHL
offers key word searches to published articles in nursing and allied health literature, but
not reviews. A nursing textbook has information about nursing care, which may include
evidence-based practices, but textbooks may not have the most up-to-date information.
While the policy and procedure manual may be based on evidence-based practices, the
most current practices will be found in evidence-based reviews of literature.
The nurse in the intensive care unit is giving a report to the nurse in the post
surgical unit about a client who had a gastrectomy. The most effective way to assure
essential information about the client is reported is to:
1. Give the report face to face with both nurses in a quiet room.
2. Audiotape the report for future reference and documentation.
3. Use a printed checklist with information individualized for the client.
4. Document essential transfer information in the client's electronic health record
Using an individualized printed checklist assures that all key information is
reported; the checklist can then serve as a record to which nurses can refer later. Giving
a verbal report leaves room for error in memory; using an audiotape or an electronic
health record requires nurses to spend unnecessary time retrieving information.
A client reports vomiting every hour for the past 8 to 10 hours. The nurse
should assess the client for risk of which of the following? Select all that apply.
1. Metabolic acidosis.
2. Metabolic alkalosis.
Gastric acid contains a substantial amount of potassium, hydrogen ions, and
chloride ions. Frequent vomiting can induce an excessive loss of these acids leading to
alkalosis. Excessive loss of potassium produces hypokalemia. Frequent vomiting does
not lead to the condition of too much potassium (hyperkalemia) or too little sodium
The nurse explains to the client with Hodgkin's disease that a bone marrow
biopsy will be taken after the aspiration. What should the nurse explain about the
1. "Your biopsy will be performed before the aspiration because enough tissue may
be obtained so that you won't have to go through the aspiration."
2. "You will feel a pressure sensation when the biopsy is taken but should not feel
actual pain; if you do, tell the doctor so that you can be given extra numbing
3. "You may hear a crunch as the needle passes through the bone, but when the
biopsy is taken, you will feel a suction-type pain that will last for just a
4. "You will be shaved and cleaned with an antiseptic agent, after which the doctor
will inject a needle without making an incision to aspirate out the bone marrow."
A biopsy needle is inserted through a separate incision in the anesthetized
area. The client will feel a pressure sensation when the biopsy is taken but should not
feel actual pain. The client should be instructed to inform the physician if pain is felt so
that more anesthetic agent can be administered to keep the client comfortable. The
biopsy is performed after the aspiration and from a slightly different site so that the
tissue is not disturbed by either test. The client will feel a suction-type pain for a
moment when the aspiration is being performed, not the biopsy. A small incision is
made for the biopsy to accommodate the larger-bore needle. This may require a stitch
A client with advanced Hodgkin's disease is admitted to hospice because
death is imminent. The goal of nursing care at this time is to:
1. Reduce the client's fear of pain.
2. Support the client's wish to discontinue further therapy.
3. Prevent feelings of isolation.
4. Help the client overcome feelings of social inadequacy.
Terminally ill clients most often describe feelings of isolation because they
tend to be ignored, they are often left out of conversations (especially those dealing with
the future), and they sense the attitudes of discomfort that many people feel in their
presence. Helpful nursing measures include taking the time to be with the client, offering
opportunities to talk about feelings, and answering questions honestly.
The client is a survivor of non-Hodgkin's lymphoma. Which of the following
statements indicates the client needs additional information?
1. "Regular screening is very important for me."
2. "The survivor rate is directly proportional to the incidence of second
3. "The survivor rate is indirectly proportional to the incidence of second
4. "It is important for survivors to know the stage of the disease and their current
It is incorrect that the survivor rate is directly proportional to the incidence
of second malignancy. The survivor rate is indirectly proportional to the incidence of
second malignancy, and regular screening is very important to detect a second
malignancy, especially acute myeloid leukemia or myelodysplastic syndrome. Survivors
should know the stage of the disease and their current treatment plan so that they can
remain active participants in their health care.
Which of the following is the most important goal of nursing care for a client
who is in shock?
1. Manage fluid overload.
2. Manage increased cardiac output.
3. Manage inadequate tissue perfusion.
4. Manage vasoconstriction of vascular beds
Nursing interventions and collaborative management are focused on
correcting and maintaining adequate tissue perfusion. Inadequate tissue perfusion may
be caused by hemorrhage, as in hypovolemic shock; by decreased cardiac output, as in
cardiogenic shock; or by massive vasodilation of the vascular bed, as in neurogenic,
anaphylactic, and septic shock. Fluid deficit, not fluid overload, occurs in shock
Which of the following indicates hypovolemic shock in a client who has had a
15% blood loss?
1. Pulse rate less than 60 bpm.
2. Respiratory rate of 4 breaths/min.
3. Pupils unequally dilated.
4. Systolic blood pressure less than 90 mm Hg.
Typical signs and symptoms of hypovolemic shock include systolic blood
pressure less than 90 mm Hg, narrowing pulse pressure, tachycardia, tachypnea, cool
and clammy skin, decreased urine output, and mental status changes, such as irritability
or anxiety. Unequal dilation of the pupils is related to central nervous system injury or
possibly to a previous history of eye injury.
Which of the following findings is the best indication that fluid replacement
for the client in hypovolemic shock is adequate?
1. Urine output greater than 30 mL/h.
2. Systolic blood pressure greater than 110 mm Hg.
3. Diastolic blood pressure greater than 90 mm Hg.
4. Respiratory rate of 20 breaths/min.
Urine output provides the most sensitive indication of the client's response to
therapy for hypovolemic shock. Urine output should be consistently greater than 35
mL/h. Blood pressure is a more accurate reflection of the adequacy of vasoconstriction
than of tissue perfusion. Respiratory rate is not a sensitive indicator of fluid balance in
the client recovering from hypovolemic shock.
Which of the following is a risk factor for hypovolemic shock?
2. Antigen-antibody reaction.
3. Gram-negative bacteria.
Causes of hypovolemic shock include external fluid loss, such as
hemorrhage; internal fluid shifting, such as ascites and severe edema; and dehydration.
Massive vasodilation is the initial phase of vasogenic or distributive shock, which can
be further subdivided into three types of shock: septic, neurogenic, and anaphylactic. A
severe antigen-antibody reaction occurs in anaphylactic shock. Gram-negative bacterial
infection is the most common cause of septic shock. Loss of sympathetic tone
(vasodilation) occurs in neurogenic shock.
Which is a priority assessment for the client in shock who is receiving an IV
infusion of packed red blood cells and normal saline solution?
1. Fluid balance.
2. Anaphylactic reaction.
4. Altered level of consciousness.
The client who is receiving a blood product requires astute assessment for
signs and symptoms of allergic reaction and anaphylaxis, including pruritus (itching),
urticaria (hives), facial or glottal edema, and shortness of breath. If such a reaction
occurs, the nurse should stop the transfusion immediately, but leave the IV line intact,
and notify the physician. Usually, an antihistamine such as diphenhydramine
hydrochloride (Benadryl) is administered. Epinephrine and corticosteroids may be
administered in severe reactions. Fluid balance is not an immediate concern during the
blood administration. The administration should not cause pain unless it is extravasating
out of the vein, in which case the IV administration should be stopped. Administration
of a unit of blood should not affect the level of consciousness.
The client who does not respond adequately to fluid replacement has a
prescription for an IV infusion of dopamine hydrochloride at 5 mcg/kg/min. To
determine that the drug is having the desired effect, the nurse should assess the client
1. Increased renal and mesenteric blood flow.
2. Increased cardiac output.
4. Reduced preload and afterload.
At medium doses (4 to 8 mcg/kg/min), dopamine hydrochloride slightly
increases the heart rate and improves contractility to increase cardiac output and
improve tissue perfusion. When given at low doses (0.5 to 3.0 mcg/kg/min), dopamine
increases renal and mesenteric blood flow. At high doses (8 to 10 mcg/kg/min),
dopamine produces vasoconstriction, which is an undesirable effect. Dopamine is not
given to affect preload and afterload.
A client is receiving dopamine hydrochloride for treatment of shock. The
1. Administer pain medication concurrently.
2. Monitor blood pressure continuously.
3. Evaluate arterial blood gases at least every 2 hours.
4. Monitor for signs of infection.
The client who is receiving dopamine hydrochloride requires continuous
blood pressure monitoring with an invasive or noninvasive device. The nurse may
titrate the IV infusion to maintain a systolic blood pressure of 90 mm Hg. Administration
of a pain medication concurrently with dopamine hydrochloride, which is a potent
sympathomimetic with dose-related alpha-adrenergic agonist, beta 1-selective
adrenergic agonist, and dopaminergic blocking effects, is not an essential nursing action
for a client who is in shock with already low hemodynamic values. Arterial blood gas
concentrations should be monitored according to the client's respiratory status and acidbase
balance status and are not directly related to the dopamine hydrochloride dosage.
Monitoring for signs of infection is not related to the nursing action for the client
receiving dopamine hydrochloride.
A client who has been taking warfarin has been admitted with severe acute
rectal bleeding and the following laboratory results: International Normalized Ratio
(INR), 8; hemoglobin, 11 g/dL (110 g/L); and hematocrit, 33% (0.33). In which order
should the nurse implement the following physician prescriptions?
1. Give 1 unit fresh frozen plasma (FFP).
2. Administer vitamin K 2.5 mg by mouth.
3. Schedule client for sigmoidoscopy.
4. Administer IV dextrose 5% in 0.45% normal saline solution.
Analysis of the client's laboratory results indicate that an INR of 8 is increased
beyond therapeutic ranges. The client is also experiencing severe acute rectal bleeding
and has a hemoglobin level in the low range of normal and a hematocrit reflecting fluid
volume loss. The nurse should first establish an IV line and administer the dextrose in
saline. Next the nurse should administer the FFP. FFP contains concentrated clotting
factors and provides an immediate reversal of the prolonged INR. Vitamin K 2.5 mg PO
should be given next because it reverses the warfarin by returning the PT to normal
values. However, the reversal process occurs over 1 to 2 hours. Last, the nurse can
schedule the client for the sigmoidoscopy.
When assessing a client for early septic shock, the nurse should assess the
client for which of the following?
1. Cool, clammy skin.
2. Warm, flushed skin.
3. Increased blood pressure.
Warm, flushed skin from a high cardiac output with vasodilation occurs in
warm shock or the hyperdynamic phase (first phase) of septic shock. Other signs and
symptoms of early septic shock include fever with restlessness and confusion; normal or
decreased blood pressure with tachypnea and tachycardia; increased or normal urine
output; and nausea and vomiting or diarrhea. Cool, clammy skin occurs in the
hypodynamic or cold phase (later phase). Hemorrhage is not a factor in septic shock.
A client with toxic shock has been receiving ceftriaxone sodium (Rocephin), 1
g every 12 hours. In addition to culture and sensitivity studies, which other laboratory
findings should the nurse monitor?
1. Serum creatinine.
2. Spinal fluid analysis.
3. Arterial blood gases.
4. Serum osmolality.
The nurse monitors the blood levels of antibiotics, white blood cells, serum
creatinine, and blood urea nitrogen because of the decreased perfusion to the kidneys,
which are responsible for filtering out the Rocephin. It is possible that the clearance of
the antibiotic has been decreased enough to cause toxicity. Increased levels of these
laboratory values should be reported to the physician immediately. A spinal fluid
analysis is done to examine cerebral spinal fluid, but there is no indication of central
nervous system involvement in this case. Arterial blood gases are used to determine
actual blood gas levels and assess acid-base balance. Serum osmolality is used to
monitor fluid and electrolyte balance.
Which nursing intervention is most important in preventing septic shock?
1. Administering IV fluid replacement therapy as prescribed.
2. Obtaining vital signs every 4 hours for all clients.
3. Monitoring red blood cell counts for elevation.
4. Maintaining asepsis of indwelling urinary catheters.
Which of the following is an indication of a complication of septic shock?
2. Acute respiratory distress syndrome (ARDS).
3. Chronic obstructive pulmonary disease (COPD).
4. Mitral valve prolapse.
A nurse has two middle-aged clients who have a prescription to receive a
blood transfusion of packed red blood cells at the same time. The first client's blood
pressure dropped from the preoperative value of 120/80 mm Hg to a postoperative
value of 100/50. The second client is hospitalized because he developed dehydration
and anemia following pneumonia. After checking the patency of their IV lines and vital
signs, what should the nurse do next?
1. Call for both clients' blood transfusions at the same time.
2. Ask another nurse to verify the compatibility of both units at the same time.
3. Call for and hang the first client's blood transfusion.
4. Ask another nurse to call for and hang the blood for the second client.
The nurse identifies deficient knowledge when the client undergoing induction
therapy for leukemia makes which of the following statements?
1. "I will pace my activities with rest periods."
2. "I can't wait to get home to my cat!"
3. "I will use warm saline gargle instead of brushing my teeth."
4. "I must report a temperature of 100°F (37.7°C)."
The nurse identifies that the client does not understand that contact with
animals must be avoided because they carry infection and the induction therapy will
destroy the client's white blood cells (WBCs). The induction therapy will cause anemia,
and the client will experience fatigue and will have to pace activities with rest periods.
Platelet production will be decreased, and the client will be at risk for bleeding
tendencies; oral hygiene will have to be provided by using a warm saline gargle instead
of brushing the teeth and gums. The client will be at risk for infection owing to the
decrease in WBC production and should report a temperature of 100°F (37.8°C) or
. A client with acute myeloid leukemia (AML) reports overhearing one of the
other clients say that AML had a very poor prognosis. The client has understood that the
client's physician informed the client that his physician told him that he has a good
prognosis. Which is the nurse's best response?
1. "You must have misunderstood. Who did you hear that from?"
2. "AML does have a very poor prognosis for poorly differentiated cells."
3. "AML is the most common nonlymphocytic leukemia."
4. "Your doctor stated your prognosis based on the differentiation of your cells."
The statement "Your doctor stated your prognosis based on the differentiation
of your cells" addresses the client's situation on an individual basis. The nurse is
clarifying that clients have different prognoses—even though they may have the same
type of leukemia—because of the cell differentiation. Stating that the client
misunderstood is inappropriate for an advocate of the client and serves no useful
purpose. The other statements are true but do not address this client's individual
The goal of nursing care for a client with acute myeloid leukemia (AML) is to
1. Cardiac arrhythmias.
2. Liver failure.
3. Renal failure.
Bleeding and infection are the major complications and causes of death for
clients with AML. Bleeding is related to the degree of thrombocytopenia, and infection
is related to the degree of neutropenia. Cardiac arrhythmias rarely occur as a result of
AML. Liver or renal failure may occur, but neither is a major cause of death in AML.
The nurse is assessing a client with chronic myeloid leukemia (CML). The
nurse should assess the client for:
2. Hyperplasia of the gum.
3. Bone pain from expansion of marrow.
4. Shortness of breath
Although the clinical manifestations of CML vary, clients usually have
confusion and shortness of breath related to decreased capillary perfusion to the brain
and lungs. Lymphadenopathy is rare in CML. Hyperplasia of the gum and bone pain are
clinical manifestations of AML.
Which of the following individuals is most at risk for acquiring acute
lymphocytic leukemia (ALL)? The client who is:
1. 4 to 12 years.
2. 20 to 30 years.
3. 40 to 50 years.
4. 60 to 70 years.
The peak incidence of ALL is at 4 years of age. ALL is uncommon after 15
years of age. The median age at incidence of CML is 40 to 50 years. The peak incidence
of AML occurs at 60 years of age. Two-thirds of cases of chronic lymphocytic leukemia
occur in clients older than 60 years of age.
The client with acute lymphocytic leukemia (ALL) is at risk for infection. The
1. Place the client in a private room.
2. Have the client wear a mask.
3. Have staff wear gowns and gloves.
4. Restrict visitors
Clients with ALL are at risk for infection due to granulocytopenia. The nurse
should place the client in a private room. Strict hand-washing procedures should be
enforced and will be the most effective way to prevent infection. It is not necessary to
have the client wear a mask. The client is not contagious and the staff does not need to
wear gloves. The client can have visitors; however, they should be screened for
infection and use hand-washing procedures.
In assessing a client in the early stage of chronic lymphocytic leukemia (CLL),
the nurse should determine if the client has:
1. Enlarged, painless lymph nodes.
3. Hyperplasia of the gums.
4. Unintentional weight loss.
Clients with CLL develop unintentional weight loss; fever and drenching night
sweats; enlarged, painful lymph nodes, spleen, and liver; decreased reaction to skin
sensitivity tests (anergy); and susceptibility to viral infections. Enlarged, painless lymph
nodes are a clinical manifestation of Hodgkin's lymphoma. A headache would not be
one of the early signs and symptoms expected in CLL because CLL does not cross the
blood-brain barrier and would not irritate the meninges. Hyperplasia of the gums is a
clinical manifestation of AML.
The nurse is planning care with a client with acute leukemia who has mucositis.
The nurse should advise the client that after every meal and every 4 hours while awake
the client should use:
1. Lemon-glycerin swabs.
2. A commercial mouthwash.
3. A saline solution.
4. A commercial toothpaste and brush
Simple rinses with saline or a baking soda and water solution are effective
and moisten the oral mucosa. Commercial mouthwashes and lemon-glycerin swabs
contain glycerin and alcohol, which are drying to the mucosa and should be avoided.
Brushing after each meal is recommended, but every 4 hours may be too traumatic.
During acute leukemia, the neutrophil and platelet counts are often low and a soft-bristle
toothbrush, instead of the client's usual brush, should be used to prevent bleeding gums.
The client with acute leukemia and the health care team establish mutual client
outcomes of improved tidal volume and activity tolerance. Which measure would be
least likely to promote outcome achievement?
1. Ambulating in the hallway.
2. Sitting up in a chair.
3. Lying in bed and taking deep breaths.
4. Using a stationary bicycle in the room.
The client with acute leukemia experiences fatigue and deconditioning. Lying
in bed and taking deep breaths will not help achieve the goals. The client must get out of
bed to increase activity tolerance and improve tidal volume. Ambulating in the hall
(using a HEPA filter mask if neutropenic) is a sensible activity and helps improve
conditioning. Sitting up in a chair facilitates lung expansion. Using a stationary bicycle
in the room allows the client to increase activity as tolerated.
The nurse is evaluating the client's learning about combination chemotherapy.
Which of the following statements by the client about reasons for using combination
chemotherapy indicates the need for further explanation?
1. "Combination chemotherapy is used to interrupt cell growth cycle at different
2. "Combination chemotherapy is used to destroy cancer cells and treat side effects
3. "Combination chemotherapy is used to decrease resistance."
4. "Combination chemotherapy is used to minimize the toxicity from using high
doses of a single agent."
Combination chemotherapy does not mean two groups of drugs, one to kill the
cancer cells and one to treat the adverse effects of the chemotherapy. Combination
chemotherapy means that multiple drugs are given to interrupt the cell growth cycle at
different points, decrease resistance to a chemotherapy agent, and minimize the toxicity
associated with use of a high dose of a single agent (ie, by using multiple agents with
In providing care to the client with leukemia who has developed
thrombocytopenia, the nurse assesses the most common sites for bleeding. Which of the
following is not a common site?
1. Biliary system.
2. Gastrointestinal tract.
3. Brain and meninges.
4. Pulmonary system.
The biliary system is not especially prone to hemorrhage. Thrombocytopenia
(a low platelet count) leaves the client at risk for a potentially life-threatening
spontaneous hemorrhage in the gastrointestinal, respiratory, and intracranial cavities.
The nurse's best explanation for why the severely neutropenic client is placed
in reverse isolation is that reverse isolation helps prevent the spread of organisms:
1. To the client from sources outside the client's environment.
2. From the client to health care personnel, visitors, and other clients.
3. By using special techniques to dispose of contaminated materials.
4. By using special techniques to handle the client's linens and personal items.
The primary purpose of reverse isolation is to reduce transmission of
organisms to the client from sources outside the client's environment.
Which of the following clinical manifestations does the nurse most likely
observe in a client with Hodgkin's disease?
1. Difficulty swallowing.
2. Painless, enlarged cervical lymph nodes.
3. Difficulty breathing.
4. A feeling of fullness over the liver.
Painless and enlarged cervical lymph nodes, tachycardia, weight loss,
weakness and fatigue, and night sweats are signs of Hodgkin's disease. Difficulty
swallowing and breathing may occur, but only with mediastinal node involvement.
Hepatomegaly is a late-stage manifestation.
A client with a suspected diagnosis of Hodgkin's disease is to have a lymph
node biopsy. The nurse should make sure that personnel involved with the procedure do
which of the following when obtaining the lymph node biopsy specimen for histologic
examination for this client?
1. Maintain sterile technique.
2. Use a mask, gloves, and a gown when assisting with the procedure.
3. Send the specimen to the laboratory when someone is available to take it.
4. Ensure that all instruments used are placed in a sealed and labeled container.
The nurse must ensure that sterile technique is used when a biopsy is obtained
because the client is at high risk for infection. In most cases, a lymph node biopsy is sent
immediately to the laboratory once it is placed in a specific solution in a closed
container. It is not necessary to wear a gown and mask when obtaining the specimen. It
is not necessary to use special handling procedures for the instruments used.
The client with Hodgkin's disease undergoes an excisional cervical lymph node
biopsy under local anesthesia. After the procedure, which does the nurse assess first?
1. Vital signs.
2. The incision.
3. The airway.
4. Neurologic signs.
Assessing for an open airway is always first. The procedure involves the
neck; the anesthesia may have affected the swallowing reflex, or the inflammation may
have closed in on the airway, leading to ineffective air exchange. Once a patent airway
is confirmed and an effective breathing pattern established, the circulation is checked.
Vital signs and the incision are assessed as soon as possible, but only after it is
established that the airway is patent and the client is breathing normally. A neurologic
assessment is completed as soon as possible after other important assessments.
When assessing the client with Hodgkin's disease, the nurse should observe the
client for which of the following findings?
1. Herpes zoster infections.
2. Discolored teeth.
4. Hypercellular immunity.
Herpes zoster infections are common in clients with Hodgkin's disease.
Discoloring of the teeth is not related to Hodgkin's disease but rather to the ingestion of
iron supplements or some antibiotics such as tetracycline. Mild anemia is common in
Hodgkin's disease, but the platelet count is not affected until the tumor has invaded the
bone marrow. A cellular immunity defect occurs in Hodgkin's disease in which there is
little or no reaction to skin sensitivity tests. This is called anergy.
The client with Hodgkin's disease develops B symptoms. These manifestations
indicate which of the following?
1. The client has a low-grade fever (temperature lower than 100°F [37.8°C]).
2. The client has a weight loss of 5% or less of body weight.
3. The client has night sweats.
4. The client probably has not progressed to an advanced stage.
A temperature higher than 100.4°F (38°C), profuse night sweats, and an
unintentional weight loss of 10% of body weight represent the cluster of clinical
manifestations known as the B symptoms. Forty percent of clients with Hodgkin's
disease have B symptoms, and B symptoms are more common in advanced stages of the
The client probably has not progressed to an advanced stage.
98. The nurse is developing a discharge plan about home care with a client who has
lymphoma. The nurse should emphasize which of the following?
1. Use analgesics as needed.
2. Take a shower with perfumed shower gel.
3. Wear a mask when outside of the home.
4. Take an antipyretic every morning.
Analgesics are used as needed to relieve painful encroachment of enlarged
lymph nodes. Perfumed shower gel will increase pruritus. Wearing a mask does not
protect the client from infection if pathogens are not spread by airborne droplets.
Antipyretics should be used to treat fever symptomatically after infection is ruled out.
The client asks the nurse to explain what it means that his Hodgkin's disease is
diagnosed at stage 1A. Which of the following describes the involvement of the
1. Involvement of a single lymph node.
2. Involvement of two or more lymph nodes on the same side of the diaphragm.
3. Involvement of lymph node regions on both sides of the diaphragm.
4. Diffuse disease of one or more extralymphatic organs
In the staging process, the designations A and B signify that symptoms were or
were not present when Hodgkin's disease was found, respectively. The Roman numerals
I through IV indicate the extent and location of involvement of the disease. Stage I
indicates involvement of a single lymph node; stage II, two or more lymph nodes on the
same side of the diaphragm; stage III, lymph node regions on both sides of the
diaphragm; and stage IV, diffuse disease of one or more extralymphatic organs.
A client is undergoing a bone marrow aspiration and biopsy. What is the best
way for the nurse to help the client and two upset family members handle anxiety during
1. Allow the client's family to stay as long as possible.
2. Stay with the client without speaking.
3. Encourage the client to take slow, deep breaths to relax.
4. Allow the client time to express feelings.
Encouraging the client to take slow, deep breaths during uncomfortable parts
of procedures is the best method of decreasing the stress response of tightening and
tensing the muscles. Slow, deep breathing affects the level of carbon dioxide in the
brain to increase the client's sense of well-being. Allowing the client's family to stay
may be appropriate if the family has a calming effect on the client, but this family is
upset and may contribute to the client's stress. Silence can be therapeutic, but when the
client is faced with a potentially life-threatening diagnosis and a new, invasive
procedure, taking deep breaths will be more effective in reducing the stress response.
Expressing feelings is important, but deep breathing will promote relaxation; the nurse
can encourage the client to express feelings when the procedure is completed.
The nurse is completing a health assessment of a 42-year-old female with
suspected Graves' disease. The nurse should assess this client for:
3. Weight gain.
4. Cold skin.
Graves' disease, the most common type of thyrotoxicosis, is a state of
hypermetabolism. The increased metabolic rate generates heat and produces tachycardia
and fine muscle tremors. Anorexia is associated with hypothyroidism. Loss of weight,
despite a good appetite and adequate caloric intake, is a common feature of
hyperthyroidism. Cold skin is associated with hypothyroidism.
When conducting a health history with a female client with thyrotoxicosis, the
nurse should ask about which of the following changes in the menstrual cycle?
A change in the menstrual interval, diminished menstrual flow
(oligomenorrhea), or even the absence of menstruation (amenorrhea) may result from the
hormonal imbalances of thyrotoxicosis. Oligomenorrhea in women and decreased libido
and impotence in men are common features of thyrotoxicosis. Dysmenorrhea is painful
menstruation. Metrorrhagia, blood loss between menstrual periods, is a symptom of
hypothyroidism. Menorrhagia, excessive bleeding during menstrual periods, is a
symptom of hypothyroidism.
A 34-year-old female is diagnosed with hypothyroidism. The nurse should assess
the client for which of the following? Select all that apply.
1. Rapid pulse.
2. Decreased energy and fatigue.
3. Weight gain of 10 lb (4.5 kg).
4. Fine, thin hair with hair loss.
2, 3, 5, 6.
Clients with hypothyroidism exhibit symptoms indicating a lack of
thyroid hormone. Bradycardia, decreased energy and lethargy, memory problems,
weight gain, coarse hair, constipation, and menorrhagia are common signs and
symptoms of hypothyroidism.
Propylthiouracil (PTU) is prescribed for a client with Graves' disease. The nurse
should teach the client to immediately report which of the following?
1. Sore throat.
2. Painful, excessive menstruation.
4. Increased urine output.
The most serious adverse effects of PTU are leukopenia and agranulocytosis,
which usually occur within the first 3 months of treatment. The client should be taught to
promptly report to the health care provider signs and symptoms of infection, such as a
sore throat and fever. Clients having a sore throat and fever should have an immediate
white blood cell count and differential performed, and the drug must be withheld until
the results are obtained. Painful menstruation, constipation, and increased urine output
are not associated with PTU therapy.
A client with thyrotoxicosis says to the nurse, "I am so irritable. I am having
problems at work because I lose my temper very easily." Which of the following
responses by the nurse would give the client the most accurate explanation of her
1. "Your behavior is caused by temporary confusion brought on by your illness."
2. "Your behavior is caused by the excess thyroid hormone in your system."
3. "Your behavior is caused by your worrying about the seriousness of your
A typical sign of thyrotoxicosis is irritability caused by the high levels of
circulating thyroid hormones in the body. This symptom decreases as the client responds
to therapy. Thyrotoxicosis does not cause confusion. The client may be worried about
her illness, and stress may influence her mood; however, irritability is a common
symptom of thyrotoxicosis and the client should be informed of that fact rather than
The nurse is evaluating a client with hyperthyroidism who is taking
Propylthiouracil (PTU) 100 mg/day in three divided doses for maintenance therapy.
Which of the following statements from the client indicates the desired outcome of the
1. "I have excess energy throughout the day."
2. "I am able to sleep and rest at night."
3. "I have lost weight since taking this medication."
4. "I do perspire throughout the entire day."
PTU is a prototype of thioamide antithyroid drugs. It inhibits production of
thyroid hormones and peripheral conversion of T4 to the more active T3. A client taking
this antithyroid drug should be able to sleep and rest well at night since the level of
thyroid hormones is reduced in the blood. Excess energy throughout the day, loss of
weight and perspiring through the day are symptoms of hyperthyroidism indicating the
drug has not produced its outcome.
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