02/27/2021 Print ATI Medical-Surgical: Cardiovascular and Hematology flashcards | Easy Notecards
ATI Medical-Surgical: Cardiovascular and Hematology
1. A nurse is assessing a client who has late-stage heart failure and is experiencing fluid volume
overload. Which of thefollowing findings should thenurse expect?
Weight gain 1 kg (2.2 lb) in 1 day.
A weight gain of 1 kg (2.2 lb) in 1 day alerts thenurse that theclient is retaining fluid and is at risk of
fluid volume overload. This is an indication that theclient's heart failure is worsening.
2. A nurse is assessing a client who has an abdominal aortic aneurysm. Which of thefollowing
manifestations should thenurse expect?
Lower back discomfort
Abdominal aortic aneurysm involves a widening, stretching, or ballooning of theaorta. Back and
abdominal pain indicate that theaneurysm is extending downward and pressing on lumbar spinal
nerve roots, causing pain.
3. A nurse is caring for a client who is in hypovolemic shock. While waiting for a unit of blood,
thenurse should administer which of thefollowing IV solutions?
0.9% sodium chloride
Solutions of 0.9% sodium chloride, as well as Lactated Ringer's solution, are used for fluid volume
replacement. Sodium chloride, a crystalloid, is a physiologic isotonic solution that replaces lost
volume in theblood stream and is theonly solution to use when infusing blood products.
4. A nurse is planning care for a client who has pernicious anemia. Which of thefollowing
interventions should thenurse include in theplan?
Initiate weekly injections of vitamin B12.
The nurse should initiate weekly injections of vitamin B12 for a client who has pernicious anemia,
and then decrease to monthly. Pernicious anemia is caused by a lack of intrinsic factor needed to
absorb vitamin B12 from thegastrointestinal tract.
5. A nurse is administering a unit of packed red blood cells (RBCs) to a client who is
postoperative. theclient reports itching and has hives 30 min after theinfusion begins. Which
of thefollowing actions should thenurse take first?
Stop theinfusion of blood.
The nurse should apply theurgent vs. nonurgent priority-setting framework. Using this framework,
thenurse should consider urgent needs thepriority because they pose more of a threat to theclient.
thenurse might also need to use Maslow's hierarchy of needs, theABC priority-setting framework, or
nursing knowledge to identify which finding is themost urgent. thenurse should stop theinfusion of
blood because theclient has manifestations of an allergic reaction.
6. A nurse is caring for a client who had a myocardial infarction 5 days ago. theclient has a
sudden onset of shortness of breath and begins coughing frothy, pink sputum. thenurse
auscultates loud, bubbly sounds on inspiration. Which of thefollowing adventitious breath
sounds should thenurse document?
Coarse crackles
A client who had a recent myocardial infarction is at risk for left-sided heart failure. Crackles are
breath sounds caused by movement of air through airways partially or intermittently occluded with
fluid and are associated with heart failure and frothy sputum. Crackling sounds are heard at theend of
inspiration and are not cleared by coughing.
7. A nurse is assessing a client who has fluid volume overload from a cardiovascular disorder…
1/
, 02/27/2021 Print ATI Medical-Surgical: Cardiovascular and Hematology flashcards | Easy Notecards
Jugular vein distension
Moist crackles
Increased Heart Rate
8. A nurse is assessing a client who has right-sided heart failure. Which of thefollowing findings
should thenurse expect?
Dependent edema
Blood return from thevenous system to theright atrium is impaired by a weakened right heart.
thesubsequent systemic venous backup leads to development of dependent edema.
9. A nurse is providing teaching to a client who has anemia and a new prescription for epoetin
alfa. Which of thefollowing information should thenurse include in theteaching?
Hypertension is a common adverse effect of this medication.
The nurse should teach that a common adverse effect of epoetin alfa is hypertension because of
therise in theproduction 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 thered blood cell level.
10. A nurse is reviewing a client's repeat laboratory results 4 hr after administering fresh
frozen plasma (FFP). Which of thefollowing laboratory results should thenurse review?
Atrial rate of 300/min with QRS complex of 80/min
The nurse should interpret this finding as atrial flutter, which indicates a lack of conduction between
theatria and ventricles. theadditional atrial beats are not conducting.
11. A nurse on a telemetry unit is caring for a client who has an irregular radial pulse. Which of
thefollowing ECG abnormalities should thenurse recognize as atrial flutter?
Atrial rate of 300/min with QRS complex of 80/min
The nurse should interpret this finding as atrial flutter, which indicates a lack of conduction between
theatria and ventricles. theadditional atrial beats are not conducting.
12. A nurse is planning care for a client who is having a percutaneous transluminal coronary
angioplasty (PTCA) with stent placement. Which of thefollowing actions should thenurse
anticipate in thepostprocedure plan of care?
Monitor for bleeding.
Bleeding is a post-procedure complication of PTCA because of theadministration of heparin during
theprocedure and theremoval of thefemoral (or brachial) sheath. Manual pressure or a closure
device is used to obtain hemostasis to thesite. theclient remains on bed rest until hemostasis is
assured.
13. A nurse is preparing to transfuse a unit of packed red blood cells (RBCs) to a client who has
anemia. Which of thefollowing actions should thenurse take first?
Witness theinformed consent.
The nurse should apply theleast invasive priority-setting framework. This framework assigns priority
to nursing interventions that are least invasive to theclient, as long as those interventions do not
jeopardize client safety. thenurse should take interventions that are not invasive to theclient before
interventions that are invasive; therefore, as witnessing theinformed consent is theleast invasive, it is
theaction that should be performed first. Unless it is an emergency, informed consent should be
obtained prior to initiating a blood transfusion to a client.
14. A nurse is caring for a client who has hemophilia. theclient reports pain and swelling in a joint
following an injury. Which of thefollowing actions should thenurse take?
2/
ATI Medical-Surgical: Cardiovascular and Hematology
1. A nurse is assessing a client who has late-stage heart failure and is experiencing fluid volume
overload. Which of thefollowing findings should thenurse expect?
Weight gain 1 kg (2.2 lb) in 1 day.
A weight gain of 1 kg (2.2 lb) in 1 day alerts thenurse that theclient is retaining fluid and is at risk of
fluid volume overload. This is an indication that theclient's heart failure is worsening.
2. A nurse is assessing a client who has an abdominal aortic aneurysm. Which of thefollowing
manifestations should thenurse expect?
Lower back discomfort
Abdominal aortic aneurysm involves a widening, stretching, or ballooning of theaorta. Back and
abdominal pain indicate that theaneurysm is extending downward and pressing on lumbar spinal
nerve roots, causing pain.
3. A nurse is caring for a client who is in hypovolemic shock. While waiting for a unit of blood,
thenurse should administer which of thefollowing IV solutions?
0.9% sodium chloride
Solutions of 0.9% sodium chloride, as well as Lactated Ringer's solution, are used for fluid volume
replacement. Sodium chloride, a crystalloid, is a physiologic isotonic solution that replaces lost
volume in theblood stream and is theonly solution to use when infusing blood products.
4. A nurse is planning care for a client who has pernicious anemia. Which of thefollowing
interventions should thenurse include in theplan?
Initiate weekly injections of vitamin B12.
The nurse should initiate weekly injections of vitamin B12 for a client who has pernicious anemia,
and then decrease to monthly. Pernicious anemia is caused by a lack of intrinsic factor needed to
absorb vitamin B12 from thegastrointestinal tract.
5. A nurse is administering a unit of packed red blood cells (RBCs) to a client who is
postoperative. theclient reports itching and has hives 30 min after theinfusion begins. Which
of thefollowing actions should thenurse take first?
Stop theinfusion of blood.
The nurse should apply theurgent vs. nonurgent priority-setting framework. Using this framework,
thenurse should consider urgent needs thepriority because they pose more of a threat to theclient.
thenurse might also need to use Maslow's hierarchy of needs, theABC priority-setting framework, or
nursing knowledge to identify which finding is themost urgent. thenurse should stop theinfusion of
blood because theclient has manifestations of an allergic reaction.
6. A nurse is caring for a client who had a myocardial infarction 5 days ago. theclient has a
sudden onset of shortness of breath and begins coughing frothy, pink sputum. thenurse
auscultates loud, bubbly sounds on inspiration. Which of thefollowing adventitious breath
sounds should thenurse document?
Coarse crackles
A client who had a recent myocardial infarction is at risk for left-sided heart failure. Crackles are
breath sounds caused by movement of air through airways partially or intermittently occluded with
fluid and are associated with heart failure and frothy sputum. Crackling sounds are heard at theend of
inspiration and are not cleared by coughing.
7. A nurse is assessing a client who has fluid volume overload from a cardiovascular disorder…
1/
, 02/27/2021 Print ATI Medical-Surgical: Cardiovascular and Hematology flashcards | Easy Notecards
Jugular vein distension
Moist crackles
Increased Heart Rate
8. A nurse is assessing a client who has right-sided heart failure. Which of thefollowing findings
should thenurse expect?
Dependent edema
Blood return from thevenous system to theright atrium is impaired by a weakened right heart.
thesubsequent systemic venous backup leads to development of dependent edema.
9. A nurse is providing teaching to a client who has anemia and a new prescription for epoetin
alfa. Which of thefollowing information should thenurse include in theteaching?
Hypertension is a common adverse effect of this medication.
The nurse should teach that a common adverse effect of epoetin alfa is hypertension because of
therise in theproduction 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 thered blood cell level.
10. A nurse is reviewing a client's repeat laboratory results 4 hr after administering fresh
frozen plasma (FFP). Which of thefollowing laboratory results should thenurse review?
Atrial rate of 300/min with QRS complex of 80/min
The nurse should interpret this finding as atrial flutter, which indicates a lack of conduction between
theatria and ventricles. theadditional atrial beats are not conducting.
11. A nurse on a telemetry unit is caring for a client who has an irregular radial pulse. Which of
thefollowing ECG abnormalities should thenurse recognize as atrial flutter?
Atrial rate of 300/min with QRS complex of 80/min
The nurse should interpret this finding as atrial flutter, which indicates a lack of conduction between
theatria and ventricles. theadditional atrial beats are not conducting.
12. A nurse is planning care for a client who is having a percutaneous transluminal coronary
angioplasty (PTCA) with stent placement. Which of thefollowing actions should thenurse
anticipate in thepostprocedure plan of care?
Monitor for bleeding.
Bleeding is a post-procedure complication of PTCA because of theadministration of heparin during
theprocedure and theremoval of thefemoral (or brachial) sheath. Manual pressure or a closure
device is used to obtain hemostasis to thesite. theclient remains on bed rest until hemostasis is
assured.
13. A nurse is preparing to transfuse a unit of packed red blood cells (RBCs) to a client who has
anemia. Which of thefollowing actions should thenurse take first?
Witness theinformed consent.
The nurse should apply theleast invasive priority-setting framework. This framework assigns priority
to nursing interventions that are least invasive to theclient, as long as those interventions do not
jeopardize client safety. thenurse should take interventions that are not invasive to theclient before
interventions that are invasive; therefore, as witnessing theinformed consent is theleast invasive, it is
theaction that should be performed first. Unless it is an emergency, informed consent should be
obtained prior to initiating a blood transfusion to a client.
14. A nurse is caring for a client who has hemophilia. theclient reports pain and swelling in a joint
following an injury. Which of thefollowing actions should thenurse take?
2/
