Chapter 23Assessment of Cardiovascular and Hematological Function My Nursing Test Banks

Chapter 23Assessment of Cardiovascular and Hematological Function

MULTIPLE CHOICE

1.A client, receiving a transfusion of packed red blood cells, asks the nurse why it is needed since she knows the body makes new blood. Which of the following should the nurse respond to this client?

1.

It will take 30 days for you body to make the new blood cells.

2.

Your body will make the new blood cells in about 60 days.

3.

It takes at least 3 months for your body to make enough blood cells to replace what you have lost.

4.

Red blood cells last about 120 days. Your body needs to have a constant supply to replace them.

ANS: 4

Red blood cells have a life span of about 120 days. Abnormal red blood cells have a shorter life span and are lysed and extracted from the circulation. The nurse should explain that since red blood cells live 120 days, the body needs a constant supply. The transfusion will provide the cells until the body makes new ones.

PTS: 1 DIF: Apply REF: Erythrocytes

2.The nurse is reviewing a clients white blood cell count. Which of the following would not be affected by the presence of an infection?

1.

Basophils

2.

Eosinophils

3.

Lymphocytes

4.

Neutrophils

ANS: 3

Basophils, eosinophils, and neutrophils are considered granulocytes which are present in increased amounts in the presence of an infection. Lymphocytes are common in the lymphatic system and work with acquired immunity.

PTS:1DIF:AnalyzeREF:White Blood Cells

3.A client is diagnosed with a parasitic infection. The nurse realizes that which of the following white blood cell counts will be elevated?

1.

Basophils

2.

Eosinophils

3.

Lymphocytes

4.

Neutrophils

ANS: 2

Eosinophils are classically associated with infections from parasites. Eosinophils are also more involved in the reactions to allergies. Basophils are central to the inflammatory process and neutrophils respond to bacterial infections. Lymphocytes are cells that work in acquired immunity.

PTS:1DIF:AnalyzeREF:White Blood Cells

4.A client is diagnosed with a low red blood cell count. Which of the following should the nurse assess in this client?

1.

Urine output

2.

Bowel sounds

3.

Respirations

4.

Consciousness

ANS: 3

The function of the erythrocyte or red blood cell is to transport oxygen from the lungs to the cells of the body. With a low red blood cell count, the nurse should assess the clients respiratory status. The urine output, bowel sounds, and consciousness may or may not be affected by the decrease in red blood cells.

PTS: 1 DIF: Apply REF: Erythrocytes

5.A client is prescribed a vitamin B-12 injection every month. Which of the following should the nurse explain to the client as the purpose of this medication?

1.

It is needed to make new red blood cells.

2.

It makes the red blood cells more flexible.

3.

It makes the red blood cells hold more oxygen.

4.

It makes the red blood cells hold their shape.

ANS: 1

Vitamin B-12 is necessary to make erythrocytes and help make thymine, which is a precursor to the red blood cell. The erythrocyte cytoskeleton makes the red blood cell more flexible. Cholesterol helps the red blood cells hold their shape. There is nothing physiologically that will make a red blood cell hold more oxygen.

PTS: 1 DIF: Apply REF: Erythrocytes

6.During the assessment of a client, the nurse identifies pinpoint hemorrhages under the skin that are dark red and less than 2 mm in size. How should the nurse document this finding?

1.

Petechiae

2.

Ecchymosis

3.

Hematoma

4.

Purpura

ANS: 1

Petechiae are pinpoint hemorrhages under the skin which are round, dark red and less than 2 mm in diameter. Ecchymosis is superficial bleeding under the mucous membrane or skin. Hematoma is a deeper palpable bleeding under the skin. Purpura is abnormal bleeding under the skin as seen from blood leaking from capillaries after minor trauma.

PTS:1DIF:Apply

REF:Table 23-3 Physical Assessment for Hematological Problems

7.The nurse is auscultating the area to the right of the sternum at the second intercostal space. The nurse is listening to which of the following valves?

1.

Aortic

2.

Mitral

3.

Tricuspid

4.

Pulmonic

ANS: 1

The aortic area is the second intercostal space to the right of the sternum. The pulmonic area is the second intercostal space on the left side of the sternum. The tricuspid area is the fifth intercostal space on the left side of the sternum. The mitral area is the fifth intercostal space at the midclavicular line on the left side of the pericardium.

PTS: 1 DIF: Apply REF: Assessment

8.A client is diagnosed with a normal ejection fraction. The nurse realizes that the clients ejection fraction is most likely between:

1.

10% to 20%.

2.

30% to 40%.

3.

60% to 70%.

4.

80% to 90%.

ANS: 3

Ejection fraction is the percentage of blood that is emptied from the ventricle during systole. An ejection fraction of 60% to 70% is considered normal. Lower ejection fraction findings indicate damage to the ventricle. Ejection fractions are not usually as high as 80% to 90%.

PTS:1DIF:AnalyzeREF:Cardiac Cycle

9.A client is experiencing chest pain that occurs in the third costochondral joint. The onset was sudden; it radiated to the shoulders; and it becomes worse when taking a deep breath or twisting the torso. The nurse suspects that this client is experiencing:

1.

aortic dissection.

2.

pulmonary embolus.

3.

pneumothorax.

4.

musculoskeletal-costochondritis.

ANS: 4

The pain of costochondritis includes locations at the 3rd, 4th, or 5th costochondral joint; a sudden or gradual onset; and radiation to the shoulders. Costochondritis is aggravated by deep inspirations or twisting. The pain of aortic dissection is sudden and tearing, and it radiates to the shoulders, neck, back, and abdomen. The pain of a pulmonary embolus includes a sudden, sharp pleuritic pain that varies with respiration. The pain of a pneumothorax is a sudden onset of tearing or pleuritic pain that is worsened by breathing.

PTS: 1 DIF: Analyze REF: Table 23-7 Differentiating Chest Pain

10.The nurse applies pressure to the fingernail of a client and watches for the color to return after releasing the pressure. The nurse is assessing this clients:

1.

skin changes.

2.

capillary refill.

3.

skin turgor.

4.

peripheral edema.

ANS: 2

Capillary refill is assessed by applying pressure to the fingernail and then quickly releasing the pressure and watching for the return of color. Skin changes, skin turgor, and peripheral edema are all assessments of the extremities; however, do not use the application of pressure to a fingernail to assess.

PTS: 1 DIF: Apply REF: Assessment

11.A client is having a diagnostic test that will evaluate the hearts structure and function using an ultrasound. The client is most likely having a(n):

1.

exercise electrocardiography.

2.

electrocardiogram.

3.

echocardiogram.

4.

chest x-ray.

ANS: 3

An echocardiogram is the evaluation of the hearts structure and function with images and recordings using ultrasound. Exercise electrocardiography is the use of exercise while assessing a clients 12-lead electrocardiogram. A 12-lead electrocardiogram is a standardized recording of the electrical activity of the heart. A chest x-ray provides information on the size of the heart and pulmonary circulation, lung disease, and abnormalities of the aorta.

PTS:1DIF:AnalyzeREFiagnostic Tests

12.A client is scheduled for a cardiac catheterization. The nurse realizes that the indications for this diagnostic test would be:

1.

hypertension.

2.

peripheral edema.

3.

cerebral vascular accident.

4.

diagnose coronary artery disease.

ANS: 4

Clinical implications for cardiac catheterization are to diagnose coronary artery disease and assess for atherosclerotic lesions. Hypertension, peripheral edema, and cerebral vascular accident are not indications for a cardiac catheterization.

PTS:1DIF:AnalyzeREFiagnostic Tests

13.Which of the following should the nurse instruct a client who is scheduled for a stress test?

1.

Eat nothing before the test.

2.

Expect to feel chest pain.

3.

The test will take between 20 and 50 minutes.

4.

You will be videotaped performing the test.

ANS: 3

The nurse should instruct the client that the test will take between 20 to 50 minutes to complete. The client may be permitted to eat a light meal before the test. Eating nothing before the test is not standard. Chest pain during the test should be reported. The client will not be videotaped performing the test. The client will be monitored during the test.

PTS:1DIF:Apply

REF: Patient Playbook: Preparing the Patient for a Stress Test

MULTIPLE RESPONSE

1.The nurse is administering an anticoagulant to a client. Which of the following medications are anticoagulants? (Select all that apply.)

1.

Acetylsalicylic acid

2.

Clopidogrel

3.

Dalteparin

4.

Reteplase

5.

Tirofiban

6.

Warfarin

ANS: 3, 6

Warfarin (Coumadin) and dalteparin (Fragmin) are anticoagulants. Acetylsalicylic acid (aspirin), clopidogrel (Plavix), and tirofiban (Ticlid) are antiplatelet agents. Reteplase (Retavase) is a thrombolytic.

PTS: 1 DIF: Analyze REF: Table 23-2 Medications That Alter Coagulation

2.During the assessment of a clients thoracic region, the nurse determines that the client has a chest abnormality. Which of the following are common chest abnormalities? (Select all that apply.)

1.

Barrel chest

2.

Jugular vein distention

3.

Pectus excavatum

4.

Retracting rib cage

5.

Pectus carinatum

6.

Displaced trachea

ANS: 1, 3, 5

Three common physical abnormalities of the chest are barrel chest; pectus excavatum, or funnel chest; and pectus carinatum, or pigeon chest. Jugular vein distention would be noted on the neck and not the chest. Retracting rib cage would occur with rib fractures and is considered a flail chest. Displaced trachea would be a medical emergency since this indicates a hemo- or pneumothorax.

PTS: 1 DIF: Analyze REF: Table 23-8 Physical Abnormalities of the Chest

3.The nurse is assessing a client for a heart murmur. Which of the following should be included in this assessment? (Select all that apply.)

1.

Blood pressure

2.

Heart rate

3.

Location

4.

Radiation

5.

Timing

6.

Intensity

ANS: 3, 4, 5, 6

When assessing heart murmurs, the following are evaluated: location, radiation, timing, and intensity. Blood pressure and heart rate are not assessed during the assessment of a heart murmur.

PTS: 1 DIF: Apply REF: Box 23-5 Assessment of Heart Murmur

4.The nurse is evaluating a client who is experiencing chest pain. Which of the following should be included in this assessment? (Select all that apply.)

1.

Grade the pain on a scale of 1 to 10.

2.

Precipitating factors.

3.

Assess for sleep disturbance.

4.

Determine what was used to eliminate the pain.

5.

Assess for sweating.

6.

Determine if the pain is related to an injury or surgery.

ANS: 1, 2, 4, 5, 6

When evaluating a clients chest pain, the following should be assessed: pain intensity with a pain scale; duration; characteristics to include precipitating factors, onset, pattern of disappearance; recurrence and time of day; what is used to treat the pain; other symptoms such as shortness of breath or sweating; and if the pain is related to an injury or surgery. Assessment for sleep disturbance is not a part of the chest pain assessment.

PTS: 1 DIF: Apply REF: Box 23-1 Chest Pain Evaluation

5.The nurse is assessing a clients precordium. Which of the following should be included in this assessment? (Select all that apply.)

1.

Palpate the precordium.

2.

Palpate temperature and pulses of extremities.

3.

Assess blood pressure.

4.

Percuss the precordium.

5.

Auscultate heart sounds.

6.

Identify the location and timing of heart sounds.

ANS: 1, 2, 4, 5, 6

When assessing a clients precordium, the following should be included palpation of the precordium, palpation of extremities for temperature and pulses, percussion of the precordium, auscultation of heart sounds, and location and timing of heart sounds. Blood pressure is not a part of the precordium assessment.

PTS: 1 DIF: Apply REF: Box. 23-4 Steps of the Precordium Assessment

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