Question 1

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?

Accepted Answer

Vitamin B-12 is required for proper red blood cell formation. It is necessary for the maturation of red blood cells and helps to maintain their normal functioning.

Question 2

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?

Accepted Answer

The aortic valve is best auscultated at the second intercostal space to the right of the sternum. This location is known as the aortic area, where sounds produced by the aortic valve are most clearly heard.

Question 3

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

Accepted Answer

A,B,D,E,F

Question 4

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

Accepted Answer

An echocardiogram uses ultrasound waves to produce images of the heart's structure and function, making it the best option for this scenario. Exercise electrocardiography involves monitoring the heart's electrical activity during exercise, while an electrocardiogram involves measuring the heart's electrical activity at rest. A chest x-ray produces an image of the chest and does not specifically evaluate the heart's structure and function.

Question 5

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:

Accepted Answer

The client's symptoms are consistent with musculoskeletal-costochondritis, which is inflammation of the cartilage that connects a rib to the sternum. The pain is usually localized to a specific costochondral joint and worsens with movement or deep breathing. Aortic dissection, pulmonary embolus, and pneumothorax present with different symptoms and are not likely in this case.

Question 6

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?

Accepted Answer

Red blood cells have a lifespan of approximately 120 days. Therefore, the body needs a constant supply of new red blood cells to replace the old ones. In situations such as blood loss or anemia, a transfusion of packed red blood cells can provide the body with the necessary supply of red blood cells until the body can produce its own.

Question 7

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?

Accepted Answer

Petechiae are pinpoint hemorrhages under the skin that are dark red and less than 2 mm in size.

Question 8

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

Accepted Answer

A normal ejection fraction typically ranges between 55% and 70%. Therefore, the most likely range for this client's ejection fraction is 60% to 70%, which is option C. Options A, B, and D represent ejection fractions outside the normal range.

Question 9

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

Accepted Answer

Barrel chest, pectus excavatum, and pectus carinatum are common chest abnormalities. Barrel chest is often associated with chronic respiratory conditions, pectus excavatum is a sunken chest, and pectus carinatum is a protruding chest.

Question 10

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

Accepted Answer

The nurse should instruct the client that the test will take between 20 and 50 minutes. This information is important to manage the client's expectations and reduce anxiety. Instructing the client to eat nothing before the test (A) is incorrect, as the client may be instructed to fast or eat a light meal before the test depending on the specific protocol. Instructing the client to expect chest pain (B) is incorrect, as chest pain during a stress test is not normal and should be reported immediately. Instructing the client that they will be videotaped (D) is incorrect, as this is not a standard part of a stress test and would depend on the specific facility's protocol.

Question 11

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

Accepted Answer

Eosinophils are white blood cells that are elevated in response to parasitic infections, as well as allergies and asthma. Basophils may be elevated in allergic reactions and some types of leukemia, but not specifically parasitic infections. Lymphocytes play a role in the immune response but are not specifically elevated in parasitic infections. Neutrophils are typically elevated in bacterial infections.

Question 12

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

Accepted Answer

Location, radiation, timing, and intensity are all important characteristics to assess in a heart murmur. Blood pressure and heart rate may be relevant to overall cardiovascular health but are not specific to a heart murmur assessment.

Question 13

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

Accepted Answer

The answer of The nurse is reviewing a client's white...

Question 14

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 client's:

Accepted Answer

The nurse is assessing capillary refill by applying pressure to the fingernail and then monitoring how long it takes for the color to return after the pressure is released. This is a quick and simple way to assess peripheral circulation.

Question 15

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

Accepted Answer

Cardiac catheterization is frequently done to diagnose coronary artery disease. It is an invasive test usually done in patients with chest pain or other symptoms that suggest blockages in their coronary arteries.

Question 16

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

Accepted Answer

Anticoagulants are medications that prevent blood clot formation or prolong clotting time. Acetylsalicylic acid and clopidogrel are antiplatelet medications that work by inhibiting platelet aggregation, but they do not directly affect coagulation. Reteplase and tirofiban are thrombolytic medications that dissolve blood clots that have already formed. Hence, the anticoagulant medications listed here are dalteparin and warfarin.

Question 17

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

Accepted Answer

A low red blood cell count indicates anemia, which can lead to decreased oxygenation and impaired respiratory function. Therefore, it is important for the nurse to assess the client's respirations to monitor their oxygenation status. While the other options (urine output, bowel sounds, consciousness) are important to assess for overall client health, they are not directly related to a low red blood cell count.

Quiz 23: Assessment of Cardiovascular and Hematological Function