A nurse is collecting data from a client who has anemia due to excess blood loss during surgery causing a decrease in blood flow/perfusion in the patient. The patient's vital signs are as follows: BP 100/60. HR 122. Resp 24, SPO2 92%. The nurse should expect which of the following findings/symptoms?

Dyspnea on exertion

Respiratory depression

Intense abdominal pain

Bradycardia

Answer and Explanation

The Correct Answer is A

A. Dyspnea on exertion: Anemia from blood loss reduces oxygen-carrying capacity, leading to symptoms like fatigue and dyspnea on exertion. The patient's low SpO₂, tachycardia, and increased respiratory rate are consistent with this finding.

B. Respiratory depression: Respiratory depression is typically associated with narcotics or other depressants, not anemia due to blood loss. The increased respiratory rate suggests a compensatory mechanism for decreased oxygenation, not depression.

C. Intense abdominal pain: While abdominal pain could be present in some conditions, it is not a direct symptom of anemia due to surgical blood loss and decreased perfusion.

D. Bradycardia: Anemia usually causes tachycardia (increased heart rate) as the body compensates for the decreased oxygenation, not bradycardia (slow heart rate). Therefore, bradycardia is unlikely in this case.

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Correct Answer is B

Explanation

A. Assist the patient to the chair for breakfast. Moving the patient to a chair may exacerbate venous stasis and worsen circulation in this case. This is not the correct action.

B. Check the presence of lower extremity pulses. Brown discoloration and cold, blue feet suggest poor circulation or chronic venous insufficiency. The nurse should assess the pulses to evaluate arterial blood flow in the lower extremities.

C. Apply non-skid socks to feet. While non-skid socks are generally used to prevent falls, this action does not address the circulatory concern indicated by the patient's symptoms.

D. Perform deep tissue massage on bilateral lower extremities to improve blood flow. Massage could be harmful, especially if there is a possibility of a blood clot or poor arterial circulation. This is not a recommended action in this scenario.

A. To provide analgesia B. To prevent blood clotting C. To reduce inflammation D. To prevent fever

Correct Answer is B

Explanation

A. To provide analgesia: While aspirin can reduce pain, its primary use following a myocardial infarction is not for analgesia. Other medications are used for pain management in this scenario.

B. To prevent blood clotting: Aspirin is prescribed following a myocardial infarction to inhibit platelet aggregation and prevent blood clots, which can reduce the risk of future cardiac events. This is the correct rationale for aspirin use in coronary artery disease.

C. To reduce inflammation: Although aspirin has anti-inflammatory properties, the primary reason for prescribing it after a myocardial infarction is to prevent blood clots, not to reduce inflammation.

D. To prevent fever: Aspirin can reduce fever, but this is not the reason it is prescribed after a myocardial infarction.

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Naxlex Comprehensive Predictor Exams

The nurse notes the patient’s lower legs are brown and discolored and their feet are cold and slightly blue in color when in the dependent position. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is caring for a client who asks why she is being prescribed aspirin 325 mg daily following a myocardial infarction. The nurse should instruct the client that aspirin is prescribed for clients who have coronary artery disease for which of the following effects?

Correct Answer is B

Explanation

When a nurse obtains an unusually low blood pressure measurement for a client whose blood pressure is generally elevated, she considers the possibility of a problem with her technique. Which of the following sources of error should she consider as a possible cause of the low reading?

A nurse is reinforcing instructions with a client who is scheduled for a cardiac catheterization with angiography. Which of the following statements should the nurse include in the instructions?

A nurse is reinforcing teaching with a young adult female client who has been prescribed lisinopril. Which of the following instructions should the nurse plan to include? (Select all that apply.)

A nurse is reinforcing teaching with the spouse of a client about how to take a blood pressure. Which of the following actions by the spouse indicates a need for further instruction?

A nurse is collecting data about a client's cardiac functioning. The nurse auscultates an S3 sound. Which of the following causes should the nurse suspect?

A nurse is preparing to administer morning insulin to a client who has a prescription for 14 units of regular insulin and 28 units of NPH insulin subcutaneous daily. What is the total number of units of insulin that the nurse should prepare in the insulin syringe?

A nurse is assisting with care of a client who has a prescription for 3.000 mL of intravenous fluids over the next 24 hr. The nurse should set the IV pump to deliver how many mL/hr? (Round to the nearest whole number)