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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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Aim for a total cholesterol at 225 mg/dL. A total cholesterol level of 225 mg/dL is higher than the recommended target, which is typically less than 200 mg/dL. This is not an appropriate treatment goal.

B. Maintain blood pressure at less than 140/90 mm Hg. This is a reasonable goal for many clients with atherosclerosis. Keeping blood pressure below 140/90 mm Hg helps reduce the risk of further vascular damage.

C. Limit total fat intake to 50% of total daily calories. Limiting fat intake to 50% of total daily calories is excessive. The recommendation is usually around 25-35% of total daily calories from fat, with a focus on healthy fats.

D. Keep body mass index (BMI) above 30. A BMI above 30 is classified as obese, which is a risk factor for atherosclerosis. The goal is to reduce BMI to within a healthy range (18.5-24.9).

Correct Answer is "{\"xRanges\":[80.828125,100.828125],\"yRanges\":[129,149]}"

Explanation

To auscultate the apical pulse, the nurse should place the stethoscope at the fifth intercostal space at the midclavicular line on the left side of the chest. This is the location of the apex of the heart, also referred to as the point of maximal impulse (PMI).

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a provider's office is reinforcing teaching with a client who has risk factors for atherosclerosis. The nurse should help the client identify which of the following as treatment goals?

Correct Answer is C

Explanation

A nurse is counting a client's apical pulse rate. Identify where the nurse should place the stethoscope to auscultate the apical pulse. (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)

Correct Answer is "{\"xRanges\":[80.828125,100.828125],\"yRanges\":[129,149]}"

Explanation

A nurse is preparing to administer digoxin 0.25 mg PO to a client. The amount available is digoxin 0.125 mg tablets. How many tablets should the nurse administer to the client? (Round to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

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?

A nurse is collecting data on a client who is postoperative following abdominal surgery. Which of the following data should the nurse collect first?

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)

While auscultating a client's heart sounds, the nurse hears turbulence between S1 and S2. The nurse should document this finding as which of the following?

A nurse is collecting data about a client's circulatory system. Which of the following pulse sites should the nurse avoid checking bilaterally at the same time?

A nurse is checking the apical pulse of a client who is taking several cardiovascular medications. Which of the following actions should the nurse take?

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?