Exam 1 - Practice Questions (Heme, Oncology, Diabetes, HIV, Autoimmune) Flashcards
A diabetic patient is started on intensive insulin therapy. The nurse will plan to teach the patient about mealtime coverage using _____ insulin.
a. NPH
b. lispro
c. detemir
d. glargine
B
Rationale: Rapid or short acting insulin is used for mealtime coverage for patients receiving intensive insulin therapy. NPH, glargine, or detemir will be used as the basal insulin.
You are caring for a patient with newly diagnosed type 1 diabetes. What information is essential to include in your patient teaching before discharge from the hospital? (select all that apply)
a. insulin administration
b. elimination of sugar from diet
c. need to reduce physical activity
d. use of a portable blood glucose monitor
e. signs and symptoms of hypoglycemia and hyperglycemia
A, D, E - The nurse ensures that the patient understands the proper use of insulin. The nurse teaches the patient how to use the portable blood glucose monitor and how to recognize and treat signs and symptoms of hypoglycemia and hyperglycemia.
Which one of the following methods/techniques will the nurse use when giving insulin to a thin person? [Hint]
A. Pinch the skin up and use a 90 degree angle
B. Use a 45 degree angle with the skin pinched up
C. Massage the area of injection after injecting the insulin
D. Warm the skin with a warmed towel or washcloth prior to the injection
a. Pinch the skin up and use a 90 degree angle
The best angle for a thin person is 90 degrees with the skin pinched up. The area is not massaged and it is not necessary to warm it.
The physician orders a transfusion with packed red blood cells (RBCs) for a patient hospitalized with severe iron deficiency anemia. When blood is administered, what is the most important action the nurse can take to prevent a transfusion reaction?
a) Premedicate the patient with acetaminophen (Tylenol)
b) Administer the blood as soon as it arrives
c) Stay with the patient during the first 15 minutes of the transfusion
d) Verify the patient identification according to hospital policy
d) Verify the patient identification according to hospital policy
Explanation:
Acute hemolytic transfusion reactions are preventable. Improper identification is responsible for the majority of hemolytic transfusion reactions. Meticulous attention to detail in labeling blood samples and blood components and accurately identifying the recipient cannot be overemphasized. It is the nurse’s responsibility to ensure that the correct blood component is transfused to the correct patient.
A patient with type 1 diabetes has received diet instruction as part of the treatment plan. The nurse determines a need for additional instruction when the patient says,
a. “I may have an occasional alcoholic drink if I include it in my meal plan.”
b. “I will need a bedtime snack because I take an evening dose of NPH insulin.”
c. “I will eat meals as scheduled, even if I am not hungry, to prevent hypoglycemia.”
d. “I may eat whatever I want, as long as I use enough insulin to cover the calories.”
D
Rationale: Most patients with type 1 diabetes need to plan diet choices very carefully.
Patients who are using intensified insulin therapy have considerable flexibility in diet choices but still should restrict dietary intake of items such as fat, protein, and alcohol.
The other patient statements are correct and indicate good understanding of the diet instruction.
A patient receiving antiretroviral therapy is complaining of “not urinating enough.” What is the nurse’s best action?
a) Assess liver function tests.
b) Administer fluids 100 mL/hour via IV therapy.
c) Assess BUN and creatinine.
d) Encourage the patient to drink more fluids.
c) Assess BUN and creatinine.
Explanation:
Adverse effects associated with antiretroviral therapy include potential nephrotoxicity. Assessing BUN and creatinine for patients who have decreased urination is appropriate. The other answers will not assist the nurse in determining the patient’s problem. Assessment of the problem should be undertaken before interventions.
One hour after the completion of a fresh frozen plasma transfusion, a patient complains of shortness of breath and is very anxious. The patient’s vital signs are BP 98/60, HR 110, temperature 99.4ºF, and SaO2 88%. Auscultation of the lungs reveals posterior coarse crackles to the mid and lower lobes bilaterally. Based on the symptoms, the nurse suspects the patient is experiencing which of the following problems?
a) Delayed hemolytic reaction
b) Bacterial contamination of blood
c) Transfusion-related acute lung injury
d) Exacerbation of congestive heart failure
c) Transfusion-related acute lung injury
Explanation:
Transfusion-related acute lung injury (TRALI) is a potentially fatal, idiosyncratic reaction that is defined as the development of acute lung injury occurring within 6 hours after a blood transfusion. It is more likely to occur when plasma and platelets are transfused. Onset is abrupt (usually within 6 hours of transfusion, often within 2 hours). Signs and symptoms include acute shortness of breath, hypoxia (arterial oxygen saturation [SaO2] less than 90%; pressure of arterial oxygen [PaO2] to fraction of inspired oxygen [FIO2] ratio of less than 300), hypotension, fever, and eventual pulmonary edema.
Which assessment finding is not likely to cause noncompliance with antiretroviral treatment?
a) Depression
b) Past substance abuse
c) Lack of social support
d) Active substance abuse
b) Past substance abuse
Explanation:
Past substance abuse has not been implicated as a factor for noncompliance with antiretroviral treatment. Factors associated with nonadherence include active substance abuse, depression, and lack of social support.
A patient being treated for HIV/AIDS has a decreased appetite, almost to the point of anorexia. What is the nurse’s best action?
a) Talk to the patient about his unwillingness to eat.
b) Ask the dietician to prepare his favorite meals.
c) Administer megestrol acetate (Megace).
d) Ask his family to bring in food that he enjoys.
c) Administer megestrol acetate (Megace).
Explanation:
Appetite stimulants are successfully used in patients with AIDS-related anorexia. The anorexia is compounded by medications that cause nausea and vomiting. The anorexia has a physiologic cause, and this must be addressed. Bringing in favorite foods or making favorite foods may have little or no effect on the patient’s appetite; it is physiologically rather than psychologically based.
According to the tumor-node-metastasis (TNM) classification system, T0 means there is which of the following?
a) No regional lymph node metastasis
b) No evidence of primary tumor
c) Distant metastasis
d) No distant metastasis
b) No evidence of primary tumor
Explanation:
T0 means that there is no evidence of primary tumor. N0 means that there is no regional lymph node metastasis. M0 means that there is no distant metastasis. M1 means that there is distant metastasis
The patient received regular insulin 10 units subcutaneously at 8:30 PM for a blood glucose level of 253 mg/dL. The nurse plans to monitor this patient for signs of hypoglycemia at which time related to the insulin’s peak action?
a. 8:40 PM to 9:00 PM
b. 9:00 PM to 11:30 PM
c. 10:30 PM to 1:30 AM
d. 12:30 AM to 8:30 AM
C - Regular insulin exerts peak action in 2 to 5 hours, making the patient most at risk for hypoglycemia between 10:30 PM and 1:30 AM. Rapid-acting insulin’s onset is between 10-30 minutes with peak action and hypoglycemia most likely to occur between 9:00 PM and 11:30 PM. With intermediate acting insulin, hypoglycemia may occur from 12:30 AM to 8:30 AM.
A patient with diabetes mellitus who has multiple infections every year needs a mitral valve replacement. What is the most important preoperative teaching the nurse should provide to prevent a cardiac infection postoperatively?
a. avoid sick people and wash hands.
b. obtain comprehensive dental care.
c. maintain hemoglobin A1c below 7%.
d. coughing and deep breathing with splinting
B - A person with diabetes is at high risk for postoperative infections. The most important preoperative teaching to prevent a postoperative infection in the heart is to have the patient obtain comprehensive dental care because the risk of septicemia and infective endocarditis increases with poor dental health. Avoiding sick people, hand washing, maintaining hemoglobin A1c below 7%, and coughing and deep breathing with splinting would be important for any type of surgery, but not the priority with mitral valve replacement for this patient.
The nurse is evaluating bloodwork results of a patient with cancer who is receiving chemotherapy. The patient’s platelet count is 60,000/mm3. Which of the following is an appropriate nursing action?
a) Providing commercial mouthwash to patient
b) Avoiding use of products containing aspirin
c) Taking patient’s temperature rectally
d) Providing patient with a razor to shave
b) Avoiding use of products containing aspirin
Explanation:
Patients with a platelet count of 60,000/mm3 are at mild risk for bleeding. Appropriate nursing interventions include avoiding use of products such as aspirin that may interfere with the patient’s clotting systems; avoiding taking temperature rectally and administering suppositories; providing patient with an electric shaver for shaving; and avoiding commercial mouthwashes due to their potential to dry out oral mucosa, which can lead to cracking and bleeding.
Which of the following is accurate pertaining to physical exercise and type 1 diabetes mellitus?
a. Physical exercise can slow the progression of diabetes mellitus.
b. Strenuous exercise is beneficial when the blood glucose is high.
c. Patients who take insulin and engage in strenuous physical exercise might experience hyperglycemia.
d. Adjusting insulin regimen allows for safe participation in all forms of exercise.
a. Physical exercise can slow the progression of diabetes mellitus.
Physical exercise slows the progression of diabetes mellitus, because exercise has beneficial effects on carbohydrate metabolism and insulin sensitivity.
Strenuous exercise can cause retinal damage, and can cause hypoglycemia.
Insulin and foods both must be adjusted to allow safe participation in exercise.
A patient newly diagnosed with Type I DM is being seen by the home health nurse. The doctors orders include: 1200 calorie ADA diet, 15 units NPH insulin before breakfast, and check blood sugar qid. When the nurse visits the patient at 5 pm, the nurse observes the man performing blood sugar analysis. The result is 50 mg/dL. The nurse would expect the patient to be
a. confused with cold, clammy skin an pulse of 110
b. lethargic with hot dry dkin and rapid deep respirations
c. alert and cooperative with BP of 130/80 and respirations of 12
d. short of breath, with distended neck veins and bounding pulse of 96.
a. confused with cold, clammy skin an pulse of 110
hypoglycemia
A patient with type 2 diabetes that is controlled with diet and metformin (Glucophage) also has severe rheumatoid arthritis (RA). During an acute exacerbation of the patient’s arthritis, the health care provider prescribes prednisone (Deltasone) to control inflammation. The nurse will anticipate that the patient may
a. require administration of insulin while taking prednisone.
b. develop acute hypoglycemia during the RA exacerbation.
c. have rashes caused by metformin-prednisone interactions.
d. need a diet higher in calories while receiving prednisone.
A
Rationale: Glucose levels increase when patients are taking CORTICOsteroids, and insulin may be required to control blood glucose.
Hypoglycemia is not a complication of RA exacerbation or prednisone use.
Rashes are not an adverse effect caused by taking metformin and prednisone simultaneously.
The patient is likely to have an increased appetite when taking prednisone, but it will be important to avoid weight gain for the patient with RA.
A client has recently been diagnosed with Type I diabetes and asks the nurse for help formulating a nutrition plan. Which of the following recommendations would the nurse make to help the client increase calorie consumption to offset absorption problems?
a. Eating small meals with two or three snacks may be more helpful in maintaining blood glucose levels than three large meals.
b. Eat small meals with two or three snacks throughout the day to keep blood glucose levels steady
c. Increase consumption of simple carbohydrates
d. Skip meals to help lose weight
A
Eating small meals with two or three snacks may be more helpful in maintaining blood glucose levels than three large meals.
A 51-year-old patient with diabetes mellitus is scheduled for a fasting blood glucose level at 8:00 AM. The nurse instructs the patient to only drink water after what time?
a. 6:00 PM on the evening before the test
b. midnight before the test
c. 4:00 AM on the day of the test
d. 7:00 AM on the day of the test
B - Typically, a patient is ordered to be NPO for 8 hours before a fasting blood glucose level. For this reason, the patient who has a lab draw at 8:00 AM should not have any food or beverages containing any calories after midnight.
The nurse is planning dietary changes for a client following an episode of pancreatitis. Which diet is suitable for the client?
a. Low calorie, low carbohydrate
b. High calorie, low fat
c. High protein, high fat
d. Low protein, high carbohydrate
b. High calorie, low fat
Nina, an oncology nurse educator is speaking to a women’s group about breast cancer. Questions and comments from the audience reveal a misunderstanding of some aspects of the disease. Various members of the audience have made all of the following statements. Which one is accurate?
a. Mammography is the most reliable method for detecting breast cancer.
b. Breast cancer is the leading killer of women of childbearing age.
c. Breast cancer requires a mastectomy.
d. Men can develop breast cancer.
Answer D.
Men can develop breast cancer, although they seldom do. The most reliable method for detecting breast cancer is monthly self-examination, not mammography. Lung cancer causes more deaths than breast cancer in women of all ages. A mastectomy may not be required if the tumor is small, confined, and in an early stage.
What intervention is a priority when treating a patient with HIV /AIDS?
a) Monitoring skin integrity
b) Monitoring psychological status
c) Assessing neurologic status
d) Assessing fluid and electrolyte balance
d) Assessing fluid and electrolyte balance
Explanation:
Fluid and electrolyte deficits are a priority in monitoring patients with HIV/AIDS. Assessment of fluid loss and electrolyte imbalance is essential. Skin integrity should be monitored, but is a lower priority. Neurologic and psychological status should also be monitored, but this is not as high a priority as fluid and electrolyte imbalance.
A college student who has type 1 diabetes normally walks each evening as part of an exercise regimen. The student now plans to take a swimming class every day at 1:00 PM. The clinic nurse teaches the patient to
a. delay eating the noon meal until after the swimming class.
b. increase the morning dose of neutral protamine Hagedorn (NPH) insulin on days of the swimming class.
c. time the morning insulin injection so that the peak occurs while swimming.
d. check glucose level before, during, and after swimming.
d. check glucose level before, during, and after swimming.
Rationale: The change in exercise will affect blood glucose, and the patient will need to monitor glucose carefully to determine the need for changes in diet and insulin administration.
Because exercise tends to decrease blood glucose, patients are advised to eat before exercising.
Increasing the morning NPH or timing the insulin to peak during exercise may lead to hypoglycemia, especially with the increased exercise.
A nurse is reviewing a patient’s morning lab results and notes a left shift in the band cells. Based on this observation, what interpretation can the nurse make from these results?
a) The patient has leukopenia.
b) The patient has thrombocytopenia.
c) The patient may be developing anemia.
d) The patient may be developing an infection.
d) The patient may be developing an infection.
Explanation:
The somewhat less mature granulocyte has a single-lobed, elongated nucleus and is called a band cell. Ordinarily, band cells account for only a small percentage of circulating granulocytes, although their percentage can increase greatly under conditions in which neutrophil production increases, such as infection. An increased number of band cells is sometimes called a left shift or shift to the left. Anemia refers to decreased red cell mass. Leukopenia refers to a less-than-normal amount of white blood cells (WBCs) in circulation. Thrombocytopenia refers to a lower-than-normal platelet count.
Which of the following is an early manifestation of HIV encephalopathy?
a) Headache
b) Hallucinations
c) Hyperreflexia
d) Vacant stare
a) Headache
Explanation:
An early manifestation of HIV encephalopathy is a headache. Later stages include hyperreflexia, a vacant stare, and hallucinations
Intramuscular glucagon is administered to an unresponsive patient for treatment of hypoglycemia. Which action should the nurse take after the patient regains consciousness?
a. Give the patient a snack of cheese and crackers.
b. Have the patient drink a glass of orange juice or nonfat milk.
c. Administer a continuous infusion of 5% dextrose for 24 hours.
d. Assess the patient for symptoms of hyperglycemia.
A
Rationale: Rebound hypoglycemia can occur after glucagon administration, but having a meal containing complex carbohydrates plus protein and fat will help prevent hypoglycemia.
Orange juice and nonfat milk will elevate blood sugar rapidly, but the cheese and crackers will stabilize blood sugar.
Administration of glucose intravenously might be used in patients who were unable to take in nutrition orally. The patient should be assessed for symptoms of hypoglycemia after glucagon administration.
Which of the following connective tissue disorders is characterized by insoluble collagen being formed and accumulating excessively in the tissues?
a) Systemic lupus erythematosus (SLE)
b) Scleroderma
c) Rheumatoid arthritis
d) Polymyalgia rheumatic
b) Scleroderma
Explanation:
Scleroderma occurs initially in the skin, but also occurs in blood vessels, major organs, and body systems, potentially resulting in death. Rheumatoid arthritis results from an autoimmune response in the synovial tissue, with damage taking place in body joints. SLE is an immunoregulatory disturbance that results in increased autoantibody production. In polymyalgia rheumatic, immunoglobulin is deposited in the walls of inflamed temporal arteries.
Which diagnostic study finding is decreased in patients diagnosed with rheumatoid arthritis?
a) uric acid
b) Red blood cell count
c) Creatinine
d) Erythrocyte sedimentation rate (ESR)
b) Red blood cell count
Explanation:
There is a decreased red blood cell count in patients diagnosed with rheumatic diseases. ESR increases inflammatory connective tissue disease. Uric acid is increased in gout. Increased creatinine may indicate renal damage in SLE, scleroderma, and polyarteritis.
A patient received 6 units of REGULAR INSULIN 3 hours ago. The nurse would be MOST concerned if which of the following was observed?
a. kussmaul respirations and diaphoresis
b. anorexia and lethargy
c. diaphoresis and trembling
d. headache and polyuria
c. diaphoresis and trembling
indicates hypoglycemia
A 54-year-old patient admitted with type 2 diabetes asks the nurse what “type 2” means. What is the most appropriate response by the nurse?
a. “With type 2 diabetes, the body of the pancreas becomes inflamed.”
b. “With type 2 diabetes, insulin secretion is decreased, and insulin resistance is increased.”
c. “With type 2 diabetes, the patient is totally dependent on an outside source of insulin.”
d. “With type 2 diabetes, the body produces autoantibodies that destroy β-cells in the pancreas.”
B - In type 2 diabetes mellitus, the secretion of insulin by the pancreas is reduced, and/or the cells of the body become resistant to insulin. The pancreas becomes inflamed with pancreatitis. The patient is totally dependent on exogenous insulin and may have had autoantibodies destroy the β-cells in the pancreas with type 1 diabetes mellitus.
Which of the following are the most commonly reported clinical manifestations of multiple sclerosis? Select all that apply.
a) Pain
b) Numbness
c) Depression
d) Fatigue
e) Spasticity
f) Aphasia
a) Pain, b) Numbness, c) Depression, d) Fatigue, e) Spasticity
Explanation:
The most commonly reported clinical manifestations of MS are pain, fatigue, spasticity, depression, numbness, weakness, difficulty with coordination, and loss of balance. Aphasia is not a commonly reported clinical manifestation.
Which of the following statements reflects the treatment of HIV infection?
a) Treatment should be offered to individuals with plasma HIV RNA levels less than 55,000 copies/mL (RT-PCR assay).
b) Treatment should be offered to all patients once they reach CDC category B: HIV symptomatic.
c) Treatment of HIV infection for an individual patient is based on the clinical condition of the patient, CD4 T cell count level, and HIV RNA (viral load).
d) Treatment should be offered to only select patients once they reach CDC category B: HIV symptomatic.
c) Treatment of HIV infection for an individual patient is based on the clinical condition of the patient, CD4 T cell count level, and HIV RNA (viral load).
Explanation:
Although specific therapies vary, treatment of HIV infection for an individual patient is based on three factors: the clinical condition of the patient, CD4 T cell count level, and HIV RNA (viral load).Treatment should be offered to all patients with the primary infection (acute HIV syndrome). In general, treatment should be offered to individuals with fewer than 350 CD4+ T cells/mm or plasma HIV RNA levels exceeding 55,000 copies/mL (RT-PCR assay).
A patient using a split mixed-dose insulin regimen asks the nurse about the use of intensive insulin therapy to achieve tighter glucose control. The nurse should teach the patient that
a. intensive insulin therapy requires three or more injections a day in addition to an injection of a basal long-acting insulin.
b. intensive insulin therapy is indicated only for newly diagnosed type 1 diabetics who have never experienced ketoacidosis.
c. studies have shown that intensive insulin therapy is most effective in preventing the macrovascular complications characteristic of type 2 diabetes.
d. an insulin pump provides the best glucose control and requires about the same amount of attention as intensive insulin therapy.
A
Rationale: Patients using intensive insulin therapy must check their glucose level four to six times daily and administer insulin accordingly. A previous episode of ketoacidosis is not a contraindication for intensive insulin therapy.
Intensive insulin therapy is not confined to type 2 diabetics and would prevent microvascular changes as well as macrovascular changes.
Intensive insulin therapy and an insulin pump are comparable in glucose control.
The nurse is teaching the patient with HIV about therapy. What is essential for the nurse to include in the teaching plan? Select all that apply.
a) Patients rarely respond to medication therapy.
b) Antiretroviral therapy targets different stages of the HIV life cycle.
c) The goal of antiretroviral therapy is to prevent opportunistic infections.
d) Medication therapy is rarely effective.
e) The CD4 count is the major indicator of immune function and guides therapy.
b) Antiretroviral therapy targets different stages of the HIV life cycle., e) The CD4 count is the major indicator of immune function and guides therapy.
Explanation:
The CD4 count is the major indicator of immune function. Antiretroviral therapy in HIV targets different stages of the HIV life cycle. Therapy does not prevent opportunistic infections. Medication therapy is effective and most patients respond well to therapy.
Which of these laboratory values noted by the nurse when reviewing the chart of a diabetic patient indicates the need for further assessment of the patient?
a. Fasting blood glucose of 130 mg/dl
b. Noon blood glucose of 52 mg/dl
c. Glycosylated hemoglobin of 6.9%
d. Hemoglobin A1C of 5.8%
b. Noon blood glucose of 52 mg/dl
The nurse should assess the patient with a blood glucose level of 52 mg/dl for symptoms of hypoglycemia, and give the patient some carbohydrate-containing beverage such as orange juice. The other values are within an acceptable range for a diabetic patient.
Client newly diagnosed with diabetes mellitus has been stabilized with daily insulin injections. A nurse prepares a discharge teaching plan regarding the insulin and plans to reinforce which of the following concepts?
a) always keep insulin vials refrigerated
b) ketones in the urine signify a need for less insulin
c) increase the amount of insulin before unusual exercise
d) systematically rotate insulin injections within one anatomic site
d) systematically rotate insulin injections within one anatomic site
Insulin doses should not be adjusted nor increased before unusual exercise. If ketones are found in the urine, it possibly may indicate the need for additional insulin. To minimize the discomfort associated with insulin injections, insulin should be administered at room temperature. Injection sites should be rotated systematically within one anatomic site.
A patient is admitted with diabetes mellitus, malnutrition, and cellulitis. The patient’s potassium level is 5.6 mEq/L. The nurse understands that what could be contributing factors for this laboratory result (select all that apply)?
a. the level may be increased as a result of dehydration that accompanies hyperglycemia.
b. the patient may be excreting extra sodium and retaining potassium because of malnutrition.
c. the level is consistent with renal insufficiency that can develop with renal nephropathy.
d. the level may be raised as a result of metabolic ketoacidosis caused by hyperglycemia.
e. this level demonstrates adequate treatment of the cellulitis and effective serum glucose control.
A, C, D - The additional stress of cellulitis may lead to an increase in the patient’s serum glucose levels. Dehydration may cause hemoconcentration, resulting in elevated serum readings. Kidneys may have difficulty excreting potassium if renal insufficiency exists. Finally, the nurse must consider the potential for metabolic ketoacidosis since potassium will leave the cell when hydrogen enters in an attempt to compensate for a low pH. Malnutrition does not cause sodium excretion accompanied by potassium retention. Thus it is not a contributing factor to this patient’s potassium level. The elevated potassium level does not demonstrate adequate treatment of cellulitis or effective serum glucose control.
Which of the following would be consistent with the diagnosis of rheumatoid arthritis?
a) Cloudy synovial fluid
b) Increased red blood cell count
c) Increased C4 complement component
d) Decreased ESR
a) Cloudy synovial fluid
Explanation:
In a patient with rheumatoid arthritis, arthrocentesis shows synovial fluid that is cloudy, milky, or dark yellow and contains numerous inflammatory components, such as leukocytes and complement
A nurse is teaching a patient with a vitamin B12 deficiency about appropriate food choices to increase the amount of B12 ingested with each meal. The nurse knows the teaching is effective based on which of the following patient statements?
a) “I will eat a meat source such as chicken or pork with each meal.”
b) “I will eat a spinach salad with lunch and dinner.”
c) “I will increase my daily intake of orange vegetables such as sweet potatoes and carrots.”
d) “I will eat more dairy products such as milk, yogurt, and ice cream every day.”
a) “I will eat a meat source such as chicken or pork with each meal.”
Explanation: Vitamin B12 is found only in foods of animal origin
A 37-year-old forklift operator presents with shakiness, sweating, anxiety, and palpitations and tells the nurse he has type 1 diabetes mellitus. Which of the follow actions should the nurse do first?
A. Inject 1 mg of glucagon subcutaneously.
B. Administer 50 mL of 50% glucose I.V.
C. Give 4 to 6 oz (118 to 177 mL) of orange juice.
D. Give the client four to six glucose tablets.
Correct answer: C
Because the client is awake and complaining of symptoms, the nurse should first give him 15 grams of carbohydrate to treat hypoglycemia. This could be 4 to 6 oz of fruit juice, five to six hard candies such as Lifesavers, or 1 tablespoon of sugar. When a client has worsening symptoms of hypoglycemia or is unconscious, treatment includes 1 mg of glucagon subcutaneously or intramuscularly, or 50 mL of 50% glucose I.V. The nurse may also give two to three glucose tablets for a hypoglycemic reaction.
A patient is brought to the ER complaining of fatigue, large amounts of bruising on the extremities, and abdominal pain localized in the left upper quadrant. A health history reveals the patient has been treated three times in the past 2 months for a sore throat. Lab tests indicate severe anemia, significant neutropenia, and thrombocytopenia. Based on the symptoms, with what could the patient be diagnosed?
a) Sickle cell anemia
b) Hemolytic anemia
c) Aplastic anemia
d) Iron deficiency anemia
c) Aplastic anemia
Explanation:
Aplastic anemia can be congenital or acquired, but most cases are idiopathic. It can be triggered by infection. The manifestations of aplastic anemia are symptoms of anemia, purpura (bruising), retinal hemorrhages, significant neutropenia, and thrombocytopenia. Other lymphadenopathies and splenomegaly sometimes occur.
The nurse assisting in the admission of a client with diabetic ketoacidosis will anticipate the physician ordering which of the following types of intravenous solution if the client cannot take fluids orally?
a. 0.45% normal saline solution
b. Lactated Ringer’s solution
c. 0.9 normal saline solution
d. 5% dextrose in water (D5W)
a. 0.45% normal saline solution
A female client with cancer is receiving chemotherapy and develops thrombocytopenia. The nurse identifies which intervention as the highest priority in the nursing plan of care?
a. Monitoring temperature
b. Ambulation three times daily
c. Monitoring the platelet count
d. Monitoring for pathological fractures
Answer C.
Thrombocytopenia indicates a decrease in the number of platelets in the circulating blood. A major concern is monitoring for and preventing bleeding. Option A elates to monitoring for infection, particularly if leukopenia is present. Options B and D, although important in the plan of care, are not related directly to thrombocytopenia.
What is the priority action for the nurse to take if the patient with type 2 diabetes complains of blurred vision and irritability?
a. call the physician
b. administer insulin as ordered
c. check the patient’s blood glucose level
d. assess for other neurologic symptoms
C - Blood glucose testing should be performed whenever hypoglycemia is suspected so that immediate action can be taken if necessary.
A patient who is undergoing chemotherapy for AML complains of pain in his lower back. What is the nurse’s first action?
a) Administer pain medication, as ordered.
b) Assess renal function.
c) Refer the client to a chiropractor.
d) Place heating pads on the patient’s back.
b) Assess renal function.
Explanation:
Chemotherapy results in the destruction of cells and tumor lysis syndrome. There is an increase in uric acid and phosphorus levels and the patient is susceptible to renal failure. The nurse should assess renal function if the patient complains of lower back pain as this could be indicative of a kidney stone formation. Heating pads, pain medication, and referrals could be instituted once the cause of the pain is determined. The priority is further assessment to rule out priority problems.
Which of the following points should be included in the medication-teaching plan for a patient taking adalimumab (Humira)?
a) It is important to monitor for injection site reactions.
b) The medication is given at room temperature.
c) The patient should continue taking the medication if fever occurs.
d) The medication is administered IM.
a) It is important to monitor for injection site reactions.
Explanation:
It is important to monitor for injection site reactions. The medication is injected subcutaneously and must be refrigerated. The medication should be withheld if fever occurs
Which of the following is a symptom of severe thrombocytopenia?
a) Dyspnea
b) Inflammation of the tongue
c) Petechiae
d) Inflammation of the mout
c) Petechiae
Patients with severe thrombocytopenia have petechiae (i.e. pinpoint hemorrhagic lesions, usually more prominent on the trunk or anterior aspects of the lower extremities)
A patient has completed induction therapy and has diarrhea and severe mucositis. What is the appropriate nursing goal?
a) Place client in reverse isolation.
b) Administer pain medication.
c) Maintain nutrition.
d) Address issues of negative body image.
c) Maintain nutrition.
Explanation:
Maintaining nutrition is the most important goal after induction therapy because the patient experiences severe diarrhea and can easily become nutritionally deficient as well as develop fluid and electrolyte imbalance. The patient is most likely not in pain at this point, and this is an intervention not a goal.
The nurse recognizes the most common cause of iron deficiency anemia in an adult is which of the following?
a) Lack of dietary iron
b) Bleeding
c) Iron malabsorption
d) Chronic alcoholism
b) Bleeding
Explanation:
Iron deficiency in the adult generally indicates blood loss (e.g., from bleeding in the GI tract or heavy menstrual flow). Lack of dietary iron is rarely the sole cause of iron deficiency anemia in adults. The source of iron deficiency should be investigated promptly, because iron deficiency in an adult may be a sign of bleeding in the GI tract or colon cancer.
