LA#2 (Hematological Challenges) Chapters 8, 32,33 of Med Surg

Question 1

Which of the following patients does the nurse deduce is seeing an alternative medical practitioner?

a. A patient who prevents and treats migraine headaches with acupuncture
b. A patient who uses progressive relaxation to control the nausea of cancer chemotherapy
c. A patient who supplements chiropractic manipulation for low back pain with muscle relaxants
d. A patient who takes vitamin and mineral supplements as treatment for gastrointestinal malabsorption

Answer 1

ANS: A
Alternative therapies are those used instead of conventional Western medical practice. This patient is using acupuncture instead of taking medications to prevent or treat migraine.

Question 2

A patient with high blood pressure asks the nurse about the use of fish oil supplements to help lower blood pressure. Which is the nurse’s best response?

a. “Some evidence exists that fish oil supplements are helpful in treating hypertension.”
b. “Fish oil supplements are helpful for treating rheumatoid arthritis.”
c. “No clear evidence exists that fish oil supplements are helpful.”
d. “Discuss the use of fish oil supplements with the hospital dietitian.”

Answer 2

ANS: A

Good evidence exists that fish oil is helpful in treating hypertension as well as preventing cardiovascular disease.

Question 3

Which therapy is appropriate for the nurse to suggest for a patient with fibromyalgia?

a. Acupuncture
b. Aromatherapy
c. Magnetic therapy
d. Therapeutic touch

Answer 3

ANS: A
Acupuncture may be useful in the treatment of fibromyalgia, whereas the research related to therapeutic touch is inconclusive.

Question 4

Which of the following should the nurse assess to evaluate the effect of aromatherapy on a patient after surgery?

a. Incision for signs of infection
b. Intake and output
c. Blood pressure and pulse
d. Breath sounds

Answer 4

ANS: C
Aromatherapy is used for stress reduction, and a decrease in the patient’s blood pressure and pulse would indicate that the aromatherapy was effective.

Question 5

Which of the following is used to gently lift and knead the muscle?

a. Simple massage
b. Effleurage
c. Pétrissage
d. Circular massage

Answer 5

ANS: C

Pétrissage is a kneading stroke, used to gently knead and lift muscles, often used following effleurage.

Question 6

The nurse is using imagery as a technique for pain management with a patient who has rheumatoid arthritis. What should the nurse tell the patient to promote reinforcement of the image of a pleasant scene by the patient?

a. “Tell me what you hear, smell, or feel at this place.”
b. “Place your pain in the image of a form you can destroy.”
c. “Bring what you hear and sense in your present environment into your image of the scene.”
d. “If your scene is distressing to you, continue its visualization until you can overcome the distress.”

Answer 6

ANS: A
Imagery uses one’s mind to create images that have a calming effect on the body. Outcomes may include reduction of anxiety, relaxation, enhanced immunity, and changes in hormonal responses.

Question 7

Which one of the following patients is most likely to use complementary and alternative therapies?

a. A patient who is a vegetarian
b. A patient who is of Asian heritage
c. A patient who is an older adults with a chronic condition
d. A patient who is pregnant

Answer 7

ANS: C
Older adults with non–life-threatening, chronic conditions are most likely to use complementary and alternative therapies.

Question 8

A patient with chronic headaches seeks treatment from a nurse trained in therapeutic touch. What does the nurse explain to the patient that therapeutic touch involves?

a. The use of the practitioner’s hands to assess and redirect energy
b. The forceful, passive movement of joints to restore structural and functional imbalances
c. Application of pressure with the fingers at points on the body where energy is obstructed
d. Manipulation of soft tissue and small joints that alters the length and tone of myofascial tissue

Answer 8

ANS: A
Therapeutic touch is a method of detecting and balancing human energy. It involves the conscious use of the practitioner’s hands to direct or modulate human energy.

Question 9

A patient comes to an outpatient clinic and requests an acupuncturist for treatment of her asthma. In responding to the patient’s request, what does the nurse recognize about the effect of acupuncture on asthma?

a. Asthma is a disorder that should not be treated with acupuncture because of the risk for respiratory complications.
b. Acupuncture needles stimulate or block specific superficial nerves that cause alterations in physiological function.
c. Research has indicated that asthma patients may benefit from the effects of acupuncture.
d. The patient must have a strong belief in the concepts of health and disease held by traditional Chinese medicine for treatment to be effective.

Answer 9

ANS: C

Some research has indicated that acupuncture improves lung function, which would benefit the patient with asthma.

Question 10

A patient always seems to develop an upper respiratory tract infection in the spring, and he asks if any herbal preparation is available that would help him. Which one of the following recommended herbs should the nurse suggest?

a. Comfrey
b. Echinacea
c. Ginkgo biloba
d. St. John’s wort

Answer 10

ANS: B
Good scientific evidence exists to suggest that echinacea prevents upper respiratory tract infections, and strong evidence suggests that it is also beneficial in the treatment of upper respiratory tract infections.

Question 11

A patient tells the nurse that she has been taking melatonin every day. The nurse would ask questions about which of the following during assessment, to evaluate the effectiveness of this herb for its intended use?

a. Glucose levels
b. Sleep habits
c. Bruising or bleeding tendencies
d. Bowel habits

Answer 11

ANS: B
Melatonin use as a sleep enhancement has been informed by scientific evidence; therefore, the nurse would want to assess sleep habits.

Question 12

During a routine health examination, the patient tells the nurse that she uses a variety of herbal therapies to maintain her health. In discussing her use of herbs, what should the nurse caution the patient about?

a. Most herbs are toxic and carcinogenic and should be used only when proven effective.
b. Herbs are not any better than conventional drugs in maintaining health and may be more unsafe.
c. Herbs should be purchased only from manufacturers with a history of quality control of their products.
d. Because herbal therapies may mask the symptoms of serious disease, frequent medical evaluation is required during their use.

Answer 12

ANS: C
The quality of herb preparations can vary, so it is important that patients purchase herbal remedies from reputable manufacturers. Health Canada (2011) advises Canadians to use only herbal products that have been approved for sale under the Natural Health Products regulations. If the product has been assessed, it will have a Drug Identification Number or Natural Products Number on its label. This certifies that the product has passed a review of formulation, labelling, and instructions for use.

Question 13

Which of the following is a commonly used herb for treating nausea and vomiting during pregnancy?

a. Aloe
b. Ginger
c. Kava
d. Milk thistle

Answer 13

ANS: B

Ginger is commonly used for treating nausea and vomiting during pregnancy.

Question 14

Which of the following is true regarding healing touch?

a. It has strong ties to religious beliefs.
b. It is a physician-based program.
c. It assists the patient to self-heal.
d. The nurse determines its effectiveness.

Answer 14

ANS: C

Healing touch is a nurse-based program that is an organized system designed to assist the patient to self-heal.

Question 15

Which of the following cells function to provide protection from parasitic infections?

a. Monocytes
b. Basophils
c. Eosinophils
d. Neutrophils

Answer 15

ANS: C

Eosinophils function in the allergic response, phagocytosis, and protection from parasitic infections.

Question 16

While obtaining a health history from a patient with numerous petechiae on the skin, the nurse asks the patient specifically about the patient’s use of which of the following drugs?

a. Antiseizure medications
b. Oral contraceptives
c. Aspirin compounds
d. Antihypertensive agents

Answer 16

ANS: C

Salicylates interfere with platelet function and can lead to petechiae and ecchymoses.

Question 17

Which one of the following hematological findings would the nurse question in a 78-year-old patient?

a. White blood cell (WBC) count 3500 cells/microlitre
b. Hematocrit 37%
c. Platelets 450,000 cells/microlitre
d. Hemoglobin 7.3 mmol/L (11.8 g/dL)

Answer 17

ANS: A
The total WBC count is not usually affected by aging, and the low WBC count here would indicate that the patient’s immune function may be compromised.

Question 18

The physician performs a bone marrow aspiration from the posterior iliac crest on a patient with pancytopenia. Following the procedure, what should the nurse do?

a. Apply a topical antimicrobial agent to the site.
b. Administer an analgesic to control pain at the site.
c. Apply pressure over the site for 5 to 10 minutes.
d. Position the patient supine with a small pillow at the aspiration site.

Answer 18

ANS: C
Because the patient has pancytopenia and is at increased risk for bleeding, pressure should be applied for at least 5 to 10 minutes at the site of the aspiration.

Question 19

During physical assessment of a patient, the nurse suspects a chronic, severe iron-deficiency anemia on finding which of the following?

a. Yellowed sclera
b. Shiny, smooth tongue
c. Gum bleeding and tenderness
d. Loss of position and vibratory sensation in the extremities

Answer 19

ANS: B

Loss of the papillae of the tongue occurs with chronic iron deficiency.

Question 20

A patient is found to have leukopenia, anemia, neutropenia, and thrombocytopenia. Which drug classification is known to exhibit these hematological alterations?

a. Isoniazid
b. Aminoglycosides
c. H2-receptor blockers
d. Trimethoprim–sulfamethoxazole (Septra)

Answer 20

ANS: D
Hematological alterations with the use of trimethoprim–sulfamethoxazole include leukopenia, anemia, neutropenia, and thrombocytopenia.

Question 21

The nurse reviews the results of coagulation testing for a patient with a bleeding disorder. Which of the following diagnostic tests is most valuable in evaluating the intrinsic coagulation process?

a. Bleeding time
b. Prothrombin time
c. Fibrin split products
d. Activated partial thromboplastin time (aPTT)

Answer 21

ANS: D

aPTT testing is an assessment of intrinsic coagulation by measuring factors I, II, V, VIII, IX, X, XI, and XII.

Question 22

When evaluating the red blood cell (RBC) indices of a patient, what does the nurse know is indicated by a low mean corpuscular volume (MCV)?

a. RBCs of small size
b. A decrease in RBCs
c. Decreased saturation of RBCs with hemoglobin
d. Decreased weight of the amount of hemoglobin or RBCs

Answer 22

ANS: A

The MCV is low when the RBCs are smaller than normal.

Question 23

While examining the lymph nodes during physical assessment, about which of the following findings would the nurse be most concerned?

a. Firm inguinal nodes in a patient with an infected foot
b. Inability to palpate any superficial lymph nodes
c. 1-cm mobile and nontender axillary node
d. 2-cm nonpainful supraclavicular node

Answer 23

ANS: D

Enlarged and nontender nodes are most suggestive of malignancy, such as lymphoma.

Question 24

Which of the following is a normal age-related change in hematological studies?

a. MCV slightly decreased
b. Hemoglobin slightly increased in men
c. Ferritin level increased
d. Erythrocyte sedimentation rate (ESR) decreased

Answer 24

ANS: C
Ferritin level is increased as a result of normal age-related changes. MCV is slightly increased. Hemoglobin is slightly decreased in men. ESR is increased significantly.

Question 25

How would the nurse document a physical assessment finding of a small group of conditions characterized by ecchymosis on the skin and mucous membranes?

a. Excoriation
b. Angioma
c. Purpura
d. Spider nevus

Answer 25

ANS: C
A physical assessment finding of a small group of conditions characterized by ecchymosis or other small hemorrhages in skin and mucous membranes is purpura.

Question 26

The history and physical examination for a newly admitted patient states that the complete blood count shows a “shift to the left.” What is the priority nursing assessment?

a. Elevated temperature
b. Low oxygen saturation
c. Pallor and weakness
d. Cool extremities

Answer 26

ANS: A
The term shift to the left indicates that the number of immature polymorphonuclear neutrophils, or bands, is elevated and is a sign of severe infection, including an elevated temperature.

Question 27

Approximately what percentage of the composition of blood is plasma?

a. 30%
b. 45%
c. 55%
d. 75%

Answer 27

ANS: C

Approximately 55% of blood is plasma. Blood cells compose about 45% of blood.

Question 28

Which one of the following cells is a WBC?

a. Myeloblast
b. Band cell
c. Basophil
d. Megakaryocyte

Answer 28

ANS: C

WBCs include basophils, eosinophils, neutrophils, monocytes, and lymphocytes.

Question 29

A patient with a history of iron-deficiency anemia who has not taken iron supplements for several years is experiencing increased fatigue and dizziness. What would the nurse expect the patient’s laboratory findings to include?

a. Hematocrit 0.38 (38%)
b. Red blood cell (RBC) count 4,500,000/µL
c. Hemoglobin (Hb) 86 g/L
d. Normal RBC indices

Answer 29

ANS: C

The patient’s clinical manifestations indicate moderate anemia, which is consistent with an Hb of 60 to 100 g/L.

Question 30

When the nurse discusses foods high in iron with a patient who has iron-deficiency anemia, the patient tells the nurse that she prepares low-cholesterol foods for her family and probably does not eat enough meat to meet her iron requirements. It is an appropriate goal for the patient to increase dietary intake of which of the following?

a. Eggs and fish
b. Nuts and cornmeal
c. Milk and milk products
d. Legumes and dried fruit

Answer 30

ANS: D

Legumes and dried fruits are high in iron and low in fat and cholesterol.

Question 31

Which one of the following groups of people is at an increased risk for developing iron-deficiency anemia?

a. Postmenopausal women
b. Middle-class people
c. Pregnant women
d. School-aged males

Answer 31

ANS: C
Those at risk for the development of iron-deficiency anemia are premenopausal and pregnant women, people from low socioeconomic backgrounds, older adults, and individuals experiencing blood loss.

Question 32

A 52-year-old patient has pernicious anemia with long-standing weakness and paraesthesia of the feet and hands. The nurse determines that expected outcomes related to knowledge of the therapeutic regimen have been met when the patient states which of the following?

a. “I will need to have cobalamin (B12) injections regularly for the rest of my life.”
b. “I will increase sources of cobalamin (B12), such as muscle meats and liver, in my diet.”
c. “The feeling in my hands and feet will return when my hemoglobin level returns to normal.”
d. “I should plan for only part-time employment because of the chronic fatigue that pernicious anemia causes.”

Answer 32

ANS: A
Pernicious anemia prevents the absorption of vitamin B12, and the patient requires injections or intranasal administration of cobalamin.

Question 33

A patient with chronic lymphocytic leukemia is hospitalized for treatment of severe hemolytic anemia. What is an appropriate nursing intervention for the patient?

a. Provide a diet high in vitamin K and folic acid.
b. Plan care to alternate periods of rest and activity.
c. Isolate the patient from visitors and other patients.
d. Encourage increased intake of fluid and fibre in the diet.

Answer 33

ANS: B
Nursing care for patients with anemia should alternate periods of rest and activity to maintain patient mobility without causing undue fatigue.

Question 34

After teaching the patient about taking oral iron preparations for a moderate iron-deficiency anemia, which of the following patient statements indicates to the nurse that additional instruction is needed?

a. “I will contact my doctor if my stools start to turn black.”
b. “I will call the doctor if the tablets cause a lot of stomach upset.”
c. “I will increase my fluid intake if the iron tablets make me constipated.”
d. “I should take the iron tablets with orange juice about an hour before meals.”

Answer 34

ANS: A
It is normal for the stools to appear black when a patient is taking iron, and the patient should not call the doctor about this.

Question 35

A 42-year-old patient is admitted to the hospital with idiopathic aplastic anemia. What is an appropriate collaborative problem for the nurse to identify for the patient?

a. Potential complication: seizures
b. Potential complication: hemorrhage
c. Potential complication: neurogenic shock
d. Potential complication: pulmonary edema

Answer 35

ANS: B

Because the patient with aplastic anemia has pancytopenia, the patient is at risk for bleeding and infection.

Question 36

A patient with sickle cell anemia is admitted to the hospital in crisis with severe abdominal pain. While caring for the patient, what is it most important for the nurse to do?

a. Limit the patient’s intake of oral fluids.
b. Evaluate the effectiveness of narcotic analgesics.
c. Encourage the patient to ambulate as much as tolerated.
d. Teach the patient about high-protein, high-calorie foods.

Answer 36

ANS: B
Pain is the most common clinical manifestation of a crisis and usually requires large doses of continuous opioids for control.

Question 37

A 21-year-old patient is having a sickle cell crisis for the first time in many years. He asks the nurse why the sickling causes such pain. The nurse should explain that the pain of sickling is caused by which of the following?

a. Spasms of the blood cells as they change shape
b. Deposition of sickled red cells in the bone marrow
c. Tissue hypoxia caused by small blood vessel occlusion
d. Bacterial or viral infections of organs that caused the sickling

Answer 37

ANS: C
The pain associated with a sickle cell crisis is caused by ischemia, as the sickled cells occlude small blood vessels and capillaries.

Question 38

During discharge teaching for the patient with neutropenia, which of the following issues should the nurse include?

a. Caffeine and alcohol intake
b. Excessive dietary iron intake
c. Limiting fluids to 2 L per day
d. Exposure to crowds

Answer 38

ANS: D
Patients with neutropenia should be instructed to avoid crowds and people who have colds, flu, or infections. If they are in a public area, they should be taught to wear a mask.

Question 39

A patient who has experienced an acute blood loss exhibits a normal supine blood pressure and pulse at rest but complains of postural hypotension and has a pulse of 110 beats/min when exercising. The nurse knows that these signs and symptoms are manifestations of what percentage of blood loss?

a. 10%
b. 20%
c. 30%
d. 40%

Answer 39

ANS: C
A patient who has experienced an acute blood loss and exhibits a normal supine blood pressure and pulse at rest but complains of postural hypotension and has a pulse of 110 beats/min when exercising has lost approximately 30% of their total blood volume.

Question 40

During the admission assessment of a patient who has an Hb of 4.7 mmol/L (7.6 g/dL) and jaundice of the sclera, what laboratory results would the nurse assess?

a. Stool occult blood
b. Bilirubin level
c. Schilling test
d. Gastric analysis testing

Answer 40

ANS: B
Jaundice is caused by the elevation of bilirubin level associated with RBC hemolysis. The presence of jaundice suggests a hemolytic anemia, rather than gastrointestinal bleeding or cobalamin deficiency, as the cause of the anemia.

Question 41

The physician orders transfusion with packed RBCs for a patient who has severe anemia resulting from a bleeding peptic ulcer. What is the most important nursing action to prevent a transfusion reaction when administering the blood?

a. Verify and document patient identification.
b. Keep the blood chilled during administration.
c. Administer the blood at a rate of no more than 2 mL/min.
d. Stay with the patient during the first 15 minutes of the transfusion.

Answer 41

ANS: A

Improper identification is responsible for 90% of hemolytic transfusion reactions.

Question 42

A patient receiving a transfusion of whole blood develops chills and fever, headache, and anxiety 30 minutes after the transfusion is started. Which of the following does the nurse implement after stopping the transfusion?

a. Send a urine specimen to the laboratory.
b. Administer acetaminophen (Tylenol).
c. Give diphenhydramine (Benadryl).
d. Draw blood for a new crossmatch.

Answer 42

ANS: B
The patient’s clinical manifestations are consistent with a febrile, nonhemolytic transfusion reaction. The transfusion should be stopped and antipyretics administered for the fever as ordered.

Question 43

Fifteen minutes after a transfusion of packed RBCs is started, a patient develops tachycardia and tachypnea, and complains of back pain and feeling warm. What is the nurse’s priority action?

a. Discontinue transfusion, and infuse normal saline.
b. Administer oxygen therapy at a high flow rate.
c. Slow the transfusion rate, and reassess the patient in 15 minutes.
d. Stop the blood, and discard the used bag and tubing in a biohazard container.

Answer 43

ANS: A
The first action should be to disconnect the transfusion and infuse normal saline to keep the line open and maintain the patient’s blood pressure. The other actions are also needed but are not the highest priority.

Question 44

A patient who has been receiving a heparin infusion and warfarin (Coumadin) for a deep-vein thrombosis is diagnosed with heparin-induced thrombocytopenia and thrombosis syndrome (HITTS). What does the nurse anticipate that the physician will order?

a. Use saline for flushing intravenous (IV) lines.
b. Give low–molecular weight (LMW) heparin.
c. Discontinue the warfarin.
d. Administer platelet transfusions.

Answer 44

ANS: A
All heparin is discontinued when the HITTS is diagnosed. The patient should be instructed never to receive heparin or LMW heparin; therefore, saline will be ordered for flushing IV

Question 45

During treatment of the patient with an acute exacerbation of polycythemia vera, what is a critical nursing intervention?

a. Administer oxygen.
b. Evaluate fluid balance.
c. Administer anticoagulants.
d. Administer parenteral iron.

Answer 45

ANS: B
Monitoring hydration status is important during an acute exacerbation because the patient is at risk for fluid overload or underhydration.

Question 46

For which one of the following lab results would the nurse expect to see abnormal results in a patient who has hemophilia?

a. Thrombin time
b. Platelet count
c. Prothrombin time
d. Partial thromboplastin time

Answer 46

ANS: D
Partial thromboplastin time is prolonged in patients with hemophilia because of a deficiency in any intrinsic clotting system factor. Prothrombin time, thrombin time, and platelet count are expected to be normal in a patient with hemophilia.

Question 47

Of the following patients waiting to be admitted by the emergency department nurse, which one requires the most rapid assessment and care by the nurse?

a. The patient with a history of sickle cell anemia who has had nausea and diarrhea for 24 hours
b. The patient who has chemotherapy-induced neutropenia and a temperature of 38°C
c. The patient with thrombocytopenia who has oozing after having a tooth extracted
d. The patient with hemophilia A who has ankle swelling after twisting the ankle

Answer 47

ANS: C
A neutropenic patient with a fever is assumed to have an infection and is at risk for rapidly developing sepsis. Rapid assessment, cultures, and initiation of antibiotic therapy are needed.

Question 48

While a patient with severe acquired thrombocytopenia is receiving platelet transfusions, the nurse recognizes that a platelet transfusion reaction may be present when the patient experiences which of the following signs?

a. Flushing, itching, and urticaria
b. Sudden onset of chills and fever
c. Urticaria, wheezing, and hypotension
d. Tachycardia, tachypnea, and hemoglobinuria

Answer 48

ANS: B

Sudden onset of both chills and fever indicates a transfusion reaction.

Question 49

The nurse identifies a nursing diagnosis of risk for injury related to medical interventions for a patient with immune thrombocytopenic purpura. What is an appropriate nursing intervention that addresses the etiology of this nursing diagnosis?

a. Use a soft-bristled toothbrush and cotton swabs for mouth care.
b. Limit the number of venipunctures by using an intermittent-infusion device.
c. Assess the patient during the platelet transfusion for symptoms of transfusion reactions.
d. Assess the patient’s mucous membranes and skin each shift to detect the presence of bleeding.

Answer 49

ANS: B
Limit the number of venipunctures; intramuscular or subcutaneous injections should be avoided because of the risk for bleeding.

Question 50

When preparing a patient for a blood transfusion, the nurse will prepare the blood. Which IV solution would the nurse prepare to administer in a Y-type tubing adjacent to the blood?

a. Dextrose 5%
b. Lactated Ringer’s
c. Normal saline
d. Dextrose 10%

Answer 50

ANS: C
When preparing a patient for a blood transfusion, the nurse will prepare the blood and attach normal saline to Y-type tubing adjacent to the blood for administration.

Question 51

A patient with type A hemophilia has been admitted to the hospital with severe pain and swelling in his right knee. To prevent joint deformity during the initial care of the patient, what should the nurse do?

a. Immobilize the knee.
b. Elevate the right lower limb on pillows.
c. Perform passive range of motion to the knee.
d. Have the patient perform isometric exercises of the affected leg against a footboard.

Answer 51

ANS: A

The initial action should be total rest of the knee to minimize bleeding.

Question 52

Laboratory studies related to coagulation are performed on a patient with a bleeding disorder. The nurse explains to the patient that von Willebrand’s disease can be differentiated from other types of hemophilia by evaluating which of the following laboratory results?

a. Bleeding time
b. Platelet count
c. Prothrombin time
d. Partial thromboplastin time

Answer 52

ANS: A
The bleeding time is affected by von Willebrand’s disease. Platelet count, prothrombin time, and partial thromboplastin time are normal in von Willebrand’s disease.

Question 53

When caring for a patient with hemophilia, the nurse teaches the patient to seek immediate medical attention on experiencing which of the following signs?

a. Fever
b. A sore throat
c. Bleeding gums
d. Dark, tarry stools (melena)

Answer 53

ANS: D

Melena is a sign of gastrointestinal bleeding and requires further assessment.

Question 54

A patient’s family member asks the nurse what caused the patient to develop disseminated intravascular coagulation (DIC). What does the nurse tell the family member about DIC?

a. It is caused by an abnormal activation of clotting.
b. It occurs when the immune system attacks platelets.
c. It is a complication of cancer chemotherapy.
d. It is caused when hemolytic processes destroy erythrocytes.

Answer 54

ANS: A

DIC is an abnormal response of the clotting cascade stimulated by a variety of diseases or disorders.

Question 55

During treatment of the patient who has sepsis-induced DIC with moderate bleeding, on what would the nurse expect the initial collaborative care will focus?

a. Administration of heparin to reduce intravascular clotting
b. Treatment of the infectious process with IV antibiotics
c. Infusion of whole blood to replace clotting factors and RBCs
d. Supportive management of symptoms until the DIC is resolved

Answer 55

ANS: B
Treatment of the acute sepsis is essential to resolving the DIC and will be the major focus of collaborative care. Heparin administration is controversial in DIC, although it may be used if the DIC does not resolve and clotting factors continue to decrease.

Question 56

A patient with myelodysplastic syndrome has laboratory values that indicate total bone marrow suppression. The nurse identifies a nursing diagnosis of risk for infection based on which of the following findings?

a. Basophils 120 cells/mL
b. Monocytes 360 cells/mL
c. Neutrophils 4000 cells/mL
d. White blood cell (WBC) count 2.8 × 109 cells/L (2800 cells/microlitre)

Answer 56

ANS: D
The low WBC count indicates a risk for infection. The nurse should notify the physician and expect an order to check the differential WBC count.

Question 57

What is the most appropriate nursing intervention to assess for the presence of infection in a patient with neutropenia?

a. Monitor WBCs daily.
b. Monitor temperature every 4 hours.
c. Monitor the skin for temperature and diaphoresis.
d. Monitor the mouth and perianal area every shift for signs of redness and swelling.

Answer 57

ANS: B
The earliest sign of infection in a neutropenic patient is an elevation in temperature. Patients with neutropenia (low neutrophil count) are susceptible to infection and may be febrile.

Question 58

A patient receiving chemotherapy for acute lymphocytic leukemia has pancytopenia, and filgrastim (Neupogen) is prescribed. The nurse teaches the patient that the reason for the use of the medication is which of the following?

a. Remission of the leukemia
b. Improvement in the number and function of neutrophils
c. Replacement of abnormal stem cells in the bone marrow with normal cells
d. Prevention of hemorrhage complications in patients with thrombocytopenia

Answer 58

ANS: B

Filgrastim increases the neutrophil count and function in neutropenic patients.

Question 59

A 64-year-old patient with newly diagnosed acute myelogenous leukemia (AML) is undergoing induction therapy with chemotherapeutic agents. He tells the nurse that he is so sick from the induction therapy that he wonders if it is worth it. What is the best response to this patient?

a. “I know you feel really ill right now, but after this therapy, your disease will go into a remission, and you will feel normal again.”
b. “Induction therapy is very aggressive and causes the most side effects, so when this phase is completed, you won’t feel so ill.”
c. “Your type of leukemia has a survival rate of up to 10 years if aggressive therapy is started, so the effects of treatment should be worth it to you.”
d. “I know that this phase is very difficult for you, but the treatment is necessary to achieve control of your disease so that you will have some time to make choices about your life.”

Answer 59

ANS: D

AML is very aggressive, and survival after diagnosis is short without treatment.

Question 60

A patient with chemotherapy-induced neutropenia is placed in a private room, and protective isolation is instituted. The care plan the nurse develops with the patient is based on the knowledge that which of the following sources of infection is the most common in patients with neutropenia?

a. Normally nonpathogenic microorganisms of the patient’s own flora
b. Microorganisms that are not sensitive to broad-spectrum antibiotics
c. Microorganisms transmitted to the patient by the hands of health care providers
d. Microorganisms transmitted to the patient by health care providers with transmissible infections

Answer 60

ANS: A
An important consideration in the care of a neutropenic patient is the determination of the best means to protect the patient whose own defences against infection are compromised. To accomplish this goal, the following principles must be kept in mind: (1) the patient’s normal flora are the most common source of microbial colonization and infection; (2) transmission of organisms from humans most commonly occurs by direct contact with the hands; (3) air, food, water, and equipment provide additional opportunities for infection transmission; and (4) health care providers with transmissible illnesses and other patients with infections can also be sources of infection transmission under certain conditions.

Question 61

A patient with neutropenia has a nursing diagnosis of risk for infection. What is the most important nursing intervention in the prevention of transmission of harmful pathogens to the patient?

a. Prohibiting the oral intake of fresh fruits and vegetables
b. Maintaining strict administration schedules of prophylactic antibiotics
c. Strict and frequent handwashing by all persons having contact with the patient
d. Creating a “sterile” environment for the patient with the use of laminar airflow rooms

Answer 61

ANS: C

Infection control measures such as handwashing are necessary for the patient with neutropenia.

Question 62

A 45-year-old woman with chronic myelogenous leukemia is considering the possibility of treatment with a bone marrow transplant from a human leukocyte antigen–matched sibling. To assist the patient with treatment decisions, what is the best approach for the nurse to use?

a. Emphasize the positive outcomes of a bone marrow transplant.
b. Ensure that the patient understands the risks of treatment-related death or treatment failure.
c. Explain that a cure is not possible with any other type of treatment except a bone marrow transplant.
d. Encourage the patient to ask the physician about new, experimental treatments for leukemia that do not involve total body irradiation.

Answer 62

ANS: B
Offering the patient an opportunity to ask questions or discuss concerns about hematopoietic stem cell transplantation will encourage the patient to voice concerns about this treatment and will also allow the nurse to assess whether the patient needs more information about the procedure.

Question 63

During care of the patient with multiple myeloma, what is an important nursing intervention?

a. Limiting activity to prevent pathological fractures
b. Maintaining a fluid intake of 3 to 4 L/day to dilute calcium load
c. Assessing for changes in size and characteristics of lymph nodes
d. Administering narcotic analgesics continuously to control bone pain

Answer 63

ANS: B
A high fluid intake and urinary output help prevent the complications of kidney stones arising from hypercalcemia and renal failure caused by deposition of Bence-Jones protein in the renal tubules.

Question 64

A patient with non-Hodgkin’s lymphoma develops a platelet count of 10,000 cells/microlitre during chemotherapy. Based on this finding, what is an appropriate nursing intervention for the patient?

a. Provide oral hygiene every 2 hours.
b. Check the temperature every 4 hours.
c. Check all stools for occult blood.
d. Encourage fluids to 3000 mL/day.

Answer 64

ANS: C

Because the patient is at risk for spontaneous bleeding, the nurse should check stools for occult blood.

Question 65

A 26-year-old patient with stage II Hodgkin’s disease asks the nurse how long he probably has to live. What is the best response to the patient?

a. “No one can predict when someone will die, so try to focus on the present.”
b. “It will depend on how your disease responds to chemotherapy, but most patients do well.”
c. “If your initiation chemotherapy is effective, it is possible to have at least a 5-year remission.”
d. “Most patients with your stage of Hodgkin’s disease are treated successfully.”

Answer 65

ANS: D

The survival rate is almost 90% in patients with the early stages of Hodgkin’s lymphoma.

Question 66

Which nutrient plays a role in helping mature RBCs in erythropoiesis?

a. Iron
b. Folic acid
c. Pyridoxine
d. Ascorbic acid

Answer 66

ANS: B

Folic acid’s role in erythropoiesis is to cause RBC maturation.

Question 67

While monitoring a patient’s cardiac activity, the nurse recognizes that stimulation of which of the following is a normal physiological mechanism responsible for an increase in heart rate (HR) and force of cardiac contractions?

a. The vagus nerve
b. Baroreceptors in the aortic arch and carotid sinus
c. α-Adrenergic receptors in the vascular system
d. Chemoreceptors in the aortic arch and carotid body

Answer 67

ANS: D
Chemoreceptors located in the aortic arch and carotid body are capable of initiating changes in HR and arterial pressure in response to decreased arterial O2 pressure, increased arterial carbon dioxide pressure, and decreased plasma pH.

Question 68

While assessing a patient who has just arrived in the emergency department, the nurse notes a pulse deficit. Which of the following does the nurse anticipate that the patient may require?

a. Hourly blood pressure (BP) checks
b. A coronary arteriogram
c. Electrocardiographic (ECG) monitoring
d. A two-dimensional echocardiogram

Answer 68

ANS: C
Pulse deficit is a difference between simultaneously obtained apical and radial pulses and indicates that dysrhythmias might be detected with ECG monitoring.

Question 69

A patient has a BP of 142/84 mm Hg. The nurse will calculate and document the patient’s mean arterial pressure (MAP) as being which following amount?

a. 103 mm Hg
b. 113 mm Hg
c. 123 mm Hg
d. 131 mm Hg

Answer 69

ANS: A

MAP = Diastolic BP + 1/3 Pulse pressure.

Question 70

The nurse is monitoring a patient with possible coronary artery disease who is undergoing exercise (stress) testing on a treadmill. Which symptom has the most immediate implications for the patient’s care during the exercise testing?

a. BP rising from 134/68 to 150/80 mm Hg
b. HR increasing from 80 to 96 beats/min
c. Patient complaining of feeling short of breath
d. ECG indicating the presence of coronary ischemia

Answer 70

ANS: D
ECG changes associated with coronary ischemia (such as T-wave inversions and ST-segment depression) indicate that the myocardium is not getting adequate oxygen delivery and that the exercise test should be terminated immediately.

Question 71

During physical examination of a 56-year-old man, the nurse palpates the point of maximal impulse (PMI) in the sixth intercostal space lateral to the midclavicular line. What is the most appropriate interpretation of this finding?

a. The PMI is in the normal location.
b. The patient may have left ventricular hypertrophy.
c. The patient has age-related downward displacement of the heart.
d. The patient should be observed for signs of left atrial enlargement.

Answer 71

ANS: B
The PMI should be felt at the intersection of the fifth intercostal space and the midclavicular line. A PMI located outside these landmarks indicates possible cardiac enlargement, such as with left ventricular hypertrophy.

Question 72

To auscultate for extra heart sounds in the mitral area, with what part of the stethoscope will the nurse listen?

a. The bell of the stethoscope with the patient in the left lateral position
b. The diaphragm of the stethoscope with the patient in a reclining position
c. The diaphragm of the stethoscope with the patient lying flat on the left side
d. The bell of the stethoscope with the patient sitting and leaning to the right side

Answer 72

ANS: A
Gallop rhythms generate low-pitched sounds and are most easily heard with the bell of the stethoscope. Sounds associated with the mitral valve are accentuated by turning the patient to the left side, which brings the heart closer to the chest wall.

Question 73

The standard orders on the cardiac unit state, “Notify the physician for MAP less than 70 mm Hg.” For which patient would the nurse call the physician?

a. The patient with left ventricular failure who has a BP of 110/70 mm Hg
b. The patient with a myocardial infarction who has a BP of 114/50 mm Hg
c. The postoperative patient with a BP of 116/42 mm Hg
d. The newly admitted patient with a BP of 122/60 mm Hg

Answer 73

ANS: C
The MAP is calculated using the formula MAP = (Diastolic BP + 1/3 Pulse Pressure). The MAP for the postoperative patient in C is 67 mm Hg. The MAP in the other three patients is higher than 70 mm Hg.

Question 74

During physical examination of a 72-year-old patient, the nurse observes pulsation of the abdominal aorta in the epigastric area just below the xiphoid process. How will the nurse interpret this finding?

a. Normal assessment data in a thin person
b. Sclerosis and inelasticity of the aorta
c. A possible abdominal aortic aneurysm
d. Evidence of elevated systemic arterial pressure

Answer 74

ANS: A

Visible pulsation of the abdominal aorta is commonly observed in the epigastric area for thin individuals.

Question 75

A patient is scheduled for cardiac catheterization with coronary angiography. Before the test, about which of the following should the nurse inform the patient?

a. A catheter will be inserted into a vein in the arm or leg and advanced to the heart.
b. ECG monitoring will be required for 24 hours following the test to detect any dysrhythmias.
c. A feeling of warmth and a fluttering sensation may be experienced as the catheter is advanced.
d. Complications of the test include breaking of the catheter, air or blood embolism, and puncture of the ventricles.

Answer 75

ANS: C
A sensation of warmth or flushing is common when the iodine-based contrast material is injected, which can produce anxiety unless it has been discussed with the patient.

Question 76

Which of the following is a normal cardiac index (CI) assessment finding?

a. 2 L/min
b. 3 L/min/m2
c. 6 L/min
d. 8 L/min/m2

Answer 76

ANS: B

The normal range for a CI reading is 2.8 to 4.2 L/min/m2.

Question 77

What should the nurse teach the patient being evaluated for rhythm disturbances with a Holter monitor to do?

a. Remove the electrodes to shower or bathe.
b. Exercise as much as possible while his monitor is in place.
c. Keep a diary of his activities as long as he wears the monitor.
d. Attach the recorder, and call the assigned number if an episode of irregular heartbeats occurs.

Answer 77

ANS: C
The patient is instructed to keep a diary describing daily activities while Holter monitoring is being accomplished to help correlate any rhythm disturbances with patient activities.

Question 78

When auscultating over the patient’s abdominal aorta, the nurse hears a humming sound. How will the nurse document this finding?

a. Bruit
b. Thrill
c. Heave
d. Arterial obstruction

Answer 78

ANS: A

A bruit is the sound created by turbulent blood flow in an artery.

Question 79

The physician orders serum troponin levels in a patient with a possible myocardial infarction. What will the nurse explain to the patient about this test?

a. It is the most specific indicator for myocardial damage available.
b. It measures the amount of myoglobin released from damaged myocardial cells.
c. It can provide evidence of myocardial damage more quickly than can enzyme tests.
d. It is diagnostic for myocardial damage only when used in combination with creatinine kinase-MB isoenzymes.

Answer 79

ANS: C

Cardiac troponins start to elevate 1 hour after myocardial injury and are specific to myocardium.

Question 80

Which of the following is a normal age-related change in the heart?

a. Increased elastin
b. Decreased collagen
c. Decreased cardiac output
d. Increased stroke volume

Answer 80

ANS: C
A normal age-related change in the heart is a decrease in cardiac output. Elastin and stroke volume are decreased, and collagen is increased.

Question 81

The nurse hears a murmur between the S1 and S2 heart sounds at the patient’s left fifth intercostal space and midclavicular line. What is the best way to record this information?

a. “Systolic murmur heard at mitral area.”
b. “Diastolic murmur heard at aortic area.”
c. “Systolic murmur heard at Erb’s point.”
d. “Diastolic murmur heard at tricuspid area.”

Answer 81

ANS: A
The S1 sound is created by closure of the mitral and tricuspid valves and signifies the onset of ventricular systole. S2 is caused by the closure of the aortic and pulmonic valves and signifies the onset of diastole. A murmur occurring between these two sounds is a systolic murmur.

Question 82

What should the nurse expect as a possible etiology in a patient who exhibits a positive Homans sign?

a. Thyrotoxicosis
b. Thrombophlebitis
c. Incompetent valves
d. Intermittent claudication

Answer 82

ANS: B

The nurse should suspect thrombophlebitis in a patient who exhibits a positive Homans sign.

Question 83

Upon auscultation, the nurse identifies an arterial bruit. What is a possible cause?

a. Cardiac dysrhythmias
b. Aneurysm
c. Pericarditis
d. Cardiac valve disorder

Answer 83

ANS: B

An arterial bruit is suggestive of wither an aneurysm or an arterial obstruction.

Question 84

The registered nurse (RN) is observing a student nurse who is doing a physical assessment on a patient. The RN will need to intervene immediately if the student does which of the following?

a. Presses on the skin over the tibia for 10 seconds to check for edema
b. Palpates both carotid arteries simultaneously to compare pulse quality
c. Places the patient in the left lateral position to check for the PMI
d. Uses the palm of the hand to assess extremity skin temperature

Answer 84

ANS: B
The carotid pulses should never be palpated at the same time to avoid vagal stimulation, dysrhythmias, and decreased cerebral blood flow. The other assessment techniques also need to be corrected; however, they are not dangerous to the patient.

Question 85

A patient with syncope is scheduled for Holter monitoring. When teaching the patient about the purpose of the procedure, the nurse explains that Holter monitoring provides information about which of the following?

a. Ventricular ejection fraction during usual daily activities
b. Cardiovascular response to high-intensity exercise
c. Changes in cardiac output when the patient is resting
d. HR and rhythm during normal patient activities

Answer 85

ANS: D
Holter monitoring is used to assess for possible changes in HR or rhythm over a 24- to 48-hour period. The patient is usually instructed to continue with usual daily activities rather than changing exercise or activity level.

Question 86

A transesophageal echocardiogram (TEE) is ordered for a patient with possible endocarditis. Which of these actions included in the standard TEE orders will the nurse need to accomplish first?

a. Make the patient nothing by mouth (NPO) status.
b. Start a large-gauge IV line.
c. Administer O2 per mask.
d. Give lorazepam (Ativan) 1 mg IV.

Answer 86

ANS: A
The patient will need to be NPO status for 6 hours preceding the TEE, so the nurse should place the patient on NPO status as soon as the order is received.

Question 87

Which one of the following central venous pressure (CVP) readings would the nurse report to the physician as being abnormal?

a. 3 mm Hg
b. 6 mm Hg
c. 9 mm Hg
d. 12 mm Hg

Answer 87

ANS: D

The normal CVP reading is 2 to 9 mm Hg.