MIDTERM REVIEW Flashcards
A client who will have his last chemotherapy cycle in 11 days becomes neutropenic. The client understands his condition when he states which of the following? Select all that apply.
a. “I will carry hand sanitizer with me and use it often.”
b. “I need to avoid going to the movies or eating out while receiving my cancer treatment.”
c. “ have this new blender and plan to make fruit or vegetable Shakes for energy.”
d. “ill monitor my temperature frequently and go to the nearest emergency department if my temperature rises above 100.1°F (38 °C).”
a. “I will carry hand sanitizer with me and use it often.”
b. “I need to avoid going to the movies or eating out while receiving my cancer treatment.”
d. ill monitor my temperature frequently and go to the nearest emergency department if my temperature rises above 100.1°F (38 °C).
Which information should be included in the teaching plan for a client with cancer who is experiencing thrombocytopenia? Select all that apply.
a. Use an electric razor
b. Include an over-the-counter nonsteroidal anti-inflammatory (NSAID) daily for pain control
c. Monitor temperature daily
d. Use a soft-bristle toothbrush.
e. Report bleeding, such as nosebleed, petechiae, or melena, to a health care professional (HCP)
f. avoid frequent flossing for oral care
d. Use a soft-bristle toothbrush.
e. Report bleeding, such as nosebleed, petechiae, or melena, to a health care professional (HCP).
f. Avoid frequent flossing for oral care.
The nurse has reinforced a pressure dressing on a client who is post-operative mastectomy and notes there is considerable sanguineous drainage in the hemovac. Which of the following assessments should the nurse report to the physician? Select all that apply.
a. Weak thready pulse at 88 bpm; blood pressure 140/80 mm Hg
b. Fever of 102°F(30°C), no urine output for 2 hours
c. Blood pressure 86/50 mm Hg: pulse weak and thready at 120 bpm
d. Warm, dry skin; radial pulse of 86 bpm
e. Cold, clammy skin blood pressure 120/80 mm Hg
b. Fever of 102°F(30°C), no urine output for 2 hours
c. Blood pressure 86/50 mm Hg: pulse weak and thready at 120 bpm
A client with iron deficiency anemia is having trouble selecting food from the hospital menu. Which foods should the nurse suggest to meet the client’s need for iron? Select all that apply
a. Tea
b. Brown rice
c. Dark green vegetables
d. Eggs
e. oatmeal
b. Brown rice
c. Dark green vegetables
d. Eggs
e. oatmeal
which safety, measures would be most important to implement when caring for a client who is receiving 2 units of packed red blood
a. Verity that the ABO and Rh of the 2 units are the same.
b. Inspect the blood bag for leaks, abnormal color, and clots.
c. Stop the transfusion if a reaction occurs but keep the line open.
d. Take vital signs every 15 minutes while the unit is transfusing.
e. Use a 22-gauge catheter for optimal flow of a blood transfusion
f. Infuse a unit of PRBCs in less than 4 hours.
b. Inspect the blood bag for leaks, abnormal color, and clots.
c. Stop the transfusion if a reaction occurs but keep the line open.
f. Infuse a unit of PRBCs in less than 4 hours.
The nurse is caring for a client newly diagnosed with human immunodeficiency virus (HIV) obtained from unprotected sex. The nurse is in the room when the client is explaining the disease to another person which statement by the client would the nurse clarify? Select all that apply
a. Medications can cure the disease.
b. “My sexual practices will have to change.”
c. The disease can also be spread by body fluids
d. “I am afraid that I will give this disease to my nephew.”
e. I could pass this on to a baby before I give birth
f. “I will have this for the rest of my life.
a. Medications can cure the disease.
d. “I am afraid that I will give this disease to my nephew.”
After undergoing a gastrectomy, a client develops pernicious anemia, which route should the nurse use to administer cyanocobalamin (vitamin B12
a. Parenteral route
b. Oral route
C. Buccal route
d. Transdermal route
a. Parenteral route
Rationale: A client who has undergone gastrectomy is no longer able to produce the intrinsic factor necessary for vitamin B12 absorption through the gastrointestinal tract; therefore, supplementation via parenteral route is required. This medication isn’t available for buccal or transdermal routes.
A client is typed and cross-matched for three units of packed cells. What are important precautions for the nurse to take before initiating the transfusion? Select all that apply.
a. Initiate an IV with normal saline.
b. Initiate an IV with dextrose.
c. Take baseline vital signs.
d. Warm the blood to room temperature,
e. Have two nurses check the blood type and identity
a. Initiate an IV with normal saline.
c. Take baseline vital signs.
e. Have two nurses check the blood type and identity
Rationale
Prior to administering blood, the unit must be checked by two registered nurses. Baseline vital signs are obtained before the transfusion is started so any changes would be identified. Blood is always transfused with normal saline as other IV fluids are incompatible with blood. Warming to room temperature is not necessary
Which is contraindicated for a client diagnosed with disseminated intravascular coagulation (DIC)?
a. Replacing depleted blood products
b. Treating the underlying cause
c. Administering warfarin sodium
d. Administering heparin
c. Administering warfarin sodium
A client is scheduled for a renal arteriogram, No allergies are recorded in the client’s medical record, and the client is unable to provide allergy information. During the arteriogram, the nurse should be alert for which assessment finding that may indicate an allergic reaction to the dye used?
a. Pruritus
b. Hypoventilation
C. Psoriasis
d. Nausea
a. Pruritus
While obtaining a health history, a nurse learns that a client is allergic to bee stings. When obtaining this client’s medication history. the nurse should determine if the client keeps which medication on hand?
a. Pseudoephedrine
b. Guaifenesin c Loperamide
d. Diphenhydramine
d. Diphenhydramine
Which is least likely a danger associated with pancytopenia?
a. Infection
b. Anemia.
c. Hypothyroidism.
d. Bleeding
c. Hypothyroidism.
A client with anemia has been admitted to the medical surgical unit, which assessment findings are characteristic of iron deficiency anemia?
a. Dyspnea, tachycardia, and pallor
b. Nausea, vomiting, and anorexia
C Nights sweats, weight loss, and diarrhea
d. itching, rash, and jaundice
a. Dyspnea, tachycardia, and pallor
The nurse evaluates that the client correctly understands how to report signs and symptoms of bleeding when the client says:
“Abrasions are small pinpoint red dots on the skin.
b. “Purpura is an open cut on the skin.” C “Petechiae are large, red skin bruises.”
d. “Ecchymoses are large, purple skin bruises.”
d. “Ecchymoses are large, purple skin bruises.”
The nurse knows that a specific classification of drugs leads to immunosuppression. What classification of drugs is this?
a. Nonsteroidal anti-inflammatory drugs (NSAIDs; in large doses)
b. Antibiotics in small doses
c. Antineoplastics
d. Antithyroid
c. Antineoplastics
Nursing students have learned that removal of specific organs may place the patient at risk for impaired immune function. The students are taught that it is important while taking the patient’s health history, to ask the patient if he or she had surgical removal of what organ that may lead to impairment of the immune system?
a. Lung
b . Spleen
c. Kidney
d. Pancreas
b . Spleen
Client teaching regarding infection prevention for the client with an immunodeficiency includes which of these guidelines?
a. Limit bathing.
b. People who have been vaccinated recently may visit.
c. Refrain from using creams or emollients on skin.
d. Get regular exercise and rest.
d. Get regular exercise and rest.
The nurse is assessing a 28-year-old man with HIV who has been admitted with pneumonia. In assessing the patient, which of the following observations takes immediate priority?
a. Frequent loose stools
b. Tachypnea and restlessness
c. Weight loss of 1/2 kg since yesterday
d. Oral temperature of 37.8°C
b. Tachypnea and restlessness
Your patient has an HIV infection complicated with severe diarrhea. When caring for this patient what is an appropriate nursing intervention to help alleviate the diarrhea?
a. Encourage the patient to eat three balanced meals and a snack at bedtime
b. Decrease the patient’s fluid intake
c. Encourage the patient to increase his or her activity.
d. Administer an anticholinergic antispasmodic as ordered by the physician.
d. Administer an anticholinergic antispasmodic as ordered by the physician.
The nurse suspects that a client with a GI bleed who is receiving a unit of packed red blood cells may be experiencing an incompatibility reaction. Which of these nursing actions should the nurse prioritize?
a. Assessment and protection of the client’s airway
b. Monitoring the client’s vital signs C Notifying the physician
d. Starting a bolus infusion of normal saline
a. Assessment and protection of the client’s airway
The nursing instructor is talking with the students about the care of a patient with multiple myeloma who is experiencing bone destruction. What would the instructor tell the students the patient should be assessed for signs of?
a. Hyperproteinemia
b. Hypercalcemia
C Elevated serum viscosity
d. Elevated RBC count
b. Hypercalcemia
You are assessing a new patient with complaints of a sore, red and smooth tongue. Based upon your assessment findings, you know that the patient is demonstrating symptoms associated with what?
Hemolytic anemia
b. Megaloblastic anemia
c. Sickle cell anemia
d. Aplastic anemia
b. Megaloblastic anemia
A gardener sustained a deep laceration while working and requires sutures. The patient.is asked about the date of her last tetanus shot which she tells the purse, is over 10 years ago. Based on this information the patient will receive a tetanus immunization. The tetanus injection will allow for the release of what?
a. A bacteria
b. An antigen
c. A virus.
d. An antibody
d. An antibody
You are admitting an oncology patient to your unit prior to surgery. The patient has just finished radiation therapy. What does this put your patient at increased risk for?
a. Nutritional deficit
b. Tumour lysis syndrome
c. Cardiac tamponade
d. Impaired wound healing
d. Impaired wound healing