MS Midterm Flashcards
- The nurse is caring for a patient with a massive burn injury and possible hypovolemia. Which assessment data will be of most concern to the nurse?
a. Urine output is 30 mL/hr.
b. Blood pressure is 90/40 mm Hg.
c. Oral fluid intake is 100 mL for the past 8 hours.
d. There is prolonged skin tenting over the sternum.
ANS: B
The blood pressure indicates that the patient may be developing hypovolemic shock as a result of intravascular fluid loss because of the burn injury. This finding will require immediate intervention to prevent the complications associated with systemic hypoperfusion. The poor oral intake, decreased urine output, and skin tenting all indicate the need for increasing the patient’s fluid intake but not as urgently as the hypotension.
A patient who has a small cell carcinoma of the lung develops syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should notify the health care provider about which assessment finding?
a. Serum hematocrit of 42%
b. Serum sodium level of 120 mg/dL
c. Reported weight gain of 2.2 lb (1 kg)
d. Urinary output of 280 mL during past 8 hours
ANS: B
Hyponatremia is the most important finding to report. SIADH causes water retention and a decrease in serum sodium level. Hyponatremia can cause confusion and other central nervous system effects. A critically low value likely needs to be treated. At least 30 mL/hr of urine output indicates adequate kidney function. The hematocrit level is normal. Weight gain is expected with SIADH because of water retention.
A patient with multiple draining wounds is admitted for hypovolemia. Which assessment would be the most accurate way for the nurse to evaluate fluid balance?
a. Skin turgor c. Urine output
b. Daily weight d. Edema presence
ANS: B
Daily weight is the most easily obtained and accurate means of assessing volume status. Skin turgor varies considerably with age. Considerable excess fluid volume may be present before fluid moves into the interstitial space and causes edema. Urine outputs do not take account of fluid intake or of fluid loss through insensible loss, sweating, or loss from the gastrointestinal tract or wounds.
The home health nurse cares for an alert and oriented older adult patient with a history of dehydration. Which instructions should the nurse give this patient related to fluid intake?
a. “Drink more fluids in the late evening.”
b. “Increase fluids if your mouth feels dry.”
c. “More fluids are needed if you feel thirsty.”
d. “If you feel confused, you need more to drink.”
ANS: B
An alert older patient will be able to self-assess for signs of oral dryness such as thick oral secretions or dry-appearing mucosa. The thirst mechanism decreases with age and is not an accurate indicator of volume depletion. Many older patients prefer to restrict fluids slightly in the evening to improve sleep quality. The patient will not be likely to notice and act appropriately when changes in level of consciousness occur.
A patient who is taking a potassium-wasting diuretic for treatment of hypertension complains of generalized weakness. Which action is appropriate for the nurse to take?
a. Assess for facial muscle spasms.
b. Ask the patient about loose stools.
c. Recommend the patient avoid drinking orange juice with meals.
d. Suggest that the health care provider order a basic metabolic panel.
ANS: D
Generalized weakness is a manifestation of hypokalemia. After the health care provider orders the metabolic panel, the nurse should check the potassium level. Facial muscle spasms might occur with hypocalcemia. Orange juice is high in potassium and would be advisable to drink if the patient is hypokalemic. Loose stools are associated with hyperkalemia.
Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a patient. Which statement by the patient indicates that the teaching about this medication has been effective?
a. “I will try to drink at least 8 glasses of water every day.”
b. “I will use a salt substitute to decrease my sodium intake.”
c. “I will increase my intake of potassium-containing foods.”
d. “I will drink apple juice instead of orange juice for breakfast.”
ANS: D
Because spironolactone is a potassium-sparing diuretic, patients should be taught to choose low-potassium foods (e.g., apple juice) rather than foods that have higher levels of potassium (e.g., citrus fruits). Because the patient is using spironolactone as a diuretic, the nurse would not encourage the patient to increase fluid intake. Teach patients to avoid salt substitutes, which are high in potassium.
A patient with new-onset confusion and hyponatremia is being admitted. When making room assignments, the charge nurse should take which action?
a. Assign the patient to a semi-private room.
b. Assign the patient to a room near the nurse’s station.
c. Place the patient in a room nearest to the water fountain.
d. Place the patient on telemetry to monitor for peaked T waves..
ANS: B
The patient should be placed near the nurse’s station if confused for the staff to closely monitor the patient. To help improve serum sodium levels, water intake is restricted. Therefore a confused patient should not be placed near a water fountain. Peaked T waves are a sign of hyperkalemia, not hyponatremia. A confused patient could be distracting and disruptive for another patient in a semiprivate room.
IV potassium chloride (KCl) 60 mEq is prescribed for treatment of a patient with severe hypokalemia. Which action should the nurse take?
a. Administer the KCl as a rapid IV bolus.
b. Infuse the KCl at a rate of 10 mEq/hour.
c. Only give the KCl through a central venous line.
d. Discontinue cardiac monitoring during the infusion.
ANS: B
IV KCl is administered at a maximal rate of 10 mEq/hr. Rapid IV infusion of KCl can cause cardiac arrest. KCl can cause inflammation of peripheral veins, but it can be administered by this route. Cardiac monitoring should be continued while patient is receiving potassium because of the risk for dysrhythmias.
A postoperative patient who had surgery for a perforated gastric ulcer has been receiving nasogastric suction for 3 days. The patient now has a serum sodium level of 127 mEq/L (127 mmol/L). Which prescribed therapy should the nurse question?
a. Infuse 5% dextrose in water at 125 mL/hr.
b. Administer 3% saline at 50 mL/hr for a total of 200 mL.
c. Administer IV morphine sulfate 4 mg every 2 hours PRN.
d. Give IV metoclopramide (Reglan) 10 mg every 6 hours PRN for nausea.
ANS: A
Because the patient’s gastric suction has been depleting electrolytes, the IV solution should include electrolyte replacement. Solutions such as lactated Ringer’s solution would usually be ordered for this patient. The other orders are appropriate for a postoperative patient with gastric suction.
A patient who was involved in a motor vehicle crash has had a tracheostomy placed to allow for continued mechanical ventilation. How should the nurse interpret the following arterial blood gas results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mEq/L?
a. Metabolic acidosis c. Respiratory acidosis
b. Metabolic alkalosis d. Respiratory alkalosis
ANS: D
The pH indicates that the patient has alkalosis and the low PaCO2 indicates a respiratory cause. The other responses are incorrect based on the pH and the normal HCO3.
The nurse notes that a patient who was admitted with diabetic ketoacidosis has rapid, deep respirations. Which action should the nurse take?
a. Give the prescribed PRN lorazepam (Ativan).
b. Encourage the patient to take deep slow breaths.
c. Start the prescribed PRN oxygen at 2 to 4 L/min.
d. Administer the prescribed normal saline bolus and insulin.
ANS: D
The rapid, deep (Kussmaul) respirations indicate a metabolic acidosis and the need for correction of the acidosis with a saline bolus to prevent hypovolemia followed by insulin administration to allow glucose to reenter the cells. Oxygen therapy is not indicated because there is no indication that the increased respiratory rate is related to hypoxemia. The respiratory pattern is compensatory, and the patient will not be able to slow the respiratory rate. Lorazepam administration will slow the respiratory rate and increase the level of acidosis.
An older adult patient who is malnourished presents to the emergency department with a serum protein level of 5.2 g/dL. The nurse would expect which clinical manifestation?
a. Pallor c. Confusion
b. Edema d. Restlessness
ANS: B
The normal range for total protein is 6.4 to 8.3 g/dL. Low serum protein levels cause a decrease in plasma oncotic pressure and allow fluid to remain in interstitial tissues, causing edema. Confusion, restlessness, and pallor are not associated with low serum protein levels.
A patient receives 3% NaCl solution for correction of hyponatremia. Which assessment is most important for the nurse to monitor for while the patient is receiving this infusion?
a. Lung sounds c. Peripheral pulses
b. Urinary output d. Peripheral edema
ANS: A
Hypertonic solutions cause water retention, so the patient should be monitored for symptoms of fluid excess. Crackles in the lungs may indicate the onset of pulmonary edema and are a serious manifestation of fluid excess. Peripheral pulses, peripheral edema, or changes in urine output are also important to monitor when administering hypertonic solutions, but they do not indicate acute respiratory or cardiac decompensation.
The long-term care nurse is evaluating the effectiveness of protein supplements for an older resident who has a low serum total protein level. Which assessment finding indicates that the patient’s condition has improved?
a. Hematocrit 28% c. Decreased peripheral edema
b. Absence of skin tenting d. Blood pressure 110/72 mm Hg
ANS: C
Edema is caused by low oncotic pressure in individuals with low serum protein levels. The decrease in edema indicates an improvement in the patient’s protein status. Good skin turgor is an indicator of fluid balance, not protein status. A low hematocrit could be caused by poor protein intake. Blood pressure does not provide a useful clinical tool for monitoring protein status.
A patient who is lethargic and exhibits deep, rapid respirations has the following arterial blood gas (ABG) results: pH 7.32, PaO2 88 mm Hg, PaCO2 37 mm Hg, and HCO3 16 mEq/L. How should the nurse interpret these results?
a. Metabolic acidosis c. Respiratory acidosis
b. Metabolic alkalosis d. Respiratory alkalosis
ANS: A
The pH and HCO3 indicate that the patient has a metabolic acidosis. The ABGs are inconsistent with the other responses.
A patient who has been receiving diuretic therapy is admitted to the emergency department with a serum potassium level of 3.0 mEq/L. The nurse should alert the health care provider immediately that the patient is on which medication?
a. Digoxin (Lanoxin) 0.25 mg/day
b. Metoprolol (Lopressor) 12.5 mg/day
c. Ibuprofen (Motrin) 400 mg every 6 hours
d. Lantus insulin 24 U subcutaneously every evening
ANS: A
Hypokalemia increases the risk for digoxin toxicity, which can cause serious dysrhythmias. The nurse will also need to do more assessment regarding the other medications, but they are not of as much concern with the potassium level.
The nurse is caring for a patient who has a calcium level of 12.1 mg/dL. Which nursing action should the nurse include on the care plan?
a. Maintain the patient on bed rest.
b. Auscultate lung sounds every 4 hours.
c. Monitor for Trousseau’s and Chvostek’s signs.
d. Encourage fluid intake up to 4000 mL every day.
ANS: D
To decrease the risk for renal calculi, the patient should have a fluid intake of 3000 to 4000 mL daily. Ambulation helps decrease the loss of calcium from bone and is encouraged in patients with hypercalcemia. Trousseau’s and Chvostek’s signs are monitored when there is a possibility of hypocalcemia. There is no indication that the patient needs frequent assessment of lung sounds, although these would be assessed every shift.
When caring for a patient with renal failure on a low phosphate diet, the nurse will inform unlicensed assistive personnel (UAP) to remove which food from the patient’s food tray?
a. Skim milk c. Mixed green salad
b. Grape juice d. Fried chicken breast
ANS: A
Foods high in phosphate include milk and other dairy products, so these are restricted on low-phosphate diets. Green, leafy vegetables; high-fat foods; and fruits and juices are not high in phosphate and are not restricted.
A patient has a magnesium level of 1.3 mg/dL. Which assessment would help the nurse identify a likely cause of this value?
a. Daily alcohol intake
b. Dietary protein intake
c. Multivitamin/mineral use
d. Over-the-counter (OTC) laxative use
ANS: A
Hypomagnesemia is associated with alcoholism. Protein intake would not have a significant effect on magnesium level. OTC laxatives (such as milk of magnesia) and use of multivitamin/mineral supplements tend to increase magnesium levels.
A patient has a parenteral nutrition infusion of 25% dextrose. A student nurse asks the nurse why a peripherally inserted central catheter was inserted. Which response by the nurse is accurate?
a. “The prescribed infusion can be given more rapidly when the patient has a central line.”
b. “The hypertonic solution will be more rapidly diluted when given through a central line.”
c. “There is a decreased risk for infection when 25% dextrose is infused through a central line.”
d. “The required blood glucose monitoring is based on samples obtained from a central line.”
ANS: B
The 25% dextrose solution is hypertonic. Shrinkage of red blood cells can occur when solutions with dextrose concentrations greater than 10% are administered IV. Blood glucose testing is not more accurate when samples are obtained from a central line. The infection risk is higher with a central catheter than with peripheral IV lines. Hypertonic or concentrated IV solutions are not given rapidly.
The nurse is caring for a patient who has a central venous access device (CVAD). Which action by the nurse is appropriate?
a. Avoid using friction when cleaning around the CVAD insertion site.
b. Use the push-pause method to flush the CVAD after giving medications.
c. Obtain an order from the health care provider to change CVAD dressing.
d. Position the patient’s face toward the CVAD during injection cap changes.
ANS: B
The push-pause enhances the removal of debris from the CVAD lumen and decreases the risk for clotting. To decrease infection risk, friction should be used when cleaning the CVAD insertion site. The dressing should be changed whenever it becomes damp, loose, or visibly soiled. A provider’s order is not necessary. The patient should turn away from the CVAD during cap changes.
An older patient receiving iso-osmolar continuous tube feedings develops restlessness, agitation, and weakness. Which laboratory result should the nurse report to the health care provider immediately?
a. K+ 3.4 mEq/L (3.4 mmol/L) c. Na+ 154 mEq/L (154 mmol/L)
b. Ca+2 7.8 mg/dL (1.95 mmol/L) d. PO4-3 4.8 mg/dL (1.55 mmol/L)
ANS: C
The elevated serum sodium level is consistent with the patient’s neurologic symptoms and indicates a need for immediate action to prevent further serious complications such as seizures. The potassium, phosphate, and calcium levels vary slightly from normal but do not require immediate action by the nurse.
The nurse assesses a patient who has been hospitalized for 2 days. The patient has been receiving normal saline IV at 100 mL/hr, has a nasogastric tube to low suction, and is NPO. Which assessment finding would be a priority for the nurse to report to the health care provider?
a. Oral temperature of 100.1°F
b. Serum sodium level of 138 mEq/L (138 mmol/L)
c. Gradually decreasing level of consciousness (LOC)
d. Weight gain of 2 pounds (1 kg) over the admission weight
ANS: C
The patient’s history and change in LOC could be indicative of fluid and electrolyte disturbances: extracellular fluid (ECF) excess, ECF deficit, hyponatremia, hypernatremia, hypokalemia, or metabolic alkalosis. Further diagnostic information is needed to determine the cause of the change in LOC and the appropriate interventions. The weight gain, elevated temperature, crackles, and serum sodium level also will be reported but do not indicate a need for rapid action to avoid complications.
A nurse is assessing a newly admitted patient with chronic heart failure who forgot to take prescribed medications and seems confused. The patient has peripheral edema and shortness of breath. Which assessment should the nurse complete first?
a. Skin turgor c. Mental status
b. Heart sounds d. Capillary refill
ANS: C
Increases in extracellular fluid (ECF) can lead to swelling of cells in the central nervous system, initially causing confusion, which may progress to coma or seizures. Although skin turgor, capillary refill, and heart sounds may also be affected by increases in ECF, these are signs that do not have as immediate impact on patient outcomes as cerebral edema.
A patient with renal failure who arrives for outpatient hemodialysis is unresponsive to questions and has decreased deep tendon reflexes. Family members report that the patient has been taking aluminum hydroxide/magnesium hydroxide suspension (Maalox) at home for indigestion. Which action should the nurse take first?
a. Notify the patient’s health care provider.
b. Obtain an order to draw a potassium level.
c. Review the last magnesium level on the patient’s chart.
d. Teach the patient about magnesium-containing antacids.
ANS: A
The health care provider should be notified immediately. The patient has a history and manifestations consistent with hypermagnesemia. The nurse should check the chart for a recent serum magnesium level and make sure that blood is sent to the laboratory for immediate electrolyte and chemistry determinations. Dialysis should correct the high magnesium levels. The patient needs teaching about the risks of taking magnesium-containing antacids. Monitoring of potassium levels also is important for patients with renal failure, but the patient’s current symptoms are not consistent with hyperkalemia.
A patient who had a transverse colectomy for diverticulosis 18 hours ago has nasogastric suction. The patient complains of anxiety and incisional pain. The patient’s respiratory rate is 32 breaths/min, and the arterial blood gases (ABGs) indicate respiratory alkalosis. Which action should the nurse take first?
a. Check to make sure the nasogastric tube is patent.
b. Give the patient the PRN IV morphine sulfate 4 mg.
c. Notify the health care provider about the ABG results.
d. Teach the patient how to take slow, deep breaths when anxious.
ANS: B
The patient’s respiratory alkalosis is caused by the increased respiratory rate associated with pain and anxiety. The nurse’s first action should be to medicate the patient for pain. The health care provider may be notified about the ABGs but is likely to instruct the nurse to medicate for pain. The patient will not be able to take slow, deep breaths when experiencing pain. Checking the nasogastric tube can wait until the patient has been medicated for pain.
Which action can the registered nurse (RN) who is caring for a critically ill patient with multiple IV lines and medications delegate to a licensed practical/vocational nurse (LPN/LVN)?
a. Flush a saline lock with normal saline.
b. Verify blood products prior to administration.
c. Remove the patient’s central venous catheter.
d. Titrate the flow rate of vasoactive IV medications.
ANS: A
A LPN/LVN has the education, experience, and scope of practice to flush a saline lock with normal saline. Administration of blood products, adjustment of vasoactive infusion rates, and removal of central catheters in critically ill patients require RN level education and scope of practice.
A patient has a serum calcium level of 7.0 mEq/L. Which assessment finding is most important for the nurse to report to the health care provider?
a. The patient is experiencing laryngeal stridor.
b. The patient complains of generalized fatigue.
c. The patient’s bowels have not moved for 4 days.
d. The patient has numbness and tingling of the lips.
ANS: A
Hypocalcemia can cause laryngeal stridor, which may lead to respiratory arrest. Rapid action is required to correct the patient’s calcium level. The other data are also consistent with hypocalcemia, but do not indicate a need for as immediate action as laryngospasm.
Following a thyroidectomy, a patient complains of “a tingling feeling around my mouth.” Which assessment should the nurse complete?
a. Presence of the Chvostek’s sign
b. Abnormal serum potassium level
c. Decreased thyroid hormone level
d. Bleeding on the patient’s dressing
ANS: A
The patient’s symptoms indicate possible hypocalcemia, which can occur secondary to parathyroid injury or removal during thyroidectomy. There is no indication of a need to check the potassium level, the thyroid hormone level, or for bleeding.
A patient is admitted to the emergency department with severe fatigue and confusion. Laboratory studies are done. Which laboratory value will require the most immediate action by the nurse?
a. Arterial blood pH is 7.32.
b. Serum calcium is 18 mg/dL.
c. Serum potassium is 5.1 mEq/L.
d. Arterial oxygen saturation is 91%.
ANS: B
The serum calcium is well above the normal level and puts the patient at risk for cardiac dysrhythmias. The nurse should initiate cardiac monitoring and notify the health care provider. The potassium, oxygen saturation, and pH are also abnormal, and the nurse should notify the health care provider about these values as well, but they are not immediately life threatening.
When assessing a pregnant patient with eclampsia who is receiving IV magnesium sulfate, which finding should the nurse report to the health care provider immediately?
a. The bibasilar breath sounds are decreased.
b. The patellar and triceps reflexes are absent.
c. The patient has been sleeping most of the day.
d. The patient reports feeling “sick to my stomach.”
ANS: B
The loss of the deep tendon reflexes indicates that the patient’s magnesium level may be reaching toxic levels. Nausea and lethargy are also side effects associated with magnesium elevation and should be reported, but they are not as significant as the loss of deep tendon reflexes. The decreased breath sounds suggest that the patient needs to cough and deep breathe to prevent atelectasis.
A patient is receiving a 3% saline continuous IV infusion for hyponatremia. Which assessment data will require the most rapid response by the nurse?
a. The patient’s radial pulse is 105 beats/min.
b. There are crackles throughout both lung fields.
c. There is sediment and blood in the patient’s urine.
d. The blood pressure increases from 120/80 to 142/94 mm Hg.
ANS: B
Crackles throughout both lungs suggest that the patient may be experiencing pulmonary edema, a life-threatening adverse effect of hypertonic solutions. The increased pulse rate and blood pressure and the appearance of the urine should also be reported, but they are not as dangerous as the presence of fluid in the alveoli.
The nurse notes a serum calcium level of 7.9 mg/dL for a patient who has chronic malnutrition. Which action should the nurse take next?
a. Monitor ionized calcium level.
b. Give oral calcium citrate tablets.
c. Check parathyroid hormone level.
d. Administer vitamin D supplements.
ANS: A
This patient with chronic malnutrition is likely to have a low serum albumin level, which will affect the total serum calcium. A more accurate reflection of calcium balance is the ionized calcium level. Most of the calcium in the blood is bound to protein (primarily albumin). Alterations in serum albumin levels affect the interpretation of total calcium levels. Low albumin levels result in a drop in the total calcium level, although the level of ionized calcium is not affected. The other actions may be needed if the ionized calcium is also decreased.
A patient comes to the clinic complaining of frequent, watery stools for the past 2 days. Which action should the nurse take first?
a. Obtain the baseline weight.
b. Check the patient’s blood pressure.
c. Draw blood for serum electrolyte levels.
d. Ask about extremity numbness or tingling.
ANS: B
Because the patient’s history suggests that fluid volume deficit may be a problem, assessment for adequate circulation is the highest priority. The other actions are also appropriate, but are not as essential as determining the patient’s perfusion status.
Which action should the nurse take first when a patient complains of acute chest pain and dyspnea soon after insertion of a centrally inserted IV catheter?
a. Notify the health care provider.
b. Offer reassurance to the patient.
c. Auscultate the patient’s breath sounds.
d. Give prescribed PRN morphine sulfate IV.
ANS: C
The initial action should be to assess the patient further because the history and symptoms are consistent with several possible complications of central line insertion, including embolism and pneumothorax. The other actions may be appropriate, but further assessment of the patient is needed before notifying the health care provider, offering reassurance, or administration of morphine.
After receiving change-of-shift report, which patient should the nurse assess first?
a. Patient with serum potassium level of 5.0 mEq/L who is complaining of abdominal cramping
b. Patient with serum sodium level of 145 mEq/L who has a dry mouth and is asking for a glass of water
c. Patient with serum magnesium level of 1.1 mEq/L who has tremors and hyperactive deep tendon reflexes
d. Patient with serum phosphorus level of 4.5 mg/dL who has multiple soft tissue calcium-phosphate precipitates
ANS: C
The low magnesium level and neuromuscular irritability suggest that the patient may be at risk for seizures. The other patients have mild electrolyte disturbances or symptoms that require action, but they are not at risk for life-threatening complications.
During the admission process, the nurse obtains information about a patient through a physical assessment and diagnostic testing. Based on the data shown in the accompanying figure, which nursing diagnosis is appropriate?
a. Deficient fluid volume c. Risk for injury: seizures
b. Impaired gas exchange d. Risk for impaired skin integrity
ANS: C
The patient’s muscle cramps and low serum calcium level indicate that the patient is at risk for seizures, tetany, or both. The other diagnoses are not supported by the data because the skin turgor is good. The lungs are clear, arterial blood gases are normal, and there is no evidence of edema or dehydration that might suggest that the patient is at risk for impaired skin integrity.
The nurse is caring for a patient who is being discharged after an emergency splenectomy following a motor vehicle crash. Which instructions should the nurse include in the discharge teaching?
a. Check often for swollen lymph nodes.
b. Watch for excess bleeding or bruising.
c. Take iron supplements to prevent anemia.
d. Wash hands and avoid persons who are ill.
ANS: D
Splenectomy increases the risk for infection, especially with gram-positive bacteria. The risks for lymphedema, bleeding, and anemia are not increased after a person has a splenectomy.
The nurse assesses a patient who has numerous petechiae on both arms. Which question should the nurse ask the patient?
a. “Are you taking any oral contraceptives?”
b. “Have you been prescribed antiseizure drugs?”
c. “Do you take medication containing salicylates?”
d. “How long have you taken antihypertensive drugs?”
ANS: C
Salicylates interfere with platelet function and can lead to petechiae and ecchymoses. Antiseizure drugs may cause anemia but not clotting disorders or bleeding. Oral contraceptives increase a person’s clotting risk. Antihypertensives do not usually cause problems with decreased clotting.
A nurse reviews the laboratory data for an older patient. The nurse would be most concerned about which finding?
a. Hematocrit of 35%
b. Hemoglobin of 11.8 g/dL
c. Platelet count of 400,000/µL
d. White blood cell (WBC) count of 2800/µL
ANS: D
Because the total WBC count is not usually affected by aging, the low WBC count in this patient would indicate that the patient’s immune function may be compromised and the underlying cause of the problem needs to be investigated. The platelet count is normal. The slight decrease in hemoglobin and hematocrit are not unusual for an older patient.
A patient with pancytopenia has a bone marrow aspiration from the left posterior iliac crest. Which action would be important for the nurse to take after the procedure?
a. Elevate the head of the bed to 45 degrees.
b. Have the patient lie on the left side for 1 hour.
c. Apply a sterile 2-inch gauze dressing to the site.
d. Use a half-inch sterile gauze to pack the wound.
ANS: B
To decrease the risk for bleeding, the patient should lie on the left side for 30 to 60 minutes. After a bone marrow biopsy, the wound is small and will not be packed with gauze. A pressure dressing is used to cover the aspiration site. There is no indication to elevate the patient’s head.
The nurse assesses a patient with pernicious anemia. Which assessment finding would the nurse expect?
a. Yellow-tinged sclerae c. Numbness of the extremities
b. Shiny, smooth tongue d. Gum bleeding and tenderness
ANS: C
Extremity numbness is associated with cobalamin (vitamin B12) deficiency or pernicious anemia. Loss of the papillae of the tongue occurs with chronic iron deficiency. Yellow-tinged sclera is associated with hemolytic anemia and the resulting jaundice. Gum bleeding and tenderness occur with thrombocytopenia or neutropenia.
A patient’s complete blood count (CBC) shows a hemoglobin of 19 g/dL and a hematocrit of 54%. Which question should the nurse ask to determine possible causes of this finding?
a. “Have you had a recent weight loss?”
b. “Do you have any history of lung disease?”
c. “Have you noticed any dark or bloody stools?”
d. “What is your dietary intake of meats and protein?”
ANS: B
The hemoglobin and hematocrit results indicate polycythemia, which can be associated with chronic obstructive pulmonary disease. The other questions would be appropriate for patients who are anemic.
The nurse is reviewing laboratory results and notes a patient’s activated partial thromboplastin time (aPTT) level of 28 seconds. The nurse should notify the health care provider in anticipation of adjusting which medication?
a. Aspirin c. Warfarin
b. Heparin d. Erythropoietin
ANS: B
aPTT assesses intrinsic coagulation by measuring factors I, II, V, VIII, IX, X, XI, XII. aPTT is increased (prolonged) in heparin administration. aPTT is used to monitor whether heparin is at a therapeutic level (needs to be greater than the normal range of 25 to 35 sec). Prothrombin time (PT) and international normalized ratio (INR) are most commonly used to test for therapeutic levels of warfarin (Coumadin). Aspirin affects platelet function. Erythropoietin is used to stimulate red blood cell production.
The nurse notes pallor of the skin and nail beds in a newly admitted patient. The nurse should ensure that which laboratory test has been ordered?
a. Platelet count c. Hemoglobin level
b. Neutrophil count d. White blood cell count
ANS: C
Pallor of the skin or nail beds is indicative of anemia, which would be indicated by a low Hgb level. Platelet counts indicate a person’s clotting ability. A neutrophil is a type of white blood cell that helps to fight infection.
The nurse examines the lymph nodes of a patient during a physical assessment. Which assessment finding would be of most concern to the nurse?
a. A 2-cm nontender supraclavicular node
b. A 1-cm mobile and nontender axillary node
c. An inability to palpate any superficial lymph nodes
d. Firm inguinal nodes in a patient with an infected foot
ANS: A
Enlarged and nontender nodes are suggestive of malignancies such as lymphoma. Firm nodes are an expected finding in an area of infection. The superficial lymph nodes are usually not palpable in adults, but if they are palpable, they are normally 0.5 to 1 cm and nontender.
A patient who had a total hip replacement had an intraoperative hemorrhage 14 hours ago. Which laboratory test result would the nurse expect?
a. Hematocrit of 46%
b. Hemoglobin of 13.8 g/dL
c. Elevated reticulocyte count
d. Decreased white blood cell (WBC) count
ANS: C
Hemorrhage causes the release of reticulocytes (immature red blood cells) from the bone marrow into circulation. The hematocrit and hemoglobin levels are normal. The WBC count is not affected by bleeding.
The complete blood count (CBC) indicates that a patient is thrombocytopenic. Which action should the nurse include in the plan of care?
a. Avoid intramuscular injections. c. Check temperature every 4 hours.
b. Encourage increased oral fluids. d. Increase intake of iron-rich foods.
ANS: A
Thrombocytopenia is a decreased number of platelets, which places the patient at high risk for bleeding. Neutropenic patients are at high risk for infection and sepsis and should be monitored frequently for signs of infection. Encouraging fluid intake and iron-rich food intake is not indicated in a patient with thrombocytopenia.
The health care provider’s progress note for a patient states that the complete blood count (CBC) shows a “shift to the left.” Which assessment finding will the nurse expect?
a. Cool extremities c. Elevated temperature
b. Pallor and weakness d. Low oxygen saturation
ANS: C
The term “shift to the left” indicates that the number of immature polymorphonuclear neutrophils (bands) is elevated and that finding is a sign of infection. There is no indication that the patient is at risk for hypoxemia, pallor or weakness, or cool extremities
The health care provider orders a liver and spleen scan for a patient who has been in a motor vehicle crash. Which action should the nurse take before this procedure?
a. Check for any iodine allergy. c. Administer prescribed sedatives.
b. Insert a large-bore IV catheter. d. Assist the patient to a flat position.
ANS: D
During a liver and spleen scan, a radioactive isotope is injected IV, and images from the radioactive emission are used to evaluate the structure of the spleen and liver. An indwelling IV catheter and sedation are not needed. The patient is placed in a flat position before the scan.
A patient with pancytopenia of unknown origin is scheduled for the following diagnostic tests. The nurse will provide a consent form to sign for which test?
a. Bone marrow biopsy
b. Abdominal ultrasound
c. Complete blood count (CBC)
d. Activated partial thromboplastin time (aPTT)
ANS: A
A bone marrow biopsy is a minor surgical procedure that requires the patient or guardian to sign a surgical consent form. The other procedures do not require a signed consent.
The nurse reviews the laboratory test results of a patient admitted with abdominal pain. Which information will be most important for the nurse to communicate to the health care provider?
a. Monocytes 4%
b. Hemoglobin 13.6 g/dL
c. Platelet count 168,000/µL
d. White blood cell (WBC) count 15,500/µL
ANS: D
The elevation in WBCs indicates that the patient has an inflammatory or infectious process ongoing, which may be the cause of the patient’s pain, and that further diagnostic testing is needed. The monocytes are at a normal level. The hemoglobin and platelet counts are normal.
Which information shown in the table below about a patient who has just arrived in the emergency department is most urgent for the nurse to communicate to the health care provider?
Assessment Complete Blood Count Patient History
• BP 110/68
• Pulse 98 beats/min
• Brisk capillary refill
• Multiple ecchymoses on arms • Hgb 10.6 g/dL
• Hct 30%
• WBC 5100/µL
• Platelets 19,500/µL • Occasional aspirin use
• Abdominal pain x 1 week
• Large, dark stool this morning
a. Heart rate c. Abdominal pain
b. Platelet count d. White blood cell count
ANS: B
The platelet count is severely decreased and places the patient at risk for spontaneous bleeding. The other information is also pertinent but not as indicative of the need for rapid treatment as the platelet count.
A 62-year old man with chronic anemia is experiencing increased fatigue and occasional palpitations at rest. The nurse would expect the patient’s laboratory test findings to include
a. an RBC count of 4,500,000/L.
b. a hematocrit (Hct) value of 38%.
c. normal red blood cell (RBC) indices.
d. a hemoglobin (Hgb) of 8.6 g/dL (86 g/L).
ANS: D
The patient’s clinical manifestations indicate moderate anemia, which is consistent with a Hgb of 6 to 10 g/dL. The other values are all within the range of normal.
Which menu choice indicates that the patient understands the nurse’s teaching about recommended dietary choices for iron-deficiency anemia?
a. Omelet and whole wheat toast c. Strawberry and banana fruit plate
b. Cantaloupe and cottage cheese d. Cornmeal muffin and orange juice
ANS: A
Eggs and whole grain breads are high in iron. The other choices are appropriate for other nutritional deficiencies but are not the best choice for a patient with iron-deficiency anemia.
A patient who is receiving methotrexate for severe rheumatoid arthritis develops a megaloblastic anemia. The nurse will anticipate teaching the patient about increasing oral intake of
a. iron. c. cobalamin (vitamin B12).
b. folic acid. d. ascorbic acid (vitamin C).
ANS: B
Methotrexate use can lead to folic acid deficiency. Supplementation with oral folic acid supplements is the usual treatment. The other nutrients would not correct folic acid deficiency, although they would be used to treat other types of anemia.
A 52-yr-old patient has a new diagnosis of pernicious anemia. The nurse determines that the patient understands the teaching about the disorder when the patient states,
a. “I need to start eating more red meat and liver.”
b. “I will stop having a glass of wine with dinner.”
c. “I could choose nasal spray rather than injections of vitamin B12.”
d. “I will need to take a proton pump inhibitor such as omeprazole (Prilosec).”
ANS: C
Because pernicious anemia prevents the absorption of vitamin B12, this patient requires injections or intranasal administration of cobalamin. Alcohol use does not cause cobalamin deficiency. Proton pump inhibitors decrease the absorption of vitamin B12. Eating more foods rich in vitamin B12 is not helpful because the lack of intrinsic factor prevents absorption of the vitamin.
An appropriate nursing intervention for a hospitalized patient with severe hemolytic anemia is to
a. provide a diet high in vitamin K.
b. alternate periods of rest and activity.
c. teach the patient how to avoid injury.
d. place the patient on protective isolation.
ANS: B
Nursing care for patients with anemia should alternate periods of rest and activity to encourage activity without causing undue fatigue. There is no indication that the patient has a bleeding disorder, so a diet high in vitamin K or teaching about how to avoid injury is not needed. Protective isolation might be used for a patient with aplastic anemia, but it is not indicated for hemolytic anemia.
Which patient statement to the nurse indicates a need for additional instruction about taking oral ferrous sulfate?
a. “I will call my health care provider if my stools turn black.”
b. “I will take a stool softener if I feel constipated occasionally.”
c. “I should take the iron with orange juice about an hour before eating.”
d. “I should increase my fluid and fiber intake while I am taking iron tablets.”
ANS: A
It is normal for the stools to appear black when a patient is taking iron, and the patient should not call the health care provider about this. The other patient statements are correct.
Which collaborative problem will the nurse include in a care plan for a patient admitted to the hospital with idiopathic aplastic anemia?
a. Potential complication: seizures
b. Potential complication: infection
c. Potential complication: neurogenic shock
d. Potential complication: pulmonary edema
ANS: B
Because the patient with aplastic anemia has pancytopenia, the patient is at risk for infection and bleeding. There is no increased risk for seizures, neurogenic shock, or pulmonary edema.
It is important for the nurse providing care for a patient with sickle cell crisis to
a. limit the patient’s intake of oral and IV fluids.
b. evaluate the effectiveness of opioid analgesics.
c. encourage the patient to ambulate as much as tolerated.
d. teach the patient about high-protein, high-calorie foods.
ANS: B
Pain is the most common clinical manifestation of a crisis and usually requires large doses of continuous opioids for control. Fluid intake should be increased to reduce blood viscosity and improve perfusion. Rest is usually ordered to decrease metabolic requirements. Patients are instructed about the need for dietary folic acid, but high-protein, high-calorie diets are not emphasized.
Which statement by a patient indicates good understanding of the nurse’s teaching about prevention of sickle cell crisis?
a. “Home oxygen therapy is frequently used to decrease sickling.”
b. “There are no effective medications that can help prevent sickling.”
c. “Routine continuous dosage narcotics are prescribed to prevent a crisis.”
d. “Risk for a crisis is decreased by having an annual influenza vaccination.”
ANS: D
Because infection is the most common cause of a sickle cell crisis, influenza, Haemophilus influenzae, pneumococcal pneumonia, and hepatitis immunizations should be administered. Although continuous dose opioids and oxygen may be administered during a crisis, patients do not receive these therapies to prevent crisis. Hydroxyurea (Hydrea) is a medication used to decrease the number of sickle cell crises.
Which instruction will the nurse plan to include in discharge teaching for a patient admitted with a sickle cell crisis?
a. Take a daily multivitamin with iron.
b. Limit fluids to 2 to 3 quarts per day.
c. Avoid exposure to crowds when possible.
d. Drink only two caffeinated beverages daily.
ANS: C
Exposure to crowds increases the patient’s risk for infection, the most common cause of sickle cell crisis. There is no restriction on caffeine use. Iron supplementation is generally not recommended. A high-fluid intake is recommended.
The nurse notes scleral jaundice in a patient being admitted with hemolytic anemia. The nurse will plan to check the laboratory results for the
a. Schilling test. c. gastric analysis.
b. bilirubin level. d. stool occult blood.
ANS: B
Jaundice is caused by the elevation of bilirubin level associated with red blood cell hemolysis. The other tests would not be helpful in monitoring or treating a hemolytic anemia.
A patient who has been receiving IV heparin infusion and oral warfarin (Coumadin) for a deep vein thrombosis (DVT) is diagnosed with heparin-induced thrombocytopenia (HIT) when the platelet level drops to 110,000/µL. Which action will the nurse include in the plan of care?
a. Prepare for platelet transfusion.
b. Discontinue the heparin infusion.
c. Administer prescribed warfarin (Coumadin).
d. Use low-molecular-weight heparin (LMWH).
ANS: B
All heparin is discontinued when HIT is diagnosed. The patient should be instructed to never receive heparin or LMWH. Warfarin is usually not given until the platelet count has returned to 150,000/µL. The platelet count does not drop low enough in HIT for a platelet transfusion, and platelet transfusions increase the risk for thrombosis.
An expected action by the nurse caring for a patient who has an acute exacerbation of polycythemia vera is to
a. place the patient on bed rest. c. avoid use of aspirin products.
b. administer iron supplements. d. monitor fluid intake and output.
ANS: D
Monitoring hydration status is important during an acute exacerbation because the patient is at risk for fluid overload or underhydration. Aspirin therapy is used to decrease risk for thrombosis. The patient should be encouraged to ambulate to prevent deep vein thrombosis. Iron is contraindicated in patients with polycythemia vera.
Which intervention will be included in the nursing care plan for a patient with immune thrombocytopenic purpura?
a. Assign the patient to a private room.
b. Avoid intramuscular (IM) injections.
c. Use rinses rather than a soft toothbrush for oral care.
d. Restrict activity to passive and active range of motion.
ANS: B
IM or subcutaneous injections should be avoided because of the risk for bleeding. A soft toothbrush can be used for oral care. There is no need to restrict activity or place the patient in a private room.
Which laboratory result will the nurse expect to show a decreased value if a patient develops heparin-induced thrombocytopenia (HIT)?
a. Prothrombin time
b. Erythrocyte count
c. Fibrinogen degradation products
d. Activated partial thromboplastin time
ANS: D
Platelet aggregation in HIT causes neutralization of heparin, so the activated partial thromboplastin time will be shorter, and more heparin will be needed to maintain therapeutic levels. The other data will not be affected by HIT.
The nurse is caring for a patient with type A hemophilia being admitted to the hospital with severe pain and swelling in the right knee. The nurse should
a. apply heat to the knee.
b. immobilize the knee joint.
c. assist the patient with light weight bearing.
d. perform passive range of motion to the knee.
ANS: B
The initial action should be total rest of the knee to minimize bleeding. Ice packs are used to decrease bleeding. Range of motion (ROM) and weight-bearing exercise are contraindicated initially, but after the bleeding stops, ROM and physical therapy are started.
A young adult who has von Willebrand disease is admitted to the hospital for minor knee surgery. The nurse will review the coagulation survey to check the
a. platelet count. c. thrombin time.
b. bleeding time. d. prothrombin time.
ANS: B
The bleeding time is affected by von Willebrand disease. Platelet count, prothrombin time, and thrombin time are normal in von Willebrand disease.
A routine complete blood count for an active older man indicates possible myelodysplastic syndrome. The nurse will plan to teach the patient about
a. blood transfusion.
b. bone marrow biopsy.
c. filgrastim (Neupogen) administration.
d. erythropoietin (Epogen) administration.
ANS: B
Bone marrow biopsy is needed to make the diagnosis and determine the specific type of myelodysplastic syndrome. The other treatments may be necessary if there is progression of the myelodysplastic syndrome, but the initial action for this asymptomatic patient will be a bone marrow biopsy.
Which action will the admitting nurse include in the care plan for a patient who has neutropenia?
a. Avoid intramuscular injections.
b. Check temperature every 4 hours.
c. Omit fruits or vegetables from the diet.
d. Place a “No Visitors” sign on the door.
ANS: B
The earliest sign of infection in a neutropenic patient is an elevation in temperature. Although unpeeled fresh fruits and vegetables should be avoided, fruits and vegetables that are peeled or cooked are acceptable. Injections may be required for administration of medications such as filgrastim (Neupogen). The number of visitors may be limited and visitors with communicable diseases should be avoided, but a “no visitors” policy is not needed.
Which laboratory test will the nurse use to determine whether filgrastim (Neupogen) is effective for a patient with acute lymphocytic leukemia who is receiving chemotherapy?
a. Platelet count c. Total lymphocyte count
b. Reticulocyte count d. Absolute neutrophil count
ANS: D
Filgrastim increases the neutrophil count and function in neutropenic patients. Although total lymphocyte, platelet, and reticulocyte counts are also important to monitor in this patient, the absolute neutrophil count is used to evaluate the effects of filgrastim.
A patient who has acute myelogenous leukemia (AML) asks the nurse whether the planned chemotherapy will be worth undergoing. Which response by the nurse is appropriate?
a. “If you do not want to have chemotherapy, other treatment options include stem cell transplantation.”
b. “The side effects of chemotherapy are difficult, but AML frequently goes into remission with chemotherapy.”
c. “The decision about treatment is one that you and the doctor need to make rather than asking what I would do.”
d. “You don’t need to make a decision about treatment right now because leukemias in adults tend to progress slowly.”
ANS: B
This response uses therapeutic communication by addressing the patient’s question and giving accurate information. The other responses either give inaccurate information or fail to address the patient’s question, which will discourage the patient from asking the nurse for information.
A patient who has a history of a transfusion-related acute lung injury (TRALI) is to receive a transfusion of packed red blood cells (PRBCs). Which action by the nurse will decrease the risk for TRALI for this patient?
a. Infuse the PRBCs slowly over 4 hours.
b. Transfuse only leukocyte-reduced PRBCs.
c. Administer the scheduled diuretic before the transfusion.
d. Give the PRN dose of antihistamine before the transfusion.
ANS: B
TRALI is caused by a reaction between the donor and the patient leukocytes that causes pulmonary inflammation and capillary leaking. The other actions may help prevent respiratory problems caused by circulatory overload or by allergic reactions, but they will not prevent TRALI.
A patient who has acute myelogenous leukemia (AML) is considering treatment with a hematopoietic stem cell transplant (HSCT). The best approach for the nurse to assist the patient with a treatment decision is to
a. discuss the need for insurance to cover post-HSCT care.
b. ask whether there are questions or concerns about HSCT.
c. emphasize the positive outcomes of a bone marrow transplant.
d. explain that a cure is not possible with any treatment except HSCT.
ANS: B
Offering the patient an opportunity to ask questions or discuss concerns about HSCT will encourage the patient to voice concerns about this treatment and will allow the nurse to assess whether the patient needs more information about the procedure. Treatment of AML using chemotherapy is another option for the patient. It is not appropriate for the nurse to ask the patient to consider insurance needs in making this decision.
Which action will the nurse include in the plan of care for a patient admitted with multiple myeloma?
a. Monitor fluid intake and output.
b. Administer calcium supplements.
c. Assess lymph nodes for enlargement.
d. Limit weight bearing and ambulation.
ANS: A
A high fluid intake and urine output helps prevent the complications of kidney stones caused by hypercalcemia and renal failure caused by deposition of Bence-Jones protein in the renal tubules. Weight bearing and ambulation are encouraged to help bone retain calcium. Lymph nodes are not enlarged with multiple myeloma. Calcium supplements will further increase the patient’s calcium level and are not used.
An appropriate nursing intervention for a patient with non-Hodgkin’s lymphoma whose platelet count drops to 18,000/µL during chemotherapy is to
a. check all stools for occult blood.
b. encourage fluids to 3000 mL/day.
c. provide oral hygiene every 2 hours.
d. check the temperature every 4 hours.
ANS: A
Because the patient is at risk for spontaneous bleeding, the nurse should check stools for occult blood. A low platelet count does not require an increased fluid intake. Oral hygiene is important, but it is not necessary to provide oral care every 2 hours. The low platelet count does not increase risk for infection, so frequent temperature monitoring is not indicated.
A patient who has acute myelogenous leukemia develops an absolute neutrophil count of 850/µL while receiving outpatient chemotherapy. Which action by the outpatient clinic nurse is most appropriate?
a. Discuss the need for hospital admission to treat the neutropenia.
b. Teach the patient to administer filgrastim (Neupogen) injections.
c. Plan to discontinue the chemotherapy until the neutropenia resolves.
d. Order a high-efficiency particulate air (HEPA) filter for the patient’s home.
ANS: B
The patient may be taught to self-administer filgrastim injections. Although chemotherapy may be stopped with severe neutropenia (neutrophil count <500/µL), administration of filgrastim usually allows the chemotherapy to continue. Patients with neutropenia are at higher risk for infection when exposed to other patients in the hospital. HEPA filters are expensive and are used in the hospital, where the number of pathogens is much higher than in the patient’s home environment.
Which assessment finding should the nurse caring for a patient with thrombocytopenia communicate immediately to the health care provider?
a. The platelet count is 52,000/µL.
b. The patient is difficult to arouse.
c. There are purpura on the oral mucosa.
d. There are large bruises on the patient’s back.
ANS: B
Difficulty in arousing the patient may indicate a cerebral hemorrhage, which is life threatening and requires immediate action. The other information should be documented and reported but would not be unusual in a patient with thrombocytopenia.
The nurse is planning to administer a transfusion of packed red blood cells (PRBCs) to a patient with blood loss from gastrointestinal hemorrhage. Which action can the nurse delegate to unlicensed assistive personnel (UAP)?
a. Verify the patient identification (ID) according to hospital policy.
b. Obtain the temperature, blood pressure, and pulse before the transfusion.
c. Double-check the product numbers on the PRBCs with the patient ID band.
d. Monitor the patient for shortness of breath or chest pain during the transfusion.
ANS: B
UAP education includes measurement of vital signs. UAP would report the vital signs to the registered nurse (RN). The other actions require more education and a larger scope of practice and should be done by licensed nursing staff members.
A postoperative patient receiving a transfusion of packed red blood cells develops chills, fever, headache, and anxiety 35 minutes after the transfusion is started. After stopping the transfusion, what action should the nurse take?
a. Give the PRN diphenhydramine .
b. Send a urine specimen to the laboratory.
c. Administer PRN acetaminophen (Tylenol).
d. Draw blood for a new type and crossmatch.
ANS: C
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. A urine specimen is needed if an acute hemolytic reaction is suspected. Diphenhydramine is used for allergic reactions. This type of reaction does not indicate incorrect crossmatching.
A patient in the emergency department complains of back pain and difficulty breathing 15 minutes after a transfusion of packed red blood cells is started. The nurse’s first action should be to
a. administer oxygen therapy at a high flow rate.
b. obtain a urine specimen to send to the laboratory.
c. notify the health care provider about the symptoms.
d. disconnect the transfusion and infuse normal saline.
ANS: D
The patient’s symptoms indicate a possible acute hemolytic reaction caused by the transfusion. The first action should be to disconnect the transfusion and infuse normal saline. The other actions also are needed but are not the highest priority.
Which patient should the nurse assign as the roommate for a patient who has aplastic anemia?
a. A patient with chronic heart failure
b. A patient who has viral pneumonia
c. A patient who has right leg cellulitis
d. A patient with multiple abdominal drains
ANS: A
Patients with aplastic anemia are at risk for infection because of the low white blood cell production associated with this type of anemia, so the nurse should avoid assigning a roommate with any possible infectious process.
Which patient requires the most rapid assessment and care by the emergency department nurse?
a. The patient with hemochromatosis who reports abdominal pain
b. The patient with neutropenia who has a temperature of 101.8° F
c. The patient with thrombocytopenia who has oozing gums after a tooth extraction
d. The patient with sickle cell anemia who has had nausea and diarrhea for 24 hours
ANS: B
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. The other patients also require rapid assessment and care but not as urgently as the neutropenic patient.
A patient with immune thrombocytopenic purpura (ITP) has an order for a platelet transfusion. Which information indicates that the nurse should consult with the health care provider before obtaining and administering platelets?
a. Platelet count is 42,000/L.
b. Petechiae are present on the chest.
c. Blood pressure (BP) is 94/56 mm Hg.
d. Blood is oozing from the venipuncture site.
ANS: A
Platelet transfusions are not usually indicated until the platelet count is below 10,000 to 20,000/L unless the patient is actively bleeding. Therefore the nurse should clarify the order with the health care provider before giving the transfusion. The other data all indicate that bleeding caused by ITP may be occurring and that the platelet transfusion is appropriate.
Which problem reported by a patient with hemophilia is most important for the nurse to communicate to the health care provider?
a. Leg bruises c. Skin abrasions
b. Tarry stools d. Bleeding gums
ANS: B
Melena is a sign of gastrointestinal bleeding and requires collaborative actions such as checking hemoglobin and hematocrit and administration of coagulation factors. The other problems indicate a need for patient teaching about how to avoid injury but are not indicators of possible serious blood loss.
A patient with septicemia develops prolonged bleeding from venipuncture sites and blood in the stools. Which action is most important for the nurse to take?
a. Avoid other venipunctures.
b. Apply dressings to the sites.
c. Notify the health care provider.
d. Give prescribed proton-pump inhibitors.
ANS: C
The patient’s new onset of bleeding and diagnosis of sepsis suggest that disseminated intravascular coagulation (DIC) may have developed, which will require collaborative actions such as diagnostic testing, blood product administration, and heparin administration. The other actions are also appropriate, but the most important action should be to notify the health care provider so that DIC treatment can be initiated rapidly.
A patient with possible disseminated intravascular coagulation arrives in the emergency department with a blood pressure of 82/40, temperature of 102° F (38.9° C), and severe back pain. Which prescribed action will the nurse implement first?
a. Administer morphine sulfate 4 mg IV.
b. Give acetaminophen (Tylenol) 650 mg.
c. Infuse normal saline 500 mL over 30 minutes.
d. Schedule complete blood count and coagulation studies.
ANS: C
The patient’s blood pressure indicates hypovolemia caused by blood loss and should be addressed immediately to improve perfusion to vital organs. The other actions are also appropriate and should be rapidly implemented, but improving perfusion is the priority for this patient.
Which action for a patient with neutropenia is appropriate for the registered nurse (RN) to delegate to a licensed practical/vocational nurse (LPN/LVN)?
a. Assessing the patient for signs and symptoms of infection
b. Teaching the patient the purpose of neutropenic precautions
c. Administering subcutaneous filgrastim (Neupogen) injection
d. Developing a discharge teaching plan for the patient and family
ANS: C
Administration of subcutaneous medications is included in LPN/LVN education and scope of practice. Patient teaching, assessment, and developing the plan of care require RN level education and scope of practice.
Several patients call the outpatient clinic and ask to make an appointment as soon as possible. Which patient should the nurse schedule to be seen first?
a. A 44-yr-old with sickle cell anemia who says his eyes always look sort of yellow
b. A 23-yr-old with no previous health problems who has a nontender lump in the axilla
c. A 50-yr-old with early-stage chronic lymphocytic leukemia who reports chronic fatigue
d. A 19-yr-old with hemophilia who wants to learn to self-administer factor VII replacement
ANS: B
The patient’s age and presence of a nontender axillary lump suggest possible lymphoma, which needs rapid diagnosis and treatment. The other patients have questions about treatment or symptoms that are consistent with their diagnosis but do not need to be seen urgently.
After receiving change-of-shift report for several patients with neutropenia, which patient should the nurse assess first?
a. A 56-yr-old with frequent explosive diarrhea
b. A 33-yr-old with a fever of 100.8° F (38.2° C)
c. A 66-yr-old who has white pharyngeal lesions
d. A 23-yr-old who is complaining of severe fatigue
ANS: B
Any fever in a neutropenic patient indicates infection and can quickly lead to sepsis and septic shock. Rapid assessment and (if prescribed) initiation of antibiotic therapy within 1 hour are needed. The other patients also need to be assessed but do not exhibit symptoms of potentially life-threatening problems.
Which action will the nurse include in the plan of care for a patient who has thalassemia major?
a. Teach the patient to use iron supplements.
b. Avoid the use of intramuscular injections.
c. Administer iron chelation therapy as needed.
d. Notify health care provider of hemoglobin 11 g/dL.
ANS: C
The frequent transfusions used to treat thalassemia major lead to iron toxicity in patients unless iron chelation therapy is consistently used. Iron supplementation is avoided in patients with thalassemia. There is no need to avoid intramuscular injections. The goal for patients with thalassemia major is to maintain a hemoglobin of 10 g/dL or greater.
Which patient information is most important for the nurse to monitor when evaluating the effectiveness of deferoxamine (Desferal) for a patient with hemochromatosis?
a. Skin color c. Liver function
b. Hematocrit d. Serum iron level
ANS: D
Because iron chelating agents are used to lower serum iron levels, the most useful information will be the patient’s iron level. The other parameters will also be monitored, but are not the most important to monitor when determining the effectiveness of deferoxamine.
Which finding about a patient with polycythemia vera is most important for the nurse to report to the health care provider?
a. Hematocrit 55% c. Calf swelling and pain
b. Presence of plethora d. Platelet count 450,000/L
ANS: C
The calf swelling and pain suggest that the patient may have developed a deep vein thrombosis, which will require diagnosis and treatment to avoid complications such as pulmonary embolus. The other findings will also be reported to the health care provider but are expected in a patient with this diagnosis.
Following successful treatment of Hodgkin’s lymphoma for a 55-yr-old woman, which topic will the nurse include in patient teaching?
a. Potential impact of chemotherapy treatment on fertility
b. Application of soothing lotions to treat residual pruritus
c. Use of maintenance chemotherapy to maintain remission
d. Need for follow-up appointments to screen for malignancy
ANS: D
The chemotherapy used in treating Hodgkin’s lymphoma results in a high incidence of secondary malignancies; follow-up screening is needed. The fertility of a 55-yr-old woman will not be impacted by chemotherapy. Maintenance chemotherapy is not used for Hodgkin’s lymphoma. Pruritus is a clinical manifestation of lymphoma but should not be a concern after treatment.
A patient who has non-Hodgkin’s lymphoma is receiving combination treatment with rituximab (Rituxan) and chemotherapy. Which patient assessment finding requires the most rapid action by the nurse?
a. Anorexia c. Oral ulcers
b. Vomiting d. Lip swelling
ANS: D
Lip swelling in angioedema may indicate a hypersensitivity reaction to the rituximab. The nurse should stop the infusion and further assess for anaphylaxis. The other findings may occur with chemotherapy but are not immediately life threatening.
Which information obtained by the nurse assessing a patient admitted with multiple myeloma is most important to report to the health care provider?
a. Serum calcium level is 15 mg/dL.
b. Patient reports no stool for 5 days.
c. Urine sample has Bence-Jones protein.
d. Patient is complaining of severe back pain.
ANS: A
Hypercalcemia may lead to complications such as dysrhythmias or seizures, and should be addressed quickly. The other patient findings will also be discussed with the health care provider but are not life threatening.
When a patient with splenomegaly is scheduled for splenectomy, which action will the nurse include in the preoperative plan of care?
a. Discourage deep breathing to reduce risk for splenic rupture.
b. Teach the patient to use ibuprofen for left upper quadrant pain.
c. Schedule immunization with the pneumococcal vaccine (e.g., Pneumovax).
d. Avoid the use of acetaminophen (Tylenol) for at least 2 weeks prior to surgery.
ANS: C
Asplenic patients are at high risk for infection with pneumococcal infections and immunization reduces this risk. There is no need to avoid acetaminophen use before surgery, but nonsteroidal antiinflammatory drugs (NSAIDs) may increase bleeding risk and should be avoided. The enlarged spleen may decrease respiratory depth, and the patient should be encouraged to take deep breaths.
The nurse has obtained the health history, physical assessment data, and laboratory results shown in the accompanying figure for a patient admitted with aplastic anemia. Which information is most important to communicate to the health care provider?
History Physical Assessment Laboratory Results
• Fatigue, which has increased over last month
• Frequent constipation • Conjunctiva pale pink, moist
• Multiple bruises
• Clear lung sounds • Hct 33%
• WBC 1500/µL
• Platelets 70,000/µL
a. Neutropenia c. Increasing fatigue
b. Constipation d. Thrombocytopenia
ANS: A
The low white blood cell count indicates that the patient is at high risk for infection and needs immediate actions to diagnose and treat the cause of the leukopenia. The other information may require further assessment or treatment but does not place the patient at immediate risk for complications.
A patient is to receive an infusion of 250 mL of platelets over 2 hours through tubing that is labeled: 1 mL equals 10 drops. How many drops per minute will the nurse infuse?
ANS:
21
To infuse 250 mL over 2 hours, the calculated drip rate is 20.8 drops/min or 21 drops/min.
A 46-yr-old female patient returns to the clinic with recurrent dysuria after being treated with trimethoprim and sulfamethoxazole for 3 days. Which action will the nurse plan to take?
a. Remind the patient about the need to drink 1000 mL of fluids daily.
b. Obtain a midstream urine specimen for culture and sensitivity testing.
c. Suggest that the patient use acetaminophen (Tylenol) to relieve symptoms.
d. Teach the patient to take the prescribed trimethoprim and sulfamethoxazole for 3 more days.
ANS: C
Because uncomplicated urinary tract infections (UTIs) are usually successfully treated with 3 days of antibiotic therapy, this patient will need a urine culture and sensitivity to determine appropriate antibiotic therapy. Acetaminophen would not be as effective as other over-the-counter medications such as phenazopyridine in treating dysuria. The fluid intake should be increased to at least 1800 mL/day. Because the UTI has persisted after treatment with trimethoprim and sulfamethoxazole , the patient is likely to need a different antibiotic.
The nurse determines that instruction regarding prevention of future urinary tract infections (UTIs) has been effective for a 22-yr-old female patient with cystitis when the patient states which of the following?
a. “I can use vaginal antiseptic sprays to reduce bacteria.”
b. “I will drink a quart of water or other fluids every day.”
c. “I will wash with soap and water before sexual intercourse.”
d. “I will empty my bladder every 3 to 4 hours during the day.”
ANS: D
Voiding every 3 to 4 hours is recommended to prevent UTIs. Use of vaginal sprays is discouraged. The bladder should be emptied before and after intercourse, but cleaning with soap and water is not necessary to prevent UTI. A quart of fluids is insufficient to provide adequate urine output to decrease risk for UTI.
Which information will the nurse include when teaching the patient with a urinary tract infection (UTI) about the use of phenazopyridine?
a. Take phenazopyridine for at least 7 days.
b. Phenazopyridine may cause photosensitivity
c. Phenazopyridine may change the urine color
d. Take phenazopyridine before sexual intercourse.
ANS: C
Patients should be taught that phenazopyridine will color the urine deep orange. Urinary analgesics should only be needed for a few days until the prescribed antibiotics decrease the bacterial count. Phenazopyridine does not cause photosensitivity. Taking phenazopyridine before intercourse will not be helpful in reducing the risk for UTI.
Which finding by the nurse will be most helpful in determining whether a 67-yr-old patient with benign prostatic hyperplasia has an upper urinary tract infection (UTI)?
a. Bladder distention c. Suprapubic discomfort
b. Foul-smelling urine d. Costovertebral tenderness
ANS: D
Costovertebral tenderness is characteristic of pyelonephritis. Bladder distention, foul-smelling urine, and suprapubic discomfort are characteristic of a lower UTI and are likely to be present if the patient also has an upper UTI.
The nurse determines that further instruction is needed for a patient with interstitial cystitis when the patient says which of the following?
a. “I should stop having coffee and orange juice for breakfast.”
b. “I will buy calcium glycerophosphate (Prelief) at the pharmacy.”
c. “I will start taking high potency multiple vitamins every morning.”
d. “I should call the doctor about increased bladder pain or foul urine.”
ANS: C
High-potency multiple vitamins may irritate the bladder and increase symptoms. The other patient statements indicate good understanding of the teaching.
To determine possible causes, the nurse will ask a patient admitted with acute glomerulonephritis about
a. recent bladder infection. c. recent sore throat and fever.
b. history of kidney stones. d. history of high blood pressure.
ANS: C
Acute glomerulonephritis frequently occurs after a streptococcal infection such as strep throat. It is not caused by kidney stones, hypertension, or urinary tract infection.
Which finding for a patient admitted with glomerulonephritis indicates to the nurse that treatment has been effective?
a. The patient denies pain with voiding.
b. The urine dipstick is negative for nitrites.
c. The antistreptolysin-O (ASO) titer has decreased.
d. The periorbital and peripheral edema are resolved.
ANS: D
Because edema is a common clinical manifestation of glomerulonephritis, resolution of the edema indicates that the prescribed therapies have been effective. Nitrites will be negative and the patient will not experience dysuria because the patient does not have a urinary tract infection. Antibodies to streptococcus will persist after a streptococcal infection.
The nurse will anticipate teaching a patient with nephrotic syndrome who develops flank pain about treatment with
a. antibiotics. c. anticoagulants.
b. antifungals. d. antihypertensives.
ANS: C
Flank pain in a patient with nephrotic syndrome suggests a renal vein thrombosis and anticoagulation is needed. Antibiotics are used to treat a patient with flank pain caused by pyelonephritis. Fungal pyelonephritis is uncommon and is treated with antifungals. Antihypertensives are used if the patient has high blood pressure.
A 56-yr-old female patient is admitted to the hospital with new-onset nephrotic syndrome. Which assessment data will the nurse expect?
a. Poor skin turgor c. Elevated urine ketones
b. Recent weight gain d. Decreased blood pressure
ANS: B
The patient with a nephrotic syndrome will have weight gain associated with edema. Hypertension is a clinical manifestation of nephrotic syndrome. Skin turgor is normal because of the edema. Urine protein is high. Ketones are not related to nephrotic syndrome.
To prevent recurrence of uric acid renal calculi, the nurse teaches the patient to avoid eating
a. milk and cheese. c. spinach and chocolate.
b. sardines and liver. d. legumes and dried fruit.
ANS: B
Organ meats and fish such as sardines increase purine levels and uric acid. Spinach, chocolate, and tomatoes should be avoided in patients who have oxalate stones. Milk, dairy products, legumes, and dried fruits may increase the incidence of calcium-containing stones.
The nurse teaches an adult patient to prevent the recurrence of renal calculi by
a. using a filter to strain all urine.
b. avoiding dietary sources of calcium.
c. drinking 2000 to 3000 mL of fluid each day.
d. choosing diuretic fluids such as coffee and tea.
ANS: C
A fluid intake of 2000 to 3000 mL/day is recommended to help flush out minerals before stones can form. Avoidance of calcium is not usually recommended for patients with renal calculi. Coffee tends to increase stone recurrence. There is no need for a patient to strain all urine routinely after a stone has passed, and this will not prevent stones.
When planning teaching for a patient with benign nephrosclerosis, the nurse should include instructions regarding
a. preventing bleeding with anticoagulants.
b. monitoring and recording blood pressure.
c. obtaining and documenting daily weights.
d. measuring daily intake and output volumes.
ANS: B
Hypertension is the major manifestation of nephrosclerosis. Measurements of intake and output and daily weights are not necessary unless the patient develops renal insufficiency. Anticoagulants are not used to treat nephrosclerosis.
A 28-yr-old male patient is diagnosed with polycystic kidney disease. Which information is most appropriate for the nurse to include in teaching at this time?
a. Complications of renal transplantation
b. Methods for treating severe chronic pain
c. Options to consider for genetic counseling
d. Differences between hemodialysis and peritoneal dialysis
ANS: C
Because a 28-yr-old patient may be considering having children, the nurse should include information about genetic counseling when teaching the patient. A well-managed patient will not need to choose between hemodialysis and peritoneal dialysis or know about the effects of transplantation for many years. There is no indication that the patient has chronic pain.
A young adult male patient seen at the primary care clinic complains of feeling continued fullness after voiding and a split, spraying urine stream. The nurse will ask about a history of
a. recent kidney trauma. c. recurrent bladder infection.
b. gonococcal urethritis. d. benign prostatic hyperplasia.
ANS: B
The patient’s clinical manifestations are consistent with urethral strictures, a possible complication of gonococcal urethritis. These symptoms are not consistent with benign prostatic hyperplasia, kidney trauma, or bladder infection.
The nurse will plan to teach a 27-yr-old woman who smokes two packs of cigarettes daily about the increased risk for
a. kidney stones. c. bladder infection.
b. bladder cancer. d. interstitial cystitis.
ANS: B
Cigarette smoking is a risk factor for bladder cancer. The patient’s risk for developing interstitial cystitis, urinary tract infection, or kidney stones will not be reduced by quitting smoking.
A 68-yr-old female patient admitted to the hospital with dehydration is confused and incontinent of urine. Which nursing action should be included in the plan of care?
a. Restrict fluids between meals and after the evening meal.
b. Insert an indwelling catheter until the symptoms have resolved.
c. Assist the patient to the bathroom every 2 hours during the day.
d. Apply absorbent adult incontinence diapers and pads over the bed linens.
ANS: C
In older or confused patients, incontinence may be avoided by using scheduled toileting times. Indwelling catheters increase the risk for urinary tract infection. Incontinent pads and diapers increase the risk for skin breakdown. Restricting fluids is not appropriate in a patient with dehydration.
A 55-yr-old woman admitted for shoulder surgery asks the nurse for a perineal pad, stating that laughing or coughing causes leakage of urine. Which intervention is most appropriate to include in the care plan?
a. Assist the patient to the bathroom q3hr.
b. Place a commode at the patient’s bedside.
c. Demonstrate how to perform the Credé maneuver.
d. Teach the patient how to perform Kegel exercises.
ANS: D
Kegel exercises to strengthen the pelvic floor muscles will help reduce stress incontinence. The Credé maneuver is used to help empty the bladder for patients with overflow incontinence. Placing the commode close to the bedside and assisting the patient to the bathroom are helpful for functional incontinence.
Following rectal surgery, a patient voids about 50 mL of urine every 30 to 60 minutes for the first 4 hours. Which nursing action is most appropriate?
a. Monitor the patient’s intake and output overnight.
b. Have the patient drink small amounts of fluid frequently.
c. Use an ultrasound scanner to check the postvoiding residual volume.
d. Reassure the patient that this is normal after anesthesia for rectal surgery.
ANS: C
An ultrasound scanner can be used to check for residual urine after the patient voids. Because the patient’s history and clinical manifestations are consistent with overflow incontinence, it is not appropriate to have the patient drink small amounts. Although overflow incontinence is not unusual after surgery, the nurse should intervene to correct the physiologic problem, not just reassure the patient. The patient may develop reflux into the renal pelvis and discomfort from a full bladder if the nurse waits to address the problem for several hours.
A patient admitted to the hospital with pneumonia has a history of functional urinary incontinence. Which nursing action will be included in the plan of care?
a. Demonstrate the use of the Credé maneuver.
b. Teach exercises to strengthen the pelvic floor.
c. Place a bedside commode close to the patient’s bed.
d. Use an ultrasound scanner to check postvoiding residuals.
ANS: C
Modifications in the environment make it easier to avoid functional incontinence. Checking for residual urine and performing the Credé maneuver are interventions for overflow incontinence. Kegel exercises are useful for stress incontinence.
