Practice Questions r/t the Immune, Lymphatic, and Hematological systems

Question 1

A client’s wound has eviscerated. Which of the following will you implement first?

1. stay with the client and notify the physician
2. apply a clean, dry dressing to the wound
3. cleanse the wound with betadine and apply bacteriostatic ointment
4. place sterile towels soaked in sterile saline over the wound

Answer 1

4 - the nurse will place sterile towels soaked in sterile saline over the eviscerated wound. An evisceration is the protrusion of visceral organs through a wound opening. The condition is a medical emergency that requires surgical repair. If organs protrude through the wound, the blood supply to the tissues is compromised. When evisceration occurs, the nurse places sterile towels soaked in sterile saline over the extruding tissues to reduce the possibility of bacterial invasion and drying.

the physician should be notified, but only after sterile towels soaked in saline have been placed over wound

placing an unsterile dry dressing over an evisceration will expose the wound to infection and dry out the wound

surgery is required and ointment would have to be removed. Also, betadine should not be placed on the organs because it is an irritant

Question 2

a child who is due for an immunization should not receive that immunization if the child:

1. has recently been exposed to an infectious disease
2. is receiving antimicrobial (antibiotic) therapy
3. has a moderately severe illness, without fever
4. had a moderate local reaction to a previous vaccine injection

Answer 2

3 - A child who has an illness should not receive immunizations, since doing so will compromise the child’s health. The child’s health is already compromised and immunizations may compromise it further

a child who has been exposed to an infectious disease but has no symptoms should be immunized as should those who are presently receiving antimicrobial (anti-infective/antibiotic) therapy.

a moderate local reaction does not mean child should not be immunized

Question 3

the most common early symptom of hepatitis A is:

1. loss of appetite
2. abdominal distention
3. ecchymosis
4. shortness of breath

Answer 3

1 - anorexia is the most common early symptom of hepatitis A. Chills, nausea, vomiting, dyspepsia, and tenderness of the liver are other early manifestations of type A hepatitis.

Type A hepatitis is usually spread by the fecal-oral route as a result of poor hygiene or a breakdown in sanitary conditions. Enteric precautions are recommended

abdominal distention, ecchymosis and SOB are symptoms of advanced liver disease

Question 4

Which of the following statements is true regarding chemotherapy-related alopecia?

1. hair loss is temporary; growth will occur soon after chemo is discontinued
2. hair loss is transient and is one of the minor side effects of chemo
3. hair loss can be minimized by adjusting the dosage of the causative medications
4. hair loss is permanent, so clients need to prepare for alternatives such as wigs

Answer 4

1 - the alopecia (hair loss) is temporary and that hair growth will occur soon after chemotherapy is discontinued

even though alopecia is transient, it can be a very traumatic experience for many clients and would be considered more than a minor side effect.

It cannot be minimized by adjusting the dosage of the causative medication

it is not permanent, however, the client should be taught that when hair growth returns hair may be a different colour and/or texture

Question 5

An infant has a hemolytic disease of the newborn. The nurse caring for that infant should teach the parents that the development of jaundice in the newborn is caused by:

1. polycythemia
2. an abnormal production of melanin
3. excessive destruction of red blood cells
4. hypobilirubenemia

Answer 5

3 - the nurse will teach the parents that their baby’s jaundice is caused by excessive destruction of the red blood cells (RBCs). Hemolytic disease of the newborn (HDN erythroblastosis fetalis) results from excessive destruction of fetal red blood cells caused by maternal antibodies. The end product of red blood cell destruction is excessive bilirubin (hyperbilirubinemia), which the infant’s immature liver is unable to metabolize. The result is jaundice

polycythemia (an abnormal, excessive number of red blood cells) is not associated with HDN

melanin (the pigment that gives skin and hair it’s colour) is not associated with HDN

Question 6

Following a lumpectomy for breast cancer, the cyclophosphamide, methotrexate, fluorouracil protocol was prescribed. Which of the following statements should be included in the teaching plan of the client receiving these medications?

1. have the client see a cardiologist prior to chemo
2. encourage the client to increase fluid intake to approximately 3 litres per day
3. see that the client protects herself from sun during chemo
4. recommend that the client eat only food she likes because of potential nausea

Answer 6

Teaching should include the need to increase fluid intake. Hemorrhagic cystitis is a common side effect of cyclophosphamide that may be diminished by increasing fluid intake to approximately 3 litres per day

none of the prescribed medications require a cardiology workup or cause photosensitivity.

nausea will cause cliens to have aversion to foods they like and defeats the purpose of good nutrition

Question 7

A 60-year-old has terminal lung cancer. On admission, a morphine drip was prescribed to treat intractable pain. Which of the following would the nurse recognize as a side effect of this medication?

1. client awake and alert. Requires minimal rescue dose of medication for pain
2. requires rescue dose of pain medication every 4 hours
3. client has not had a bowel movement for 5 days
4. client pulse is 60 beats per minute

Answer 7

The nurse will recognize constipation as a common side effect of morphine. Other common side effects include sedation, nausea, vomiting, and decreased respiratory rate.

frequency of rescue doses indicates under-dosage of morphine, not side effects

pulse would increase, not decrease - this would be in compensation for lack of oxygen because of decreased respiratory rate

Question 8

A 3-year-old with hemophilia (factor VIII deficiency) was admitted to the hospital because of persistent bleeding from a minor laceration. In planning care, the nurse will anticipate which of the following consequences of hospitalization to be most traumatic for the client?

1. inhibition from running about freely
2. seperation from family
3. placement in an unfamiliar environment
4. disruption of routines and rituals.

Answer 8

The nurse will anticipate separation from family, especiall the mother, as the most traumatic event for a toddler

the others may require adjustments by the toddler, but not considered traumatic

Question 9

A client is admitted to the medical-surgical unit with a diagnosis of anemia. The laboratory results reveal a hemoglobin of 6.8 gm/dl. Which therapy do you anticipate

1. no therapy is anticipated; this is a normal hemoglobin
2. albumin intravenously
3. 1 unit of packed red blood cells
4. normal saline intravenously

Answer 9

The administration of packed red blood cells should be anticipated. Anemia exists when there is a reduction in the red blood cells, a decrease in hemoglobin, and a drop in the volume of packed red cells. Therapy is aimed at replacing RBCs, which carry oxygen to the body

normal hemoglobin is 12 to 16 gm/100ml for adult females and 14 to 18 gm/100ml for adult males

hemoglobin would not be affected by IV albumin or normal saline

Question 10

a 41-year-old is admitted to the hospital with chronic granulocytic leukemia. The client also has anemia and thrombocytopenia. Because the client has thrombocytopenia, the nurse should include which of the following measures into the plan of care?

1. placing the client in a semi-upright position
2. limiting the client’s intake of fluids
3. protecting the client from injury
4. exercising the client’s lower extremities.

Answer 10

The immediate concern is to prevent injury and bleeding. A client with thrombocytopenia has an abnormally low number of blood platelet. Should the client sustain an injury, abnormal bleeding would occur because of impairment of the clotting mechanism

placing client at 45-degree angle may facilitate breathing, but positioning is not a major concern

There is no indication that the client should limit fluids

Exercising the client’s lower extremities is contraindicated. Nothing should be done that would facilitate bleeding. Soft toothbrushes and electric razors should be used. The client should also avoid aspirin

Question 11

Which of the following measures should the nurse implement to control bleeding into the joints of a client who is experiencing hemarthrosis?

1. begin gentle passive exercises
2. immobilize the joint in an elastic compression bandage to apply pressure
3. Wrap the joint in an elastic compression bandage to prevent bleeding
4. apply a tourniquet above the joint

Answer 11

2 - clients who are experiencing hemarthrosis (bleeding into the cavity of a joint) should have the affected joint immobilized. Immobilization of a joint in a position of slight flexion will prevent bleeding from further trauma

passive exercise should not begin until the active phase of the disease has passed.

wrapping the joint in an elastic bandage to apply pressure would not prevent bleeding, but may be done to assist in immobilizing the joint

a tourniquet could cause additional trauma due to the restriction of blood supply

Question 12

A client who is receiving chemotherapy for treatment of breast cancer tells you that she notices her mouth is extremely dry all the time. You know this is probably a side effect of chemotherapy, and is called:

1. xerostomia
2. alopecia
3. xanthoma
4. anemia

Answer 12

1 - xerostomia is dryness of the mouth due to an alteration in normal secretions. It is a side effect of some chemotherapies and can be very distressing to clients. It places the client at an increased risk for infections of the oral cavity

alopecia refers to hair loss

xanthoma is a type of skin lesion

anemia is a blood disorder whose hallmark is low or abnormal hemoglobin levels

Question 13

A client has sickle-cell anemia. The nurse’s assessment of the client is least likely to reveal:

1. paleness of hands and soles of feet
2. height and weight retardation
3. elevated heart rate with cyanosis
4. several fresh bruises on the claves of the legs

Answer 13

2

Question 14

a client is to receive a blood transfusion. Prior to administration of the blood, it is important for the nurse to:

1. instruct the client that the transfusion takes less than 30 minutes
2. administer an antibiotic
3. infuse dextrose 5% water with the blood
4. verify the prescription and check labels carefully with another nurse

Answer 14

4

Question 15

an 8-year-old has rubella. Which of the following recommendations will the nurse stress regarding contact with others?

1. do not let the child play with brothers and sisters until there is no longer a rash
2. do not allow friends or relatives who are pregnant to visit for at least 5 days after the rash disappears
3. do not allow your children to sleep with each other until a week after the rash disappears
4. do not allow your children to play with other children in the neighborhood for several days

Answer 15

uhhhhh 2?

Question 16

a client who has been receiving chemotherapy for liver cancer is making holiday plans. The client’s while blood cell count today is 2000/cm3. Which of the following is the most appropriate advice to give this client regarding holiday plans?

1. you should avoid being with your family because you may be contagious
2. there is little point in celebrating this year, is there?
3. try not to eat foods that are high in carbohydrates over the holidays
4. you should try to avoid being in crowded public situations

Answer 16

4 - the others are ridiculously wrong

Question 17

which of the following immunizations should not be given to a 2-month-old infant whose caregiver is currently receiving chemotherapy?

1. oral polio vaccine
2. hepatitis B
3. diptheria, tetanus, and pertussis
4. haemophilus influenzae type b

Answer 17

1>?

Question 18

A client who has leukemia has a platelet count of 50 cells x 109/l. Nursing care must include which of the following?

1. scheduled analgesia, since a low platelet count is associated with profound muscle pain
2. measures to prevent bleeding and bruising
3. parenteral medications only, since GI absorption will be poor
4. vigorous range-of-motion exercises

Answer 18

2

Question 19

a young child will receive the haemophilus influenzae type b vaccine. The nurse will teach the child’s parents that the vaccine will:

1. protect the child from one cause of serious infections such as epiglottitis or meningitis
2. protect the chile from hepatitis b disease
3. help prevent HIV disease in young children
4. help prevent influenza

Answer 19

1

Question 20

a client experiencing acute hepatitis B should be advised to avoid:

1. citrus juices
2. sleeping on the right side
3. antihistamines for pruritus
4. contact sports

Answer 20

4

Question 21

a client who has been diagnosed with autoimmune chronic hepatitis will have which of the following laboratory results?

1. a positive hepatitis B surface antigen
2. low liver function tests
3. elevated liver function tests
4. low serum bilirubin levels

Answer 21

3

Question 22

Which of the following laboratory studies indicates an infectious process?

1. serum potassium level of 4
2. hemoglobin of 13
3. serum cholesterol of 180
4. white blood cell count of 14 000 mm3

Answer 22

4

Question 23

You are teaching a parent about feer management for a child who has chickenpox. Which of the following treatment modalities is contraindicated?

1. offering plenty of liquids
2. administering aspirin for fever management
3. dressing the child in lightweight clothing
4. teaching the correct technique for using a thermometer

Answer 23

2

Question 24

Who are the most likely to experience hepatitis E?

1. an IV drug user
2. an immigrant newly arrived from a developing country
3. a toddler in a day-care facility
4. a client receiving hemodialysis

Answer 24

4

Question 25

a client with cancer of the lung is receiving the colony-stimulating factor filgrastim and is complaining of bone pain. What should you administer to relieve the pain?

1. aspirin 10 g po
2. acetaminophen 650 mg po
3. meperidine hydrochloride 50 mg intramuscularly
4. morphine sulfate 30 mg po

Answer 25

..

Question 26

A 22-year-old has Hodgkin’s lymphoma. As a consequence of chemotherapy and radiation therapy, the client is immunocompromised. The nurse’s aide reported the client’s temperature as 100.3 F. The appropriate nursing action is to:

1. retake the temperature after 2 hours
2. do nothing; a fever is expected in this condition
3. give the client apriprin 10 g.
4. notify the physician and prepare to take cultures

Answer 26

.

Question 27

A 5-year-old with acute lymphocytic leukemia is to be discharged from the hospital in a state of remission. The nurse will reinforce which of the following understandings about the role of the child’s parents?

1. make few demands on the child and try to make the child as happy as possible, since the condition is terminal
2. guide the child through encouragement and setting limits so that the child may develop to full potential
3. it is not necessary to control the child’s behavior since the child’s condition will impose limitations
4. it will be necessary to develop a carefully planned schedule for the child so that energy can be conserved

Answer 27

2

Question 28

A client has a laceration approximately 2 inches long and 1 inch deep that has been sustained for approximately 2 hours. You will irrigate the wound with a minimum of:

1. 200 ml of saline solution
2. 150 ml of saline solution
3. 100 ml of saline solution
4. 250 ml of saline solution

Answer 28

3

Question 29

A 20-year-old college student is seen in the student health clinic because of fatigue, weight loss, and a low-grade fever. Physical examination reveals slight enlargement of the cervical lymph nodes. Which of the following questions pertaining to the client’s fever should the nurse ask initially

1. when did you first notice your temperature was elevated?
2. has your temperature been over 102 F
3. have you recently been exposed to anyone who has an infection?
4. have you had a sore throat?

Answer 29

do you straight up have mono. 4