TEST 3: The Client with Hematologic Health Problems 713

Question 1

The Client with Red Blood Cell Disorders
1. The nurse is assisting with a bone marrow aspiration and biopsy. In which order, from first to
last, should the nurse complete the following tasks?
1. Position the client in a side-lying position.
2. Clean the skin with an antiseptic solution.
3. Verify the client has signed an informed consent.
4. Apply ice to the biopsy site.

Answer 1

The Client with Red Blood Cell Disorders
1.
3. Verify the client has signed an informed consent.
1. Position the client in a side-lying position.
2. Clean the skin with an antiseptic solution.
4. Apply ice to the biopsy site.
First, the nurse must verify that the client has voluntarily signed a consent form before the
procedure begins, and check that the client understands the procedure. The nurse then positions the
client in a side-lying, or lateral decubitus, position with the affected side up. Then the nurse should
clean the skin site and surrounding area with an antiseptic solution such as Betadine before the health
care provider numbs the site and collects the specimen. When the procedure is finished, the nurse
must apply ice to the biopsy site to reduce pain.
CN: Management of care; CL: Synthesize

Question 2

2. A client with iron deficiency anemia is refusing to take the prescribed oral iron medication
   because the medication is causing nausea. The nurse should do which of the following? Select all that
   apply.
3. Suggest that the client use ginger when taking the medication.
4. Ask the client what is causing the nausea.
5. Tell the client to use stool softeners to minimize constipation.
6. Offer to administer the medication by an intramuscular injection.
7. Suggest that the client take the iron with orange juice.

Answer 2

2. 1, 2, 5. Nausea and vomiting are common adverse effects of oral iron preparations. The nurse
   should first ask the client why the client does not want to take the oral medication, and then suggest
   ways to decrease the nausea and vomiting. Ginger may help minimize the nausea and the client can try
   this remedy and evaluate its effectiveness. Iron should be taken on an empty stomach but can be taken
   with orange juice. The client can evaluate if this helps the nausea. Stool softeners should not be used
   in clients with iron deficiency anemia. Instead, constipation can be prevented by following a high-
   fiber diet. Administering iron intramuscularly is done only if other approaches are not effective.
   CN: Health promotion and maintenance; CL: Synthesize

Question 3

3. A client had a mastectomy followed by chemotherapy 6 months ago. She reports that she is
   now “unable to concentrate at her card game” and “it seems harder and harder to finish her errands
   because of exhaustion.” Based on this information, the nurse should suggest that the client do which of
   the following?
4. Take frequent naps.
5. Limit activities.
6. Increase fluid intake.
7. Avoid contact with others.

Answer 3

3. 1. This client is likely experiencing fatigue and should increase her periods of rest. The fatigue
      may be caused by anemia from depletion of red blood cells due to the chemotherapy. Asking the client
      to limit her activities may cause the client to become withdrawn. The information given does not
      support limiting activity. Increasing fluid intake will not reduce the fatigue. The information does notindicate that the client is immunosuppressed and should avoid contact with others.
      CN: Physiological adaptation; CL: Synthesize

Question 4

4. A client is to have a transfusion of packed red blood cells from a designated donor. The client
   asks if any diseases can be transmitted by this donor. The nurse should inform the client that which of
   the following diseases can be transmitted by a designated donor? Select all that apply.
5. Epstein-Barr virus.
6. Human immunodeficiency virus (HIV).3. Cytomegalovirus (CMV).
7. Hepatitis A.
8. Malaria.

Answer 4

4. 1, 2, 3. Using designated donors does not decrease the risk of contracting infectious diseases,
   such as the Epstein-Barr virus, HIV, or CMV. Hepatitis A is transmitted by the oral-fecal route, not the
   blood route; however, hepatitis B and C can be contracted from a designated donor. Malaria is
   transmitted by mosquitoes.
   CN: Safety and infection control; CL: Apply

Question 5

5. A client has been admitted with active rectal bleeding, and has been typed and crossmatched
   for 2 units of packed red blood cells (RBCs). Within 10 minutes of admission, the client faints when
   getting up to go to the bedside commode. The nurse notifies the health care provider, who prescribes
   a unit of blood to be administered immediately. The nurse can safely administer which type of blood
   for immediate transfusion?
6. A negative.
7. B negative.
8. AB negative.
9. O negative.

Answer 5

5. 4. A routine serology study to confirm compatibility between a blood donor and recipient takes
      about 1 hour. In an emergency, O negative RBCs can be safely administered to most clients, which is
      why a person with O-negative blood is called a universal donor. The other types of RBCs may cause
      an adverse reaction.
      CN: Safety and infection control; CL: Apply

Question 6

6. The nurse is preparing to teach a client with microcytic hypochromic anemia about the diet to
   follow after discharge. Which of the following foods should be included in the diet?
7. Eggs.
8. Lettuce.
9. Citrus fruits.
10. Cheese.

Answer 6

6. 1. One of the microcytic, hypochromic anemias is iron deficiency anemia. A rich source of iron
      is needed in the diet, and eggs are high in iron. Other foods high in iron include organ and muscle
      (dark) meats; shellfish, shrimp, and tuna; enriched, whole-grain, and fortified cereals and breads;
      legumes, nuts, dried fruits, and beans; oatmeal; and sweet potatoes. Dark green, leafy vegetables and
      citrus fruits are good sources of vitamin C. Cheese is a good source of calcium.
      CN: Reduction of risk potential; CL: Apply

Question 7

7. The nurse should instruct the client to eat which of the following foods to obtain the best
supply of vitamin B 12 ?
1. Whole grains.
2. Green leafy vegetables.
3. Meats and dairy products.
4. Broccoli and Brussels sprouts.

Answer 7

7. 3. Good sources of vitamin B 12 include meats and dairy products. Whole grains are a good
      source of thiamine. Green, leafy vegetables are good sources of niacin, folate, and carotenoids
      (precursors of vitamin A). Broccoli and Brussels sprouts are good sources of ascorbic acid (vitamin
      C).
      CN: Reduction of risk potential; CL: Apply

Question 8

8. The nurse has just admitted a 35-year-old female client who has a serum vitamin B 12
   concentration of 800 pg/mL (590 pmol/L). Which of the following laboratory findings should alert the
   nurse to focus the health history to obtain specific information about drug or alcohol use?
9. Total bilirubin, 0.3 mg/dL (5.1 μmol/L).
10. Serum creatinine, 0.5 mg/dL (44.2 μmol/L).
11. Hemoglobin, 16 g/dL (160 g/L).
12. Folate, 1.5 ng/mL (3.4 nmol/L).

Answer 8

8. 4. Normal range of folic acid is 1.8 to 9 ng/mL (4.1 to 20.4 nmol/L), and normal range of
      vitamin B 12 is 200 to 900 pg/mL (147.6 to 664 pmol/L). A low folic acid level in the presence of a
      normal vitamin B 12 level is indicative of a primary folic acid deficiency anemia. Factors that affect
      the absorption of folic acid are drugs such as methotrexate, oral contraceptives, antiseizure drugs, and
      alcohol. The total bilirubin, serum creatinine, and hemoglobin values are within normal limits.
      CN: Physiological adaptation; CL: Analyze

Question 9

9. Which of the following lab values should the nurse report to the health care provider when the
   client has anemia?
10. Schilling test result, elevated.
11. Intrinsic factor, absent.
12. Sedimentation rate, 16 mm/h.
13. Red blood cells (RBCs) within normal range.

Answer 9

9. 2. The defining characteristic of pernicious anemia, a megaloblastic anemia, is lack of the
      intrinsic factor, which results from atrophy of the stomach wall. Without the intrinsic factor, vitamin
      B 12 cannot be absorbed in the small intestine and folic acid needs vitamin B 12 for deoxyribonucleic
      acid synthesis of RBCs. The gastric analysis is done to determine the primary cause of the anemia. An
      elevated excretion of the injected radioactive vitamin B 12 , which is protocol for the first and second
      stages of the Schilling test, indicates that the client has the intrinsic factor and can absorb vitamin B 12
      in the intestinal tract. A sedimentation rate of 16 mm/h is normal for both men and women and is a
      nonspecific test to detect the presence of inflammation; it is not specific to anemias. An RBC value
      within the normal range does not indicate an anemia.
      CN: Physiological adaptation; CL: Synthesize

Question 10

10. The nurse devises a teaching plan for the client with aplastic anemia. Which of the following
    is the most important concept to teach for health promotion and maintenance?
11. Eat animal protein and dark green, leafy vegetables every day.
12. Avoid exposure to others with acute infections.
13. Practice yoga and meditation to decrease stress and anxiety.4. Get 8 hours of sleep at night and take naps during the day.

Answer 10

10. 2. Clients with aplastic anemia are severely immunocompromised and at risk for infection and
       possible death related to bone marrow suppression and pancytopenia. Strict aseptic technique and
       reverse isolation are important measures to prevent infection. Although diet, reduced stress, and rest
       are valued in supporting health, the potentially fatal consequence of an acute infection places it as a
       priority for teaching the client about health maintenance. Animal meat and dark green leafy
       vegetables, good sources of vitamin B 12 and folic acid, should be included in the daily diet. Yoga and
       meditation are good complementary therapies to reduce stress. Eight hours of rest and naps are good
       for spacing and pacing activity and rest.
       CN: Reduction of risk potential; CL: Synthesize

Question 11

11. A client had a resection of the terminal ileum 3 years ago. While obtaining a health history
    and physical assessment, the nurse finds that the client has weakness, shortness of breath, and a sore
    tongue. Which additional information from the client indicates a need for intervention and client
    teaching?
12. “I have been drinking plenty of fluids.”
13. “I have been gargling with warm salt water for my sore tongue.”
14. “I have three to four loose stools per day.”
15. “I take a vitamin B 12 tablet every day.

Answer 11

11. 4. Vitamin B 12 combines with intrinsic factor in the stomach and is then carried to the ileum,
       where it is absorbed into the bloodstream. In this situation, vitamin B 12 cannot be absorbed
       regardless of the amount of oral intake of sources of vitamin B 12 , such as animal protein or vitamin
       B 12 tablets. Vitamin B 12 needs to be injected every month because the ileum has been surgically
       removed. Replacement of fluids and electrolytes is important when the client has continuous multiple
       loose stools on a daily basis. Warm salt water is used to soothe sore mucous membranes. Crohn’s
       disease and a small-bowel resection may cause several loose stools a day.
       CN: Physiological adaptation; CL: Analyze

Question 12

12. A client who follows a vegetarian diet was referred to a dietitian for nutritional counseling
    for anemia. Which client outcome indicates that the client does not understand nutritional counseling?
    The client:
13. Adds dried fruit to cereal and baked goods.
14. Cooks tomato-based foods in iron pots.
15. Drinks coffee or tea with meals.
16. Adds vitamin C to all meals.

Answer 12

12. 3. Coffee and tea increase gastrointestinal motility and inhibit the absorption of nonheme iron.
       Clients are instructed to add dried fruits to dishes at every meal because dried fruits are a nonheme or
       nonanimal iron source. Cooking in iron cookware, especially acid-based foods such as tomatoes,
       adds iron to the diet. Clients are instructed to add a rich supply of vitamin C to every meal because
       the absorption of iron is increased when food with vitamin C or ascorbic acid is consumed.
       CN: Reduction of risk potential; CL: Evaluate

Question 13

13. A client was admitted to the hospital with iron deficiency anemia and blood-streaked emesis.
    Which question is most appropriate for the nurse to ask in determining the extent of the client’s
    activity intolerance?
14. “What daily activities were you able to do 6 months ago compared with the present?”
15. “How long have you had this problem?”
16. “Have you been able to keep up with all your usual activities?”
17. “Are you more tired now than you used to be?”

Answer 13

13. 1. It is difficult to determine activity intolerance without objectively comparing activities
       from one time frame to another. Because iron deficiency anemia can occur gradually and individual
       endurance varies, the nurse can best assess the client’s activity tolerance by asking the client to
       compare activities 6 months ago and at present. Asking a client how long a problem has existed is a
       very open-ended question that allows for too much subjectivity for any definition of the client’s
       activity tolerance. Also, the client may not even identify that a “problem” exists. Asking the client
       whether he is staying abreast of usual activities addresses whether the tasks were completed, not the
       tolerance of the client while the tasks were being completed or the resulting condition of the client
       after the tasks were completed. Asking the client if he is more tired now than usual does not address
       his activity tolerance. Tiredness is a subjective evaluation and again can be distorted by factors such
       as the gradual onset of the anemia or the endurance of the individual.
       CN: Reduction of risk potential; CL: Analyze

Question 14

14. A physician prescribes vitamin B 12 for a client with pernicious anemia. Which sites are
appropriate for the nurse to administer vitamin B 12 ? Select all that apply.
1. Median cutaneous.
2. Greater femur trochanter.
3. Acromion muscle.
4. Ventrogluteal.
5. Upper back.
6. Dorsogluteal.

Answer 14

14. 4, 6. A client with pernicious anemia has lost the ability to absorb vitamin B 12 either because
    of the lack of an acidic gastric environment or the lack of the intrinsic factor. Vitamin B 12 must be
    administered by a deep intramuscular route. The ventrogluteal and dorsogluteal locations are the most
    acceptable sites for a deep intramuscular injection. The other sites are not acceptable.
    CN: Pharmacological and parenteral therapies; CL: Apply

Question 15

15. Which position would most help to decrease a client’s discomfort when the client’s spouse
    injects vitamin B 12 using the ventrogluteal site?
16. Lying on the side with legs extended.
17. Lying on the abdomen with toes pointed inward.
18. Leaning over the edge of a low table with hips flexed.
19. Standing upright with the feet one shoulder-width apart.

Answer 15

15. 2. To promote comfort when injecting at the ventrogluteal site, the position of choice is with
       the client lying on the abdomen with toes pointed inward. This positioning promotes muscle
       relaxation, which decreases the discomfort of making an injection into a tense muscle. Lying on the
       side with legs extended will not provide the greatest muscle relaxation. Leaning over the edge of a
       table with the hips flexed and standing upright with the feet apart will increase muscular tension.
       CN: Physiological adaptation; CL: Apply

Question 16

16. A client is admitted from the emergency department after falling down a flight of stairs at
    home. The client’s vital signs are stable, and the history states that the client had a gastric stapling 2
    years ago. The client jokes about being clumsy lately and tripping over things. The nurse should ask
    the client which of the following questions? Select all that apply.
17. “Are you experiencing numbness in your extremities?”2. “How much vitamin B 12 are you getting?”
18. “Are you feeling depressed?”
19. “Do you feel safe at home?”
20. “Are you getting sufficient iron in your diet?”

Answer 16

16. 1, 2, 3, 4. The nurse should ask the client about symptoms related to pernicious anemia
    because the client had the stomach stapled 2 years ago and shows no history of supplemental vitamin
    B 12 . Numbness and tingling relate to a loss of intrinsic factor from the gastric stapling. Intrinsic factor
    is necessary for absorption of vitamin B 12 . The nurse should suspect pernicious anemia if the client is
    not taking supplemental vitamin B 12 . Other signs and symptoms of pernicious anemia include
    cognitive problems and depression. The nurse also should ask about the client’s support at home in
    case the fall was not an accident. Pernicious anemia is not related to dietary intake of iron.
    CN: Reduction of risk potential; CL: Analyze

Question 17

17. A client has fatigue, temperature of 37.5°C, dark bronze skin, and dark urine. Hemoglobin is
    9 g/dL (90 g/L); hematocrit is 49 (0.49), and red blood cells are 2.75 million/μL (2.75 × 10 12 /L).
    What should the nurse do first?
18. Initiate an intake and output record.
19. Place the client on bed rest.
20. Place the client on contact isolation.
21. Keep the client out of sunlight.

Answer 17

17. 1. The nurse should prepare to start an intake and output record because the client is
       exhibiting clinical manifestations of anemia with jaundice and is demonstrating a fluid imbalance.
       The client does not need to be on bed rest at this point. The client is not contagious and does not need
       to be placed in contact isolation. The changes in the color of the skin and urine are related to the
       jaundice and will not be affected by sunlight.
       CN: Physiological adaptation; CL: Synthesize

Question 18

18. When a client is receiving a cephalosporin, the nurse must monitor the client for which of the
following?
1. Drug-induced hemolytic anemia.
2. Purpura.
3. Infectious emboli.
4. Ecchymosis.

Answer 18

18. 1. Drug-induced hemolytic anemia is acquired, antibody-mediated, RBC destruction
       precipitated by medications, such as cephalosporins, sulfa drugs, rifampin, methyldopa,
       procainamide, quinidine, and thiazides. Purpura is a condition with various manifestations
       characterized by hemorrhages into the skin, mucous membranes, internal organs, and other tissues.
       Infectious emboli are clumps of bacteria present in blood or lymph. Ecchymoses are skin
       discolorations due to extravasations of blood into the skin or mucous membranes.
       CN: Reduction of risk potential; CL: Analyze

Question 19

19. A client is to have a Schilling test. The nurse should:
20. Administer methylcellulose.
21. Start a 24- to 48-hour urine specimen collection.
22. Maintain nothing-by-mouth (NPO) status.
23. Start a 72-hour stool specimen collection.

Answer 19

19. 2. Urinary vitamin B 12 levels are measured after the ingestion of radioactive vitamin B 12 . A
       24- to 48-hour urine specimen is collected after administration of an oral dose of radioactively
       tagged vitamin B 12 and an injection of nonradioactive vitamin B 12 . In a healthy state of absorption,
       excess vitamin B 12 is excreted in the urine; in a malabsorptive state or when the intrinsic factor is
       missing, vitamin B 12 is excreted in the feces. Methylcellulose is a bulk-forming agent. Laxatives
       interfere with the absorption of vitamin B 12 . The client is NPO 8 to 12 hours before the test but is not
       NPO during the test. A stool collection is not a part of the Schilling test. If stool contaminates the
       urine collection, the results will be altered.
       CN: Pharmacological and parenteral therapies; CL: Analyze

Question 20

20. A client from a Mediterranean country is admitted with thalassemia, jaundice, splenomegaly,
    and hepatomegaly. Which of the following should be the primary focus of nursing care for this client?
21. Providing activities of daily living on the time schedule of the client’s homeland.
22. Offering foods that the client enjoys in order to increase the intake of calories.
23. Decreasing cardiac demands by promoting rest.
24. Listening to concerns about the hospitalization.

Answer 20

20. 3. This client has clinical manifestations of thalassemia major, a disease found in descendants
       from the Mediterranean Sea area whose mother and father both possess a gene for thalassemia (ie, the
       client is homozygous for the gene). The severe hemolytic anemia causes sequestration of red blood
       cells in the spleen and liver, which leads to engorgement of the organs and chronic bone marrowhyperplasia. Rest will decrease the demands on the heart due to the diminished hemoglobin level, a
       physiologic concern. The nurse should follow the time schedule of the area in which the client is now
       living. The nurse can help the client prescribe preferred foods and listen to concerns, but the main
       priority is to decrease oxygen demands.
       CN: Physiological adaptation; CL: Synthesize

Question 21

21. A client with pernicious anemia asks why it is necessary to take vitamin B 12 injections
    forever. Which is the nurse’s best response?
22. “The reason for your vitamin deficiency is an inability to absorb the vitamin because the
    stomach is not producing sufficient acid.”
23. “The reason for your vitamin deficiency is an inability to absorb the vitamin because the
    stomach is not producing sufficient intrinsic factor.”
24. “The reason for your vitamin deficiency is an excessive excretion of the vitamin because of
    kidney dysfunction.”
25. “The reason for your vitamin deficiency is an increased requirement for the vitamin because of
    rapid red blood cell production.”

Answer 21

21. 2. Most clients with pernicious anemia have deficient production of intrinsic factor in the
       stomach. Intrinsic factor attaches to the vitamin in the stomach and forms a complex that allows the
       vitamin to be absorbed in the small intestine. The stomach is producing enough acid, there is not an
       excessive excretion of the vitamin, and there is not a rapid production of red blood cells in this
       condition.
       CN: Physiological adaptation; CL: Synthesize

Question 22

22. A woman of African descent had experienced severe palpitations, weakness, and shortness of
    breath after taking bacitracin. As a part of the discharge planning, the nurse should evaluate the
    client’s knowledge about:
23. Increased folic acid needs.2. Congenital enzyme deficiency.
24. Restricted activity in hot weather.
25. Need for blood transfusions.

Answer 22

22. 2. This client presented with the typical signs of glucose-6-phosphate dehydrogenase
       (G6PD)–deficiency anemia. Ten percent of Blacks inherit an X-linked recessive disorder of the
       G6PD enzyme in the red blood cell (RBC). When cells with decreased levels of G6PD are exposed
       to certain drugs, such as sulfonamides, acetylsalicylic acid, thiazide diuretics, and vitamin K, the
       RBC may hemolyze and anemia and jaundice may occur. The reaction is self-limited as soon as the
       causative agent is withheld. No further treatment is necessary except counseling to prevent acute
       incidence by avoiding exposure to specific drugs. There is no need for increased folic acid, restricted
       activity in hot weather, or blood transfusions.
       CN: Physiological adaptation; CL: Evaluate

Question 23

23. The nurse is assessing a client’s activity tolerance by having the client walk on a treadmill for
    5 minutes. Which of the following indicates an abnormal response?
24. Pulse rate increased by 20 bpm immediately after the activity.
25. Respiratory rate decreased by 5 breaths/min.
26. Diastolic blood pressure increased by 7 mm Hg.
27. Pulse rate within 6 bpm of resting pulse after 3 minutes of rest.

Answer 23

23. 2. The normal physiologic response to activity is an increased metabolic rate over the resting
       basal rate. The decrease in respiratory rate indicates that the client is not strong enough to complete
       the mechanical cycle of respiration needed for gas exchange. The postactivity pulse is expected to
       increase immediately after activity but by no more than 50 bpm if it is strenuous activity. The
       diastolic blood pressure is expected to rise but by no more than 15 mm Hg. The pulse returns to
       within 6 bpm of the resting pulse after 3 minutes of rest.
       CN: Physiological adaptation; CL: Evaluate

Question 24

24. In a postoperative client, the hematocrit decreased from 36% (0.36) to 34% (0.34) on the
    third day even though the red blood cell (RBC) count and hemoglobin value remained stable at 4.5
    million/μL (4.5 × 10 12 /L) and 11.9 g/dL (119 g/L), respectively. The nurse should next:
25. Check the dressing and drains for frank bleeding.
26. Call the physician.
27. Continue to monitor vital signs.
28. Start oxygen at 2 L/min per nasal cannula.

Answer 24

24. 3. The nurse should continue to monitor the client because this value reflects a normal
       physiologic response. The physician does not need to be called, and oxygen does not need to be
       started based on these laboratory findings. Immediately after surgery, the client’s hematocrit reflects a
       falsely high value related to the body’s compensatory response to the stress of sudden loss of fluids
       and blood. Activation of the intrinsic pathway and the renin-angiotensin cycle via antidiuretic
       hormone produces vasoconstriction and retention of fluid for the first 1 to 2 days postoperatively. By
       the second to third day, this response decreases and the client’s hematocrit level is more reflective of
       the amount of RBCs in the plasma. Fresh bleeding is a less likely occurrence on the third
       postoperative day but is not impossible; however, the nurse should have expected to see a decrease in
       the RBC count and hemoglobin value accompanying the hematocrit.
       CN: Physiological adaptation; CL: Synthesize

Question 25

25. The nurse is administering packed red blood cells (PRBCs) to a client. The nurse should
    first:
26. Discontinue the IV catheter if a blood transfusion reaction occurs.
27. Administer the PRBCs through a percutaneously inserted central catheter line with a 20-gauge
    needle.
28. Flush PRBCs with 5% dextrose and 0.45% normal saline solution.
29. Stay with the client during the first 15 minutes of infusion.

Answer 25

25. 4. The most likely time for a blood transfusion reaction to occur is during the first 15 minutes
       or first 50 mL of the infusion. If a blood transfusion reaction does occur, it is imperative to keep an
       established IV line so that medication can be administered to prevent or treat cardiovascular collapse
       in case of anaphylaxis. PRBCs should be administered through a 19-gauge or larger needle; aperipherally inserted central catheter line is not recommended, in order to avoid a slow flow. RBCs
       will hemolyze in dextrose or lactated Ringer’s solution and should be infused with only normal saline
       solution.
       CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 26

26. The nurse should instruct a young female adult with sickle cell anemia to do which of the
    following? Select all that apply.
27. Drink plenty of fluids when outside in hot weather.
28. Avoid being in high altitudes.
29. Be aware that since she is homozygous for HbS, she carries the sickle cell trait.
30. Know that pregnancy with sickle cell disease increases the risk of a crisis.
31. Avoid flying on commercial airlines.

Answer 26

26. 1, 2, 4. The nurse should teach the client to drink plenty of fluids to avoid becoming
    dehydrated. The client should avoid being in high altitudes, such as mountains above 5,000 feet
    (1,524 m), where there is less oxygen in the air, which may precipitate a sickle cell crisis. The nurse
    should alert young women with sickle cell anemia that pregnancy increases the risk of a crisis. People
    who are homozygous for HbS have sickle cell anemia; the heterozygous form is the sickle cell carrier
    trait. A client with sickle cell anemia may fly on commercial airlines; the airplane is pressurized and
    has an adequate oxygen level.
    CN: Health promotion and maintenance; CL: Synthesize

Question 27

27. The nurse is teaching a client and his family about the client’s new diagnosis of
    hemochromatosis. Which of the following details should the nurse include?
28. Hemochromatosis is an autoimmune disorder that affects the HFE gene.
29. Individuals who are heterozygous for hemochromatosis rarely develop the disease.
30. Individuals who are homozygous for hemochromatosis are carriers of hemochromatosis.
31. Men are at greater risk for hemochromatosis.

Answer 27

27. 2. The nurse should teach the client and family that individuals who are heterozygous for
       hemochromatosis rarely develop the disease. Men and women are equally at risk for
       hemochromatosis, but men are diagnosed earlier because women do not usually have manifestations
       until menopause. Hemochromatosis is the most common genetic disorder in Canada and the United
       States. Individuals who are homozygous for hemochromatosis received a defective gene from each
       parent. Those with homozygous genes may develop the disease.
       CN: Health promotion and maintenance; CL: Synthesize

Question 28

28. A client is having a blood transfusion reaction. The nurse must do the following in what
    order of priority from first to last?
29. Notify the attending physician and blood bank.2. Complete the appropriate Transfusion Reaction Form(s).
30. Stop the transfusion.
31. Keep the IV open with normal saline infusion.

Answer 28

28.
3. Stop the transfusion.
4. Keep the IV open with normal saline infusion.
1. Notify the attending physician and blood bank.
2. Complete the appropriate Transfusion Reaction Form(s).
When the client is having a blood transfusion reaction, the nurse should first stop the transfusion
and then keep the IV open with normal saline infusion. Next, the nurse should notify the physician and
blood bank, then complete the required form(s) regarding the transfusion reaction.
CN: Physiological adaptation; CL: Synthesize

Question 29

29. Which safety measures would be most important to implement when caring for a client who
    is receiving 2 units of packed red blood cells (PRBCs)? Select all that apply.
30. Verify that the ABO and Rh of the 2 units are the same.
31. Infuse a unit of PRBCs in less than 4 hours.
32. Stop the transfusion if a reaction occurs, but keep the line open.
33. Take vital signs every 15 minutes while the unit is transfusing.
34. Inspect the blood bag for leaks, abnormal color, and clots.
35. Use a 22-gauge catheter for optimal flow of a blood transfusion.

Answer 29

29. 2, 3, 5. The American Association of Blood Banks and Canadian Blood Services recommend
    that two qualified people, such as two registered nurses, compare the name and number on the
    identification bracelet with the tag on the blood bag. Verifying that the two units are the same is not a
    recommendation. Rather, the verification is always with the client, not with bags of blood. A unit of
    blood should infuse in 4 hours or less to avoid the risk of septicemia since no preservatives are used.
    When a blood transfusion reaction occurs, the blood transfusion should be stopped immediately, but
    the IV line should be kept open so that emergency medications and fluids can be administered.The unit of PRBCs should be inspected for contamination by looking for leaks, abnormal color,
    clots, and excessive air bubbles. When a unit of PRBCs is being transfused, vital signs are assessed
    before the transfusion begins, after the first 15 minutes, and then every hour until 1 hour after the
    transfusion has been completed. When PRBCs are being administered, a 20-gauge or larger needle is
    needed to avoid destroying the red blood cells (RBCs) passing through the lumen and to allow for
    maximal flow rate.
    CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 30

30. A client who had received 25 mL of packed red blood cells (PRBCs) has low back pain and
    pruritus. After stopping the infusion, the nurse should take what action next?
31. Administer prescribed antihistamine and aspirin.
32. Collect blood and urine samples and send to the lab.
33. Administer prescribed diuretics.
34. Administer prescribed vasopressors.

Answer 30

30. 2. ABO- and Rh-incompatible blood causes an antigen-antibody reaction that produces
       hemolysis or agglutination of red blood cells (RBCs). At the first indication of any sign/symptom of
       reaction, the blood transfusion is stopped. Blood and urine samples are obtained from the client and
       sent to the lab along with the remaining untransfused blood. Hemoglobin in the urine and blood
       samples taken at the time of the reaction provides evidence of a hemolytic blood transfusion reaction.
       Antihistamine, aspirin, diuretics, and vasopressors may be administered with different types of
       transfusion reactions.
       CN: Reduction of risk potential; CL: Synthesize

Question 31

31. A client is to receive epoetin injections. What laboratory value should the nurse assess
before giving the injection?
1. Hematocrit.
2. Partial thromboplastin time.
3. Hemoglobin concentration.
4. Prothrombin time.

Answer 31

31. 1. Epoetin is a recombinant DNA form of erythropoietin, which stimulates the production of
       red blood cells (RBCs) and therefore causes the hematocrit to rise. The elevation in hematocrit
       causes an elevation in the blood pressure; therefore, the blood pressure is a vital sign that should be
       checked. The partial thromboplastin time, hemoglobin level, and prothrombin time are not monitored
       for this drug.
       CN: Pharmacological and parenteral therapies; CL: Analyze

Question 32

32. When beginning IV erythropoietin therapy, the nurse should do which of the following? Select
    all that apply.
33. Check the hemoglobin levels before administering subsequent doses.
34. Shake the vial thoroughly to mix the concentrated white, milky solution.
35. Keep the multidose vial refrigerated between scheduled twice-a-day doses.
36. Administer the medication through the IV line without other medications.
37. Adjust the initial doses according to the client’s changes in blood pressure.
38. Instruct the client to avoid driving and performing hazardous activity during the initial
    treatment.

Answer 32

32. 4, 5, 6. Erythropoietin is administered to decrease the need for blood transfusions by
    stimulating red blood cell (RBC) production. The medication should be administered through the IV
    line without other medications to avoid a reaction. The hematocrit, a simple measurement of the
    percentage of RBCs in the total blood volume, is used to monitor this therapy. When initiating IV
    erythropoietin therapy, the nurse should monitor the hematocrit level so that it rises no more than four
    points in any 2-week period. In addition, the initial doses of erythropoietin are adjusted according to
    the client’s changes in blood pressure. The nurse should tell the client to avoid driving and performing
    hazardous activity during the initial treatment due to possible dizziness and headaches secondary to
    the adverse effect of hypertension. The hematocrit, not the hemoglobin level, is used for monitoring
    the effectiveness of therapy. The vial of erythropoietin should not be shaken because it may be
    biologically inactive. The solution should not be used if it is discolored. The nurse should not re-
    enter the vial once it has been entered; it is a one-time use vial. All remaining erythropoietin should
    be discarded since it does not contain preservatives.
    CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 33

33. A client is afraid of receiving vitamin B 12 injections because of potential toxic reactions.
    Which is the nurse’s best response to relieve these fears?
34. “Vitamin B 12 will cause ringing in the ears before a toxic level is reached.”
35. “Vitamin B 12 may cause a very mild rash initially.”
36. “Vitamin B 12 cause mild nausea but nothing toxic.”
37. “Vitamin B 12 is generally free of toxicity because it is water soluble.”

Answer 33

33. 4. Vitamin B 12 is a water-soluble vitamin. When water-soluble vitamins are taken in excess of
       the body’s needs, they are filtered through the kidneys and excreted. Vitamin B 12 is considered to be
       nontoxic. Adverse reactions that have occurred are believed to be related to impurities or to the
       preservative in B 12 preparations. Ringing in the ears, rash, and nausea are not considered to be
       related to vitamin B 12 administration.
       CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 34

34. A client with microcytic anemia is having trouble selecting food from the hospital menu.
    Which food is best for the nurse to suggest for satisfying the client’s nutritional needs?
35. Egg yolks.
36. Brown rice.
37. Vegetables.
38. Tea.

Answer 34

34. 2. Brown rice is a source of iron from plant sources (nonheme iron). Other sources of
       nonheme iron are whole-grain cereals and breads, dark green vegetables, legumes, nuts, dried fruits
       (apricots, raisins, dates), oatmeal, and sweet potatoes. Egg yolks have iron but it is not as well
       absorbed as iron from other sources. Vegetables are a good source of vitamins that may facilitate iron
       absorption. Tea contains tannin, which combines with nonheme iron, preventing its absorption.
       CN: Physiological adaptation; CL: Apply

Question 35

35. A client with macrocytic anemia has a burn on the foot and reports watching television while
    lying on a heating pad. Which action should be the nurse’s first response?
36. Assess for potential abuse.
37. Check for diminished sensations.
38. Document the findings.
39. Clean and dress the area.

Answer 35

35. 2. Macrocytic anemias can result from deficiencies in vitamin B 12 or ascorbic acid. Only
       vitamin B 12 deficiency causes diminished sensations of peripheral nerve endings. The nurse should
       assess for peripheral neuropathy and instruct the client in self-care activities for diminished sensation
       to heat and pain (eg, using a heating pad at a lower heat setting, making frequent checks to protect
       against skin trauma). The burn could be related to abuse, but this conclusion would require more
       supporting data. The findings should be documented, but the nurse would want to address the client’s
       sensations first. The decision of how to treat the burn should be determined by the physician.
       CN: Reduction of risk potential; CL: Synthesize

Question 36

36. Which of the following is a late symptom of polycythemia vera?
37. Headache.
38. Dizziness.
39. Pruritus.
40. Shortness of breath.

Answer 36

36. 3. Pruritus is a late symptom that results from abnormal histamine metabolism. Headache and
       dizziness are early symptoms from engorged veins. Shortness of breath is an early symptom from
       congested mucous membranes and ineffective gas exchange.
       CN: Physiological adaptation; CL: Analyze

Question 37

37. The nurse is teaching a client with polycythemia vera about potential complications from this
    disease. Which manifestations should the nurse include in the client’s teaching plan? Select all that
    apply.
38. Hearing loss.
39. Visual disturbance.
40. Headache.
41. Orthopnea.
42. Gout.
43. Weight loss.

Answer 37

37. 2, 3, 4, 5. Polycythemia vera, a condition in which too many red blood cells (RBCs) are
    produced in the blood serum, can lead to an increase in the hematocrit and hypervolemia,
    hyperviscosity, and hypertension. Subsequently, the client can experience dizziness, tinnitus, visual
    disturbances, headaches, or a feeling of fullness in the head. The client may also experience
    cardiovascular symptoms such as heart failure (shortness of breath and orthopnea) and increased
    clotting time or symptoms of an increased uric acid level such as painful, swollen joints (usually the
    big toe). Hearing loss and weight loss are not manifestations associated with polycythemia vera.
    CN: Reduction of risk potential; CL: Create

Question 38

38. When a client is diagnosed with aplastic anemia, the nurse should assess the client for
    changes in which of the following physiologic functions?
39. Bleeding tendencies.
40. Intake and output.
41. Peripheral sensation.
42. Bowel function.

Answer 38

38. 1. Aplastic anemia decreases the bone marrow production of red blood cells (RBCs), white
       blood cells, and platelets. The client is at risk for bruising and bleeding tendencies. A change in the
       client’s intake and output is important, but assessment for the potential for bleeding takes priority.
       Change in the peripheral nervous system is a priority problem specific to clients with vitamin B 12
       deficiency. Change in bowel function is not associated with aplastic anemia.
       CN: Physiological adaptation; CL: Synthesize

Question 39

The Client with Platelet Disorders
39. A health care provider prescribes 0.5 mg of protamine sulfate for a client who is showing
signs of bleeding after receiving a 100-unit dose of heparin. The nurse should expect the effects of the
protamine sulfate to be noted in which of the following time frames?
1. 5 minutes.
2. 10 minutes.
3. 20 minutes.
4. 30 minutes.

Answer 39

The Client with Platelet Disorders
39. 3. A dose of 0.5 mg of protamine sulfate reverses a 100-unit dose of heparin within 20
minutes. The nurse should administer protamine sulfate by IV push slowly to avoid adverse effects,
such as hypotension, dyspnea, bradycardia, and anaphylaxis.
CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 40

40. The nurse is to administer subcutaneous heparin to an older adult. What facts should the nurse
    keep in mind when administering this dose? Select all that apply.
41. It should be administered in the anterior area of the iliac crest.
42. The onset is immediate.
43. Use a 27G, 5/8′′ (1.6-cm) needle.
44. Cephalosporin potentiates the effects of heparin.
45. Double check the dose with another nurse.

Answer 40

40. 1, 3, 4, 5. Older adults may have little subcutaneous tissue, so the area around the anterior
    iliac crest is a suitable site for these clients. The nurse should use a 27G, 5/8′′ (1.6-cm) needle.
    Cephalosporin and penicillin potentiate the effects of heparin. Two nurses should check the dosebecause a dose error could cause hemorrhage. The onset of heparin is not immediate when given
    subcutaneously.
    CN: Pharmacological and parenteral therapies; CL: Apply

Question 41

41. The nurse should instruct the client with a platelet count of 31,000/μL (31 × 10 9 /L) to:
42. Pad sharp surfaces to avoid minor trauma when walking.
43. Assess for spontaneous petechiae in the extremities.
44. Keep the room darkened.
45. Check for blood in the urine.

Answer 41

41. 1. A client with a platelet count of 30,000 to 50,000/μL (30 to 50 × 10 9 /L) is susceptible to
       bruising with minor trauma. Padding areas that the client might bump, scratch, or hit may help prevent
       minor trauma. A platelet count of 15,000 to 30,000/μL (15 to 30 × 10 9 /L) may result in spontaneous
       petechiae and bruising, especially on the extremities. Padding measures would still be used, but the
       focus would be on assessing for new spontaneous petechiae. Keeping the room dark does not help the
       client with a low platelet count. With a count below 20,000/μL (20 × 10 9 /L), the client is at risk for
       spontaneous bleeding from the mucous membranes and intracranial bleeding.
       CN: Reduction of risk potential; CL: Synthesize

Question 42

42. A client with a history of systemic lupus erythematosus was admitted with a severe viral
    respiratory tract infection and diffuse petechiae. Based on these data, it is most important that the
    nurse further evaluate the client’s recent:
43. Quality and quantity of food intake.
44. Type and amount of fluid intake.
45. Weakness, fatigue, and ability to get around.
46. Length and amount of menstrual flow.

Answer 42

42. 4. A recent viral infection in a female client between the ages of 20 and 30 with a history of
       systemic lupus erythematosus and an insidious onset of diffuse petechiae are hallmarks of idiopathic
       thrombocytopenic purpura. It is important to ask whether the client’s recent menses have been
       lengthened or are heavier. Determining her ability to clot can help determine her risk of increased
       bleeding tendency until a platelet count is drawn. Petechiae are not caused by poor nutrition. Because
       of poor food and fluid intake or weakness and fatigue, the client may have gotten bruises from falling
       or bumping into things, but not petechiae.
       CN: Reduction of risk potential; CL: Analyze

Question 43

43. When a client with thrombocytopenia has a severe headache, the nurse interprets that this may
indicate which of the following?
1. Stress of the disease.
2. Cerebral bleeding.
3. Migraine headache.
4. Sinus congestion.

Answer 43

43. 2. When the platelet count is very low, red blood cells (RBCs) leak out of the blood vessels
       and into the tissue. If the blood pressure is elevated and the platelet count falls to less than 15,000/μL
       (15 × 10 9 /L), internal bleeding in the brain can occur. A severe headache occurs from meningeal
       irritation when blood leaks out of the cerebral vasculature. When a client has thrombocytopenia, the
       nurse should always assess for cerebral bleeding by checking vital signs and performing neurologic
       checks. Headaches can be caused by stress, migraines, and sinus congestion. However, the concern
       here is the risk of internal bleeding into the brain.
       CN: Health promotion and maintenance; CL: Analyze

Question 44

44. The nurse evaluates that the client correctly understands how to report signs and symptoms of
    bleeding when the client makes which of the following statements?
45. “Petechiae are large, red skin bruises.”
46. “Ecchymoses are large, purple skin bruises.”
47. “Purpura is an open cut on the skin.”
48. “Abrasions are small pinpoint red dots on the skin.”

Answer 44

44. 2. Large, purplish skin lesions caused by hemorrhage are called ecchymoses. Small, flat, red
       pinpoint lesions are petechiae. Numerous petechiae result in a reddish, bruised appearance called
       purpura. An abrasion is a wound caused by scraping.
       CN: Health promotion and maintenance; CL: Evaluate

Question 45

45. The nurse should instruct the client with a platelet count of less than 150,000/μL (150 ×10 9 /L) to avoid which of the following activities?
46. Ambulation.
47. Valsalva’s maneuver.
48. Visiting with children.
49. Semi-Fowler’s position.

Answer 45

45. 2. When the platelet count is less than 150,000/μL (150 × 10 9 /L), prolonged bleeding can
       occur from trauma, injury, or straining such as with Valsalva’s maneuver. Clients should avoid any
       activity that causes straining to evacuate the bowel. Clients can ambulate, but pointed or sharp
       surfaces should be padded. Clients can visit with their families but should avoid any scratches,
       bumps, or scrapes. Clients can sit in a semi-Fowler’s position but should change positions to promote
       circulation and check for petechiae.
       CN: Health promotion and maintenance; CL: Synthesize

Question 46

46. A client who is taking acetylsalicylic acid (ASA) caplets develops prolonged bleeding from
    a superficial skin injury on the forearm. The nurse should tell the client to do which of the following
    first?
47. Place the forearm under a running stream of lukewarm water.
48. Pat the injury with a dry washcloth.
49. Wrap the entire forearm from the wrist to the elbow.
50. Apply an ice pack for 20 minutes.

Answer 46

46. 4. Aspirin has an antiplatelet effect, and bleeding time can consequently be prolonged.
       Intermittent use of ice packs to the site may stop the bleeding; ice causes blood vessels tovasoconstrict. Use of lukewarm water, patting the injury, and wrapping the entire forearm do not
       promote vasoconstriction to stop bleeding.
       CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 47

47. A client’s bone marrow report reveals normal stem cells and precursors of platelets
    (megakaryocytes) in the presence of decreased circulating platelets. The nurse recognizes a
    knowledge deficit when the client makes which of the following statements?
48. “I need to stop flossing and throw away my hard toothbrush.”
49. “I am glad that my report turned out normal.”
50. “Now I know why I have all these bruises.”
51. “I shouldn’t jump off that last step anymore.”

Answer 47

47. 2. The client who states that the test results are normal has only heard that the bone marrow is
       functioning. The etiology is in the destruction of circulating platelets. Further tests must be completed
       to determine the cause (eg, a coating of the platelets with antibodies that are seen as foreign bodies).
       The bone marrow result does rule out other potential diagnoses such as anemia, leukemia, or
       myeloproliferative disorders that involve bone marrow depression. The client needs to stop flossing
       and throw away his hard toothbrush, which can lead to bleeding of the gums. The destruction of the
       circulating platelets accounts for the easy bruising and the need to protect oneself from further
       bruising. The client should not jump or increase exertion of joints, which may lead to bleeding in the
       joints and joint pain.
       CN: Reduction of risk potential; CL: Evaluate

Question 48

48. The nurse should assess a client with thrombocytopenia who has developed a hemorrhage for
which of the following?
1. Tachycardia.
2. Bradycardia.
3. Decreased Pa CO2 .
4. Narrowed pulse pressure.

Answer 48

48. 1. The nurse observes tachycardia in the hemorrhaging client because the heart beats faster to
       compensate for decreased circulating volume and decreased numbers of oxygen-carrying red blood
       cells (RBCs). The degree of cardiopulmonary distress and anemia will be related to the amount of
       hemorrhage that occurred and the period of time over which it occurred. Bradycardia is a late
       symptom of hemorrhage; it occurs after the client is no longer able to compromise and is debilitating
       further into shock. If bradycardia is left untreated, the client will die from cardiovascular collapse.
       Decreased Pa CO2 is a late symptom of hemorrhage, after transport of oxygen to the tissue has been
       affected. A narrowed pulse pressure is not an early sign of hemorrhage.
       CN: Physiological adaptation; CL: Analyze

Question 49

49. The client with idiopathic thrombocytopenic purpura (ITP) asks the nurse why it is necessary
    to take steroids. Which is the nurse’s best response?
50. Steroids destroy the antibodies and prolong the life of platelets.
51. Steroids neutralize the antigens and prolong the life of platelets.
52. Steroids increase phagocytosis and increase the life of platelets.
53. Steroids alter the spleen’s recognition of platelets and increase the life of platelets.

Answer 49

49. 4. ITP is treated with steroids to suppress the splenic macrophages from phagocytizing the
       antibody-coated platelets, which are recognized as foreign bodies, so that the platelets live longer.
       The steroids also suppress the binding of the autoimmune antibody to the platelet surface. Steroids do
       not destroy the antibodies on the platelets, neutralize antigens, or increase phagocytosis.
       CN: Pharmacological and parenteral therapies; CL: Apply

Question 50

50. A client is to be discharged on prednisone. Which of the following statements indicates that
    the client understands important concepts about the medication therapy?
51. “I need to take the medicine in divided doses at morning and bedtime.”
52. “I am to take 40 mg of prednisone for 2 months and then stop.”
53. “I need to wear or carry identification that I am taking prednisone.”
54. “Prednisone will give me extra protection from colds and flu.”

Answer 50

50. 3. The client needs to wear or carry information containing the name of the drug, dosage,
       physician and contact information, and emergency instructions because additional corticosteroid drug
       therapy would be needed during emergency situations. Prednisone should be taken in the morning
       because it can cause insomnia and because exogenous corticosteroid suppression of the adrenal
       cortex is less when it is administered in the morning. Prednisone must never be stopped suddenly. It
       must be tapered off to allow for the adrenal cortex to recover from drug-induced atrophy so that it can
       resume its function. Prednisone suppresses the immune response and masks infections. It does not
       provide extra protection against infection.
       CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 51

51. When teaching the client older than age 50 who is receiving long-term prednisone therapy, the
    nurse should recommend which of the following?
52. Take the prednisone with food.
53. Take over-the-counter drugs as needed.
54. Exercise three to four times a week.4. Eat foods that are low in potassium.

Answer 51

51. 1. Nausea, vomiting, and peptic ulcers are gastrointestinal adverse effects of prednisone, so it
       is recommended that clients take the prednisone with food. In some instances, the client may be
       advised to take a prescribed antacid prophylactically. The client should never take over-the-counter
       drugs without notifying the physician who prescribed the prednisone. The client should ask the
       physician about the amount and kind of exercise because of the need to establish baseline physicalvalues before starting an exercise program and because of the increased potential for comorbidity
       with increasing age. The client should eat foods that are high in potassium to prevent hypokalemia.
       CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 52

52. The nurse is preparing a teaching plan about increased exercise for a female client who is
    receiving long-term corticosteroid therapy. What type of exercise is most appropriate for this client?
53. Floor exercises.
54. Stretching.
55. Running.
56. Walking.

Answer 52

52. 4. The best exercise for females who are on long-term corticosteroid therapy is a low-impact,
       weightbearing exercise such as walking or weight lifting. Floor exercises do not provide for the
       weightbearing. Stretching is appropriate but does not offer sufficient weightbearing. Running
       provides for weightbearing but is hard on the joints and may cause bleeding.
       CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 53

53. The nurse is teaching a female client with a history of acquired thrombocytopenia about how
    to prevent and control hemorrhage. Which statement indicates that the client needs further instruction?
54. “I can apply direct pressure over small cuts for at least 5 to 10 minutes to stop a venous
    bleed.”
55. “I can count the number of tissues saturated to detect blood loss during a nosebleed.”
56. “I can take hormones to decrease blood loss during menses.”
57. “I can count the number of sanitary napkins to detect excess blood loss during menses.”

Answer 53

53. 2. The client needs further teaching if she thinks that the number of tissues saturated represents
       all of the blood lost during a nosebleed. During a nosebleed, a significant amount of blood can be
       swallowed and go undetected. It is important that clients with severe thrombocytopenia do not take a
       nosebleed lightly. Clients with thrombocytopenia can apply pressure for 5 to 10 minutes over a small,
       superficial cut. Clients with thrombocytopenia can take hormones to suppress menses and control
       menstrual blood loss. Clients can also count the number of saturated sanitary napkins to approximate
       blood loss during menses. Some authorities estimate that a completely soaked sanitary napkin holds
       50 mL.
       CN: Reduction of risk potential; CL: Evaluate

Question 54

54. A client has been on long-term prednisone therapy. The nurse should instruct the client to
consume a diet high in which of the following? Select all that apply.
1. Carbohydrate.
2. Protein.
3. Trans fat.
4. Potassium.
5. Calcium.
6. Vitamin D.

Answer 54

54. 2, 4, 5, 6. Adverse effects of prednisone are weight gain, retention of sodium and fluids with
    hypertension and cushingoid features, a low serum albumin level, suppressed inflammatory processes
    with masked symptoms, and osteoporosis. A diet high in protein, potassium, calcium, and vitamin D
    is recommended. Carbohydrate would elevate glucose and further compromise a client’s immune
    status. Trans fat does not counteract the adverse effects of steroids such as prednisone.
    CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 55

55. Platelets should not be administered under which of the following conditions?
56. The platelet bag is cold.
57. The platelets are 2 days old.
58. The platelet bag is at room temperature.
59. The platelets are 12 hours old.

Answer 55

55. 1. Platelets cannot survive cold temperatures. The platelets should be stored at room
       temperature and last for no more than 5 days.
       CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 56

56. The nurse is preparing to administer platelets. The nurse should:
57. Check the ABO compatibility.
58. Administer the platelets slowly.
59. Gently rotate the bag.
60. Use a whole blood tubing set.

Answer 56

56. 3. The bag containing platelets needs to be gently rotated to prevent clumping. ABO
       compatibility is not a necessary requirement, but human leukocyte antigen (HLA) matching of
       lymphocytes may be completed to avoid development of anti-HLA antibodies when multiple platelet
       transfusions are necessary. Platelets should be administered as fast as can be tolerated by the client to
       avoid aggregation. Most institutions use tubing especially for platelets instead of tubing for blood and
       blood products.
       CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 57

57. Which of the following indicates that a client has achieved the goal of correctly
    demonstrating deep breathing for an upcoming splenectomy? The client:
58. Breathes in through the nose and out through the mouth.
59. Breathes in through the mouth and out through the nose.
60. Uses diaphragmatic breathing in the lying, sitting, and standing positions.
61. Takes a deep breath in through the nose, holds it for 5 seconds, and blows out through pursed
    lips.

Answer 57

57. 4. The correct technique for deep breathing postoperatively to avoid atelectasis and
       pneumonia is to take in a deep breath through the nose, hold it for 5 seconds, then blow it out through
       pursed lips. The goal is to fully expand and empty the lungs for pulmonary hygiene.
       CN: Reduction of risk potential; CL: Evaluate

Question 58

58. A client is scheduled for an elective splenectomy. Immediately before the client goes to
    surgery, the nurse should determine that the client has:
59. Voided completely.2. Signed the consent.
60. Vital signs recorded.
61. Name band on wrist.

Answer 58

58. 3. An elective surgical procedure is scheduled in advance so that all preparations can be
       completed ahead of time. The vital signs are the final check that must be completed before the client
       leaves the room so that continuity of care and assessment is provided for. The first assessment thatwill be completed in the preoperative holding area or operating room will be the client’s vital signs.
       The client should have emptied the bladder before receiving preoperative medications so that the
       bladder is empty when it is time for transport into the operating room. The client should have signed
       the consent before the transport time so that if there were any questions or concerns there was time to
       meet with the surgeon. Also, the consent form must be signed before any sedative medications are
       given. The client’s name band should be placed as soon as the client arrives in the perioperative
       setting, and it remains in place through discharge.
       CN: Physiological adaptation; CL: Analyze

Question 59

59. When receiving a client from the postanesthesia care unit after a splenectomy, which should
    the nurse assess next after obtaining vital signs?
60. Nasogastric drainage.
61. Urinary catheter.
62. Dressing.
63. Need for pain medication.

Answer 59

59. 3. After a splenectomy, the client is at high risk for hypovolemia and hemorrhage. The
       dressing should be checked often; if drainage is present, a circle should be drawn around the drainage
       and the time noted to help determine how fast bleeding is occurring. The nasogastric tube should be
       connected, but this can wait until the dressing has been checked. A urinary catheter is not needed. The
       last pain medication administration and the client’s current pain level should be communicated in the
       exchange report. Checking for hemorrhage is a greater priority than assessing pain level.
       CN: Physiological adaptation; CL: Analyze

Question 60

60. The client’s family asks why the client who had a splenectomy has a nasogastric (NG) tube.
    An NG tube is used to:
61. Move the stomach away from where the spleen was removed.
62. Irrigate the operative site.
63. Decrease abdominal distention.
64. Assess for the gastric pH as peristalsis returns.

Answer 60

60. 3. A splenectomy may involve manipulation of the upper abdominal organs, such as
       diaphragm, stomach, liver, spleen, and small intestines. Manipulation of these organs and resulting
       inflammation lead to a slowed peristalsis. An NG tube is placed to decrease abdominal distention in
       the immediate postoperative phase. The stomach does not need to be manipulated away from the
       spleen postoperatively, nor would an NG tube accomplish this. The NG tube drains gastric contents
       and air in the stomach; it is not in the operative site, and therefore cannot be used to irrigate it. The
       gastric juices are not checked as an indicator that peristalsis has returned; instead, bowel sounds are
       auscultated in all four quadrants to indicate the return of peristalsis.
       CN: Physiological adaptation; CL: Apply

Question 61

61. A client who had a splenectomy is being discharged. Of the following discharge instructions,
    which is most specific to the client’s surgical procedure?
62. Do not drive.
63. Alternate rest and activity.
64. Make an appointment for the staples to be removed.
65. Report early signs of infection.

Answer 61

61. 4. Clients who have had a splenectomy are especially prone to infection. The reduction of
       immunoglobulin M leaves the client especially at risk for immunologic deficiency infections. All
       clients who have had major abdominal surgery usually receive discharge instructions not to drive
       because the stomach muscles are not strong enough to brake hard or quickly after the abdominal
       muscles have been separated. All clients need to pace activity and rest when going home after major
       surgery. Rest and sleep allow the growth hormone to repair the tissue, and activity allows the energy
       and strength to build endurance and muscle strength. An appointment is usually made to see the
       surgeon in the office 1 week after discharge for follow-up and to remove sutures or staples if this has
       not already been done.
       CN: Reduction of risk potential; CL: Synthesize

Question 62

62. What is the earliest clinical manifestation in a client with acute disseminated intravascular
coagulation (DIC)?
1. Severe shortness of breath.
2. Bleeding without history or cause.
3. Orthopnea.
4. Hematuria.

Answer 62

62. 2. There is no well-defined sequence for acute DIC other than that the client starts bleeding
       without a history or cause and does not stop bleeding. Later signs may include severe shortness of
       breath, hypotension, pallor, petechiae, hematoma, orthopnea, hematuria, vision changes, and joint
       pain.
       CN: Physiological adaptation; CL: Analyze

Question 63

63. Which of the following is contraindicated for a client diagnosed with disseminated
    intravascular coagulation (DIC)?
64. Treating the underlying cause.
65. Administering heparin.
66. Administering warfarin sodium (Coumadin).
67. Replacing depleted blood products.

Answer 63

63. 3. DIC has not been found to respond to oral anticoagulants such as warfarin sodium
       (Coumadin). Treatments for DIC are controversial but include treating the underlying cause,
       administering heparin, and replacing depleted blood products.CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 64

64. A client with disseminated intravascular coagulation develops clinical manifestations of
    microvascular thrombosis. The nurse should assess the client for:
65. Hemoptysis.
66. Focal ischemia.
67. Petechiae.
68. Hematuria.

Answer 64

64. 2. Clinical manifestations of microvascular thrombosis are those that represent a blockage of
       blood flow and oxygenation to the tissue that results in eventual death of the organ. Examples of
       microvascular thrombosis include acute respiratory distress syndrome, focal ischemia, superficial
       gangrene, oliguria, azotemia, cortical necrosis, acute ulceration, delirium, and coma. Hemoptysis,
       petechiae, and hematuria are signs of hemorrhage.
       CN: Physiological adaptation; CL: Analyze

Question 65

65. Which of the following is an assessment finding associated with internal bleeding with
disseminated intravascular coagulation?
1. Bradycardia.2. Hypertension.
3. Increasing abdominal girth.
4. Petechiae.

Answer 65

65. 3. As blood collects in the peritoneal cavity, it causes dilation and distention, which is
       reflected in increased abdominal girth. The client would be tachycardic and hypotensive. Petechiae
       reflect bleeding in the skin.
       CN: Physiological adaptation; CL: Analyze

Question 66

The Client with White Blood Cell Disorders
66. A young adult is diagnosed with infectious mononucleosis. The white blood cell (WBC)
count is 19,000/μL (19 × 10 9 /L). The client has a streptococcal throat infection, enlarged spleen, and
aching muscles. Which of the following instructions should the nurse include in discharge planning
with the client? Select all that apply.
1. Stay on bed rest until the temperature is normal.
2. Gargle with warm saline while the throat is irritated.
3. Increase intake of fluids until the infection subsides.
4. Wear a mask if others are present.
5. Avoid contact sports while the spleen is enlarged.

Answer 66

The Client with White Blood Cell Disorders
66. 1, 2, 3, 5. The nurse should teach this client to stay on bed rest as long as there is a fever,
gargle with warm saline, and increase oral fluids to prevent dehydration from the elevated
temperature. The client with an enlarged spleen should avoid contact sports due to the increased risk
of injury due to the enlargement. The client does not need to wear a mask, but should observe
handwashing procedures.
CN: Basic care and comfort; CL: Create

Question 67

67. The daily white blood cell (WBC) count in a client with aplastic anemia drops overnight
    from 3,900 to 2,900/μL (3.9 to 2.9 × 10 9 /L). Which is the appropriate nursing intervention?
68. Continue monitoring the client.
69. Call the laboratory to verify the report.
70. Document the finding.
71. Call the physician and request that the client be placed in reverse isolation.

Answer 67

67. 4. The client will need a prescription from the physician to be placed in reverse (protective)
       isolation because the normal defenses are ineffective and place the client at risk for infection
       (leukopenia, less than 5,000 cells/μL [5 × 10 9 /L]). The faster the decrease in WBCs, the greater the
       bone marrow suppression, and the more susceptible the client is to infection from not only pathogenic
       but nonpathogenic organisms. The client will continue to be monitored, the laboratory may be called,
       and the report will be placed on the chart, but protection of the client must be instituted immediately.
       CN: Physiological adaptation; CL: Synthesize

Question 68

68. A client who had an exploratory laparotomy 3 days ago has a white blood cell (WBC)
    differential with a shift to the left. The nurse instructs unlicensed personnel to report which clinical
    manifestation?
69. Swelling around the incision.
70. Redness around the incision.
71. Elevated temperature.
72. Purulent wound drainage.

Answer 68

68. 3. A shift to the left means that more immature than mature WBCs are at the site of
       inflammation or infection. Immature WBCs are less effective at phagocytosis and do not produce
       classic signs of inflammation, such as pus, redness, swelling, or heat. Fever is the only sign;
       therefore, it is a significant sign of infection in a client with immature or depressed WBCs.
       CN: Physiological adaptation; CL: Analyze

Question 69

69. The nurse is developing a care plan for a client with leukemia. The plan should include
    which of the following? Select all that apply.
70. Monitor temperature and report elevation.
71. Recognize signs and symptoms of infection.
72. Avoid crowds.
73. Maintain integrity of skin and mucous membranes.
74. Take a baby aspirin each day.

Answer 69

69. 1, 2, 3, 4. Nursing care of a client with leukemia includes managing and preventing infection,
    maintaining integrity of skin and mucous membranes, instituting measures to prevent bleeding, and
    monitoring for bleeding. Aspirin is an anticoagulant; bleeding tendencies, such as petechiae,
    ecchymosis, epistaxis, gingival bleeding, and retinal hemorrhages are likely due to thrombocytopenia.
    CN: Reduction of risk potential; CL: Create

Question 70

70. A client with neutropenia has an absolute neutrophil count (ANC) of 900 (0.9 × 10 9 /L). What
is the client's risk of infection?
1. Normal risk.
2. Moderate risk.
3. High risk.
4. Extremely high risk.

Answer 70

70. 2. A client is at moderate risk when the ANC is less than 1,000 (1 × 10 9 /L). The ANC
       decreases proportionate to the increased risk for infection. Normal risk for infection is when the ANC
       is 1,500 (1.5 × 10 9 /L) or greater. High risk for infection is when the ANC is less than 500 (0.5 ×
       10 9 /L). An ANC of 100 (0.1 × 10 9 /L) or less is life threatening.CN: Physiological adaptation; CL: Analyze

Question 71

71. Which factor in addition to the degree of neutropenia should the nurse assess in determining
    the client’s risk of infection?
72. Length of time neutropenia has existed.
73. Health status before neutropenia.3. Body build and weight.
74. Resistance to infection in childhood.

Answer 71

71. 1. The one factor that may be more important than the degree of neutropenia in determining the
       risk for infection is the duration of the neutropenia.
       CN: Physiological adaptation; CL: Analyze

Question 72

72. Which nursing action is important in preventing crosscontamination?
73. Change gloves immediately after use.
74. Stand 2 feet (61 cm) from the client.
75. Speak minimally when in the room.
76. Wear long-sleeved shirts.

Answer 72

72. 1. Bedside rails, call bells, drug-administration controls operated by the client, and other
       surface areas are frequently touched by caregivers with used gloves. Changing gloves immediately
       after use protects the client from contamination by organisms. Cross-contamination is a break in
       technique of serious consequence to the severely compromised client. Standing 2 feet (61 cm) from
       the client, speaking minimally, and wearing long-sleeved shirts are not required in standard
       interventions for risk of infection.
       CN: Safety and infection control; CL: Synthesize

Question 73

73. The nurse should teach the client with neutropenia and the family to avoid which of the
    following?
74. Using suppositories or enemas.
75. Using a high-efficiency particulate air (HEPA) filter mask.
76. Performing perianal care after every bowel movement.
77. Performing oral care after every meal.

Answer 73

73. 1. The neutropenic client is at risk for infection, especially bacterial infection of the
       respiratory and gastrointestinal tracts. Breaks in the mucous membranes, such as those that could be
       caused by the insertion of a suppository or enema tube, would be a break in the first line of the body’s
       defense and a direct port of entry for infection. The client with neutropenia is encouraged to wear a
       HEPA filter mask and to use an incentive spirometer for pulmonary hygiene. The client needs to know
       the importance of completing meticulous total body hygiene daily, including perianal care after every
       bowel movement, to decrease the flora at normal body orifices. The client also needs to know the
       importance of performing oral care after every meal and every 4 hours while the client is awake to
       decrease the bacterial buildup in the oropharynx.
       CN: Health promotion and maintenance; CL: Synthesize

Question 74

74. The nurse should remind family members who are visiting a client with granulocytopenia to:
75. Visit only if they do not have a cold.
76. Wash their hands.
77. Leave the children at home.
78. Avoid kissing the client on the lips.

Answer 74

74. 2. Washing hands before, during, and after care has a significant effect in reducing infections.
       It is advisable to avoid introducing a cold or children’s germs and to avoid kissing on the lips, but the
       primary prevention technique is hand washing.
       CN: Health promotion and maintenance; CL: Synthesize

Question 75

75. The nurse should remind the unlicensed personnel that which of the following is the most
    important goal in the care of the neutropenic client in isolation?
76. Listening to the client’s feelings of concern.
77. Completing the client’s care in a nonhurried manner.
78. Completing all of the client’s care at one time.
79. Instructing the client to dispose of the tissue used after blowing the nose.

Answer 75

75. 4. The most common source of infection and microbial colonization in neutropenic clients is
       their own nonpathogenic normal flora. Attention to personal hygiene, such as oral, pulmonary, urinary,
       and rectal care, is essential. It is important to acknowledge the client’s concerns and fears and to
       provide organized, nonhurried, caring care, but it is more important to teach the client how to prevent
       an infection that could be life-threatening.
       CN: Health promotion and maintenance; CL: Synthesize

Question 76

76. A nurse is obtaining consent for a bone marrow aspiration. What should the nurse do? Select
    all that apply.
77. Witness the client signing the consent form.
78. Evaluate that the client understands the procedure.
79. Explain the risks of the procedure to the client.
80. Verify that the client is signing the consent form of his or her own free will.
81. Determine that the client understands postprocedure care.

Answer 76

76. 1, 2, 4, 5. The nurse can serve as a witness for consent for procedures. The nurse also
    ascertains whether the client has an understanding that is consistent with the procedure listed on the
    form, determines that the client is signing the consent of his or her own free will, and determines that
    the client understands postprocedure care. The nurse’s role does not include explaining the risks of
    the procedure; that responsibility belongs to the person who is to perform the procedure, such as the
    physician.
    CN: Management of care; CL: Synthesize

Question 77

77. A client is about to undergo bone marrow aspiration of the sternum. Which of the following
    statements should the nurse include to provide information to the client about what the client will feel
    during the procedure?
78. “You may feel a warm solution being wiped over your entire front from your neck down to
    your navel and out to your shoulders.”
79. “You will not feel the local anesthetic being applied because it will be sprayed on.”
80. “You will feel a pulling type of discomfort for a few seconds.”
81. “After the needle is removed, you will feel a bandage being applied around your chest.”

Answer 77

77. 3. As the bone marrow is being aspirated, the client will feel a suction or pulling type of
       sensation or discomfort that lasts a few seconds. A systemic premedication may be given to decreasethis discomfort. A small area over the sternum is cleaned with an antiseptic. It is unnecessary to paint
       the entire anterior chest. The local anesthetic is injected through the subcutaneous tissue to numb the
       tissue for the larger-bore needle that is used for aspiration and biopsy. After the needle is removed,
       pressure is held over the aspiration site for 5 to 10 minutes to achieve hemostasis. A small dressing is
       applied; a large pressure dressing, such as an Ace bandage, would restrict the expansion of the lungs
       and is not used.
       CN: Psychosocial adaptation; CL: Apply

Question 78

78. Twenty-four hours after a bone marrow aspiration, the nurse evaluates which of the following
    as an appropriate client outcome?
79. The client maintains bed rest.2. There is redness and swelling at the aspiration site.
80. The client requests morphine sulfate for pain.
81. There is no bleeding at the aspiration site.

Answer 78

78. 4. After a bone marrow aspiration, the puncture site should be checked every 10 to 15 minutes
       for bleeding. For a short period after the procedure, bed rest may be prescribed. Signs of infection,
       such as redness and swelling, are not anticipated at the aspiration site. A mild analgesic may be
       prescribed. If the client continues to need the morphine for longer than 24 hours, the nurse should
       suspect that internal bleeding or increased pressure at the puncture site may be the cause of the pain
       and should consult the physician.
       CN: Physiological adaptation; CL: Evaluate

Question 79

79. A client states, “I don’t want any more tests. Who cares what kind of leukemia I have? I just
    want to be treated now.” Which is the nurse’s best response?
80. “I’m sure you are frustrated and want to be well now.”
81. “Your treatment can be more effective if it is based on more specific information about your
    disease.”
82. “Now, you know the tests are necessary and that you are just upset right now.”
83. “I understand how you feel.”

Answer 79

79. 2. The nurse is an advocate for the client with leukemia who can be empowered with
       knowledge of the treatment. Immunologic, cytogenic, morphologic, histochemical, and other means
       are used to identify cell subtypes and stages of leukemia cell development for very specific and
       optimal treatment. The nurse should not label the client’s feeling, such as frustration or emotional;
       only the client can identify her own feelings. Chastising the client is not helpful. It disavows the
       client’s emotional state and responses to her diagnosis and involved treatment. Unless nurses have
       had leukemia, they cannot possibly know how the client feels even though they may be trying to offer
       her empathy.
       CN: Psychosocial adaptation; CL: Synthesize

Question 80

80. During the induction stage for treatment of leukemia, the nurse should remove which items
    that the family has brought into the room?
81. A Bible.
82. A picture.
83. A sachet of lavender.
84. A hairbrush.

Answer 80

80. 3. The induction phase of chemotherapy is an aggressive treatment to kill leukemia cells. The
       client is severely immunocompromised and severely at risk for infection. Flowers, herbs, and plants
       should be avoided during this time. The client’s Bible, pictures, and other personal belongings can be
       cleaned before being brought into the room to prevent client contact with pathogenic and
       nonpathogenic organisms.
       CN: Safety and infection control; CL: Synthesize

Question 81

81. The nurse identifies deficient knowledge when the client undergoing induction therapy for
    leukemia makes which of the following statements?
82. “I will pace my activities with rest periods.”
83. “I can’t wait to get home to my cat!”
84. “I will use warm saline gargle instead of brushing my teeth.”
85. “I must report a temperature of 100°F (37.7°C).”

Answer 81

81. 2. The nurse identifies that the client does not understand that contact with animals must be
       avoided because they carry infection and the induction therapy will destroy the client’s white blood
       cells (WBCs). The induction therapy will cause anemia, and the client will experience fatigue and
       will have to pace activities with rest periods. Platelet production will be decreased, and the client
       will be at risk for bleeding tendencies; oral hygiene will have to be provided by using a warm saline
       gargle instead of brushing the teeth and gums. The client will be at risk for infection owing to the
       decrease in WBC production and should report a temperature of 100°F (37.8°C) or higher.
       CN: Safety and infection control; CL: Evaluate

Question 82

82. A client with acute myeloid leukemia (AML) reports overhearing one of the other clients say
    that AML had a very poor prognosis. The client has understood that the client’s physician informed the
    client that his physician told him that he has a good prognosis. Which is the nurse’s best response?
83. “You must have misunderstood. Who did you hear that from?”
84. “AML does have a very poor prognosis for poorly differentiated cells.”
85. “AML is the most common nonlymphocytic leukemia.”
86. “Your doctor stated your prognosis based on the differentiation of your cells.”

Answer 82

82. 4. The statement “Your doctor stated your prognosis based on the differentiation of your cells”
       addresses the client’s situation on an individual basis. The nurse is clarifying that clients have
       different prognoses—even though they may have the same type of leukemia—because of the cell
       differentiation. Stating that the client misunderstood is inappropriate for an advocate of the client and
       serves no useful purpose. The other statements are true but do not address this client’s individualconcern.
       CN: Psychosocial adaptation; CL: Synthesize

Question 83

83. The goal of nursing care for a client with acute myeloid leukemia (AML) is to prevent:
84. Cardiac arrhythmias.
85. Liver failure.
86. Renal failure.
87. Hemorrhage.

Answer 83

83. 4. Bleeding and infection are the major complications and causes of death for clients with
       AML. Bleeding is related to the degree of thrombocytopenia, and infection is related to the degree of
       neutropenia. Cardiac arrhythmias rarely occur as a result of AML. Liver or renal failure may occur,
       but neither is a major cause of death in AML.
       CN: Reduction of risk potential; CL: Synthesize

Question 84

84. The nurse is assessing a client with chronic myeloid leukemia (CML). The nurse should
assess the client for:
1. Lymphadenopathy.
2. Hyperplasia of the gum.
3. Bone pain from expansion of marrow.
4. Shortness of breath

Answer 84

84. 4. Although the clinical manifestations of CML vary, clients usually have confusion and
       shortness of breath related to decreased capillary perfusion to the brain and lungs. Lymphadenopathy
       is rare in CML. Hyperplasia of the gum and bone pain are clinical manifestations of AML.
       CN: Reduction of risk potential; CL: Analyze

Question 85

85. Which of the following individuals is most at risk for acquiring acute lymphocytic leukemia
    (ALL)? The client who is:1. 4 to 12 years.
86. 20 to 30 years.
87. 40 to 50 years.
88. 60 to 70 years.

Answer 85

85. 1. The peak incidence of ALL is at 4 years of age. ALL is uncommon after 15 years of age.
       The median age at incidence of CML is 40 to 50 years. The peak incidence of AML occurs at 60
       years of age. Two-thirds of cases of chronic lymphocytic leukemia occur in clients older than 60
       years of age.
       CN: Physiological adaptation; CL: Analyze

Question 86

86. The client with acute lymphocytic leukemia (ALL) is at risk for infection. The nurse should:
87. Place the client in a private room.
88. Have the client wear a mask.
89. Have staff wear gowns and gloves.
90. Restrict visitors.

Answer 86

86. 1. Clients with ALL are at risk for infection due to granulocytopenia. The nurse should place
       the client in a private room. Strict hand-washing procedures should be enforced and will be the most
       effective way to prevent infection. It is not necessary to have the client wear a mask. The client is not
       contagious and the staff does not need to wear gloves. The client can have visitors; however, they
       should be screened for infection and use hand-washing procedures.
       CN: Physiological adaptation; CL: Synthesize

Question 87

87. In assessing a client in the early stage of chronic lymphocytic leukemia (CLL), the nurse
should determine if the client has:
1. Enlarged, painless lymph nodes.
2. Headache.
3. Hyperplasia of the gums.
4. Unintentional weight loss.

Answer 87

87. 4. Clients with CLL develop unintentional weight loss; fever and drenching night sweats;
       enlarged, painful lymph nodes, spleen, and liver; decreased reaction to skin sensitivity tests (anergy);
       and susceptibility to viral infections. Enlarged, painless lymph nodes are a clinical manifestation of
       Hodgkin’s lymphoma. A headache would not be one of the early signs and symptoms expected in CLL
       because CLL does not cross the blood-brain barrier and would not irritate the meninges. Hyperplasia
       of the gums is a clinical manifestation of AML.
       CN: Physiological adaptation; CL: Analyze

Question 88

88. The nurse is planning care with a client with acute leukemia who has mucositis. The nurse
    should advise the client that after every meal and every 4 hours while awake the client should use:
89. Lemon-glycerin swabs.
90. A commercial mouthwash.
91. A saline solution.
92. A commercial toothpaste and brush

Answer 88

88. 3. Simple rinses with saline or a baking soda and water solution are effective and moisten the
       oral mucosa. Commercial mouthwashes and lemon-glycerin swabs contain glycerin and alcohol,
       which are drying to the mucosa and should be avoided. Brushing after each meal is recommended, but
       every 4 hours may be too traumatic. During acute leukemia, the neutrophil and platelet counts are
       often low and a soft-bristle toothbrush, instead of the client’s usual brush, should be used to prevent
       bleeding gums.
       CN: Reduction of risk potential; CL: Synthesize

Question 89

89. The client with acute leukemia and the health care team establish mutual client outcomes of
    improved tidal volume and activity tolerance. Which measure would be least likely to promote
    outcome achievement?
90. Ambulating in the hallway.
91. Sitting up in a chair.
92. Lying in bed and taking deep breaths.
93. Using a stationary bicycle in the room.

Answer 89

89. 3. The client with acute leukemia experiences fatigue and deconditioning. Lying in bed and
       taking deep breaths will not help achieve the goals. The client must get out of bed to increase activity
       tolerance and improve tidal volume. Ambulating in the hall (using a HEPA filter mask if neutropenic)
       is a sensible activity and helps improve conditioning. Sitting up in a chair facilitates lung expansion.Using a stationary bicycle in the room allows the client to increase activity as tolerated.
       CN: Reduction of risk potential; CL: Synthesize

Question 90

90. The nurse is evaluating the client’s learning about combination chemotherapy. Which of the
    following statements by the client about reasons for using combination chemotherapy indicates the
    need for further explanation?
91. “Combination chemotherapy is used to interrupt cell growth cycle at different points.”
92. “Combination chemotherapy is used to destroy cancer cells and treat side effects
    simultaneously.”
93. “Combination chemotherapy is used to decrease resistance.”
94. “Combination chemotherapy is used to minimize the toxicity from using high doses of a single
    agent.”

Answer 90

90. 2. Combination chemotherapy does not mean two groups of drugs, one to kill the cancer cells
       and one to treat the adverse effects of the chemotherapy. Combination chemotherapy means that
       multiple drugs are given to interrupt the cell growth cycle at different points, decrease resistance to a
       chemotherapy agent, and minimize the toxicity associated with use of a high dose of a single agent (ie,
       by using multiple agents with different toxicities).
       CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 91

91. In providing care to the client with leukemia who has developed thrombocytopenia, the nurse
    assesses the most common sites for bleeding. Which of the following is not a common site?
92. Biliary system.
93. Gastrointestinal tract.
94. Brain and meninges.4. Pulmonary system.

Answer 91

91. 1. The biliary system is not especially prone to hemorrhage. Thrombocytopenia (a low
       platelet count) leaves the client at risk for a potentially life-threatening spontaneous hemorrhage in the
       gastrointestinal, respiratory, and intracranial cavities.
       CN: Physiological adaptation; CL: Analyze

Question 92

92. The nurse’s best explanation for why the severely neutropenic client is placed in reverse
    isolation is that reverse isolation helps prevent the spread of organisms:
93. To the client from sources outside the client’s environment.
94. From the client to health care personnel, visitors, and other clients.
95. By using special techniques to dispose of contaminated materials.
96. By using special techniques to handle the client’s linens and personal items.

Answer 92

92. 1. The primary purpose of reverse isolation is to reduce transmission of organisms to the
       client from sources outside the client’s environment.
       CN: Safety and infection control; CL: Apply

Question 93

The Client with Lymphoma
93. Which of the following clinical manifestations does the nurse most likely observe in a client
with Hodgkin’s disease?
1. Difficulty swallowing.
2. Painless, enlarged cervical lymph nodes.
3. Difficulty breathing.
4. A feeling of fullness over the liver.

Answer 93

The Client with Lymphoma
93. 2. Painless and enlarged cervical lymph nodes, tachycardia, weight loss, weakness and
fatigue, and night sweats are signs of Hodgkin’s disease. Difficulty swallowing and breathing may
occur, but only with mediastinal node involvement. Hepatomegaly is a late-stage manifestation.
CN: Physiological adaptation; CL: Analyze

Question 94

94. A client with a suspected diagnosis of Hodgkin’s disease is to have a lymph node biopsy. The
    nurse should make sure that personnel involved with the procedure do which of the following when
    obtaining the lymph node biopsy specimen for histologic examination for this client?
95. Maintain sterile technique.
96. Use a mask, gloves, and a gown when assisting with the procedure.
97. Send the specimen to the laboratory when someone is available to take it.
98. Ensure that all instruments used are placed in a sealed and labeled container.

Answer 94

94. 1. The nurse must ensure that sterile technique is used when a biopsy is obtained because the
       client is at high risk for infection. In most cases, a lymph node biopsy is sent immediately to the
       laboratory once it is placed in a specific solution in a closed container. It is not necessary to wear a
       gown and mask when obtaining the specimen. It is not necessary to use special handling procedures
       for the instruments used.
       CN: Management of care; CL: Apply

Question 95

95. The client with Hodgkin’s disease undergoes an excisional cervical lymph node biopsy under
    local anesthesia. After the procedure, which does the nurse assess first?
96. Vital signs.
97. The incision.
98. The airway.
99. Neurologic signs.

Answer 95

95. 3. Assessing for an open airway is always first. The procedure involves the neck; the
       anesthesia may have affected the swallowing reflex, or the inflammation may have closed in on the
       airway, leading to ineffective air exchange. Once a patent airway is confirmed and an effective
       breathing pattern established, the circulation is checked. Vital signs and the incision are assessed as
       soon as possible, but only after it is established that the airway is patent and the client is breathing
       normally. A neurologic assessment is completed as soon as possible after other important
       assessments.
       CN: Physiological adaptation; CL: Synthesize

Question 96

96. When assessing the client with Hodgkin's disease, the nurse should observe the client for
which of the following findings?
1. Herpes zoster infections.
2. Discolored teeth.
3. Hemorrhage.
4. Hypercellular immunity.

Answer 96

96. 1. Herpes zoster infections are common in clients with Hodgkin’s disease. Discoloring of the
       teeth is not related to Hodgkin’s disease but rather to the ingestion of iron supplements or some
       antibiotics such as tetracycline. Mild anemia is common in Hodgkin’s disease, but the platelet count is
       not affected until the tumor has invaded the bone marrow. A cellular immunity defect occurs in
       Hodgkin’s disease in which there is little or no reaction to skin sensitivity tests. This is called anergy.CN: Physiological adaptation; CL: Analyze

Question 97

97. The client with Hodgkin’s disease develops B symptoms. These manifestations indicate
    which of the following?
98. The client has a low-grade fever (temperature lower than 100°F [37.8°C]).
99. The client has a weight loss of 5% or less of body weight.
100. The client has night sweats.
101. The client probably has not progressed to an advanced stage.

Answer 97

97. 3. A temperature higher than 100.4°F (38°C), profuse night sweats, and an unintentional
       weight loss of 10% of body weight represent the cluster of clinical manifestations known as the B
       symptoms. Forty percent of clients with Hodgkin’s disease have B symptoms, and B symptoms are
       more common in advanced stages of the disease.
       CN: Physiological adaptation; CL: Analyze

Question 98

98. The nurse is developing a discharge plan about home care with a client who has lymphoma.
    The nurse should emphasize which of the following?
99. Use analgesics as needed.
100. Take a shower with perfumed shower gel.
101. Wear a mask when outside of the home.
102. Take an antipyretic every morning.

Answer 98

98. 1. Analgesics are used as needed to relieve painful encroachment of enlarged lymph nodes.
       Perfumed shower gel will increase pruritus. Wearing a mask does not protect the client from infection
       if pathogens are not spread by airborne droplets. Antipyretics should be used to treat fever
       symptomatically after infection is ruled out.
       CN: Health promotion and maintenance; CL: Create

Question 99

99. The client asks the nurse to explain what it means that his Hodgkin’s disease is diagnosed at
    stage 1A. Which of the following describes the involvement of the disease?1. Involvement of a single lymph node.
100. Involvement of two or more lymph nodes on the same side of the diaphragm.
101. Involvement of lymph node regions on both sides of the diaphragm.
102. Diffuse disease of one or more extralymphatic organs.

Answer 99

99. 1. In the staging process, the designations A and B signify that symptoms were or were not
       present when Hodgkin’s disease was found, respectively. The Roman numerals I through IV indicate
       the extent and location of involvement of the disease. Stage I indicates involvement of a single lymph
       node; stage II, two or more lymph nodes on the same side of the diaphragm; stage III, lymph node
       regions on both sides of the diaphragm; and stage IV, diffuse disease of one or more extralymphatic
       organs.
       CN: Physiological adaptation; CL: Apply

Question 100

100. A client is undergoing a bone marrow aspiration and biopsy. What is the best way for the
     nurse to help the client and two upset family members handle anxiety during the procedure?
101. Allow the client’s family to stay as long as possible.
102. Stay with the client without speaking.
103. Encourage the client to take slow, deep breaths to relax.
104. Allow the client time to express feelings.

Answer 100

100. 3. Encouraging the client to take slow, deep breaths during uncomfortable parts of
        procedures is the best method of decreasing the stress response of tightening and tensing the muscles.
        Slow, deep breathing affects the level of carbon dioxide in the brain to increase the client’s sense of
        well-being. Allowing the client’s family to stay may be appropriate if the family has a calming effect
        on the client, but this family is upset and may contribute to the client’s stress. Silence can be
        therapeutic, but when the client is faced with a potentially life-threatening diagnosis and a new,
        invasive procedure, taking deep breaths will be more effective in reducing the stress response.
        Expressing feelings is important, but deep breathing will promote relaxation; the nurse can encourage
        the client to express feelings when the procedure is completed.
        CN: Psychosocial adaptation; CL: Synthesize

Question 101

101. The nurse explains to the client with Hodgkin’s disease that a bone marrow biopsy will be
     taken after the aspiration. What should the nurse explain about the biopsy?
102. “Your biopsy will be performed before the aspiration because enough tissue may be obtained
     so that you won’t have to go through the aspiration.”
103. “You will feel a pressure sensation when the biopsy is taken but should not feel actual pain; if
     you do, tell the doctor so that you can be given extra numbing medicine.”
104. “You may hear a crunch as the needle passes through the bone, but when the biopsy is taken,
     you will feel a suction-type pain that will last for just a moment.”
105. “You will be shaved and cleaned with an antiseptic agent, after which the doctor will inject a
     needle without making an incision to aspirate out the bone marrow.”

Answer 101

101. 2. A biopsy needle is inserted through a separate incision in the anesthetized area. The client
        will feel a pressure sensation when the biopsy is taken but should not feel actual pain. The client
        should be instructed to inform the physician if pain is felt so that more anesthetic agent can be
        administered to keep the client comfortable. The biopsy is performed after the aspiration and from a
        slightly different site so that the tissue is not disturbed by either test. The client will feel a suction-
        type pain for a moment when the aspiration is being performed, not the biopsy. A small incision is
        made for the biopsy to accommodate the larger-bore needle. This may require a stitch.
        CN: Psychosocial adaptation; CL: Synthesize

Question 102

102. A client with advanced Hodgkin’s disease is admitted to hospice because death is imminent.
     The goal of nursing care at this time is to:
103. Reduce the client’s fear of pain.
104. Support the client’s wish to discontinue further therapy.
105. Prevent feelings of isolation.
106. Help the client overcome feelings of social inadequacy.

Answer 102

102. 3. Terminally ill clients most often describe feelings of isolation because they tend to be
        ignored, they are often left out of conversations (especially those dealing with the future), and they
        sense the attitudes of discomfort that many people feel in their presence. Helpful nursing measures
        include taking the time to be with the client, offering opportunities to talk about feelings, and
        answering questions honestly.CN: Psychosocial adaptation; CL: Synthesize

Question 103

103. The client is a survivor of non-Hodgkin’s lymphoma. Which of the following statements
     indicates the client needs additional information?
104. “Regular screening is very important for me.”
105. “The survivor rate is directly proportional to the incidence of second malignancy.”
106. “The survivor rate is indirectly proportional to the incidence of second malignancy.”
107. “It is important for survivors to know the stage of the disease and their current treatment plan.”

Answer 103

103. 2. It is incorrect that the survivor rate is directly proportional to the incidence of second
        malignancy. The survivor rate is indirectly proportional to the incidence of second malignancy, and
        regular screening is very important to detect a second malignancy, especially acute myeloid leukemia
        or myelodysplastic syndrome. Survivors should know the stage of the disease and their current
        treatment plan so that they can remain active participants in their health care.
        CN: Physiological adaptation; CL: Evaluate

Question 104

The Client Who Is in Shock
104. Which of the following is the most important goal of nursing care for a client who is in
shock?
1. Manage fluid overload.
2. Manage increased cardiac output.
3. Manage inadequate tissue perfusion.
4. Manage vasoconstriction of vascular beds.

Answer 104

The Client Who Is in Shock
104. 3. Nursing interventions and collaborative management are focused on correcting and
maintaining adequate tissue perfusion. Inadequate tissue perfusion may be caused by hemorrhage, as
in hypovolemic shock; by decreased cardiac output, as in cardiogenic shock; or by massive
vasodilation of the vascular bed, as in neurogenic, anaphylactic, and septic shock. Fluid deficit, not
fluid overload, occurs in shock.
CN: Physiological adaptation; CL: Synthesize

Question 105

105. Which of the following indicates hypovolemic shock in a client who has had a 15% blood
     loss?
106. Pulse rate less than 60 bpm.
107. Respiratory rate of 4 breaths/min.
108. Pupils unequally dilated.
109. Systolic blood pressure less than 90 mm Hg.

Answer 105

105. 4. Typical signs and symptoms of hypovolemic shock include systolic blood pressure less
        than 90 mm Hg, narrowing pulse pressure, tachycardia, tachypnea, cool and clammy skin, decreased
        urine output, and mental status changes, such as irritability or anxiety. Unequal dilation of the pupils is
        related to central nervous system injury or possibly to a previous history of eye injury.
        CN: Physiological adaptation; CL: Analyze

Question 106

106. Which of the following findings is the best indication that fluid replacement for the client in
     hypovolemic shock is adequate?
107. Urine output greater than 30 mL/h.
108. Systolic blood pressure greater than 110 mm Hg.
109. Diastolic blood pressure greater than 90 mm Hg.
110. Respiratory rate of 20 breaths/min.

Answer 106

106. 1. Urine output provides the most sensitive indication of the client’s response to therapy for
        hypovolemic shock. Urine output should be consistently greater than 35 mL/h. Blood pressure is a
        more accurate reflection of the adequacy of vasoconstriction than of tissue perfusion. Respiratory rate
        is not a sensitive indicator of fluid balance in the client recovering from hypovolemic shock.
        CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 107

107. Which of the following is a risk factor for hypovolemic shock?
108. Hemorrhage.
109. Antigen-antibody reaction.
110. Gram-negative bacteria.
111. Vasodilation.

Answer 107

107. 1. Causes of hypovolemic shock include external fluid loss, such as hemorrhage; internal
        fluid shifting, such as ascites and severe edema; and dehydration. Massive vasodilation is the initial
        phase of vasogenic or distributive shock, which can be further subdivided into three types of shock:
        septic, neurogenic, and anaphylactic. A severe antigen-antibody reaction occurs in anaphylactic
        shock. Gram-negative bacterial infection is the most common cause of septic shock. Loss of
        sympathetic tone (vasodilation) occurs in neurogenic shock.
        CN: Physiological adaptation; CL: Analyze

Question 108

108. Which is a priority assessment for the client in shock who is receiving an IV infusion of
     packed red blood cells and normal saline solution?
109. Fluid balance.
110. Anaphylactic reaction.
111. Pain.
112. Altered level of consciousness.

Answer 108

108. 2. The client who is receiving a blood product requires astute assessment for signs and
        symptoms of allergic reaction and anaphylaxis, including pruritus (itching), urticaria (hives), facial or
        glottal edema, and shortness of breath. If such a reaction occurs, the nurse should stop the transfusion
        immediately, but leave the IV line intact, and notify the physician. Usually, an antihistamine such as
        diphenhydramine hydrochloride (Benadryl) is administered. Epinephrine and corticosteroids may be
        administered in severe reactions. Fluid balance is not an immediate concern during the blood
        administration. The administration should not cause pain unless it is extravasating out of the vein, in
        which case the IV administration should be stopped. Administration of a unit of blood should not
        affect the level of consciousness.CN: Pharmacological and parenteral therapies; CL: Analyze

Question 109

109. The client who does not respond adequately to fluid replacement has a prescription for an
     IV infusion of dopamine hydrochloride at 5 mcg/kg/min. To determine that the drug is having the
     desired effect, the nurse should assess the client for:
110. Increased renal and mesenteric blood flow.
111. Increased cardiac output.
112. Vasoconstriction.
113. Reduced preload and afterload.

Answer 109

109. 2. At medium doses (4 to 8 mcg/kg/min), dopamine hydrochloride slightly increases the heart
        rate and improves contractility to increase cardiac output and improve tissue perfusion. When given
        at low doses (0.5 to 3.0 mcg/kg/min), dopamine increases renal and mesenteric blood flow. At high
        doses (8 to 10 mcg/kg/min), dopamine produces vasoconstriction, which is an undesirable effect.
        Dopamine is not given to affect preload and afterload.
        CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 110

110. A client is receiving dopamine hydrochloride for treatment of shock. The nurse should:
111. Administer pain medication concurrently.
112. Monitor blood pressure continuously.3. Evaluate arterial blood gases at least every 2 hours.
113. Monitor for signs of infection.

Answer 110

110. 2. The client who is receiving dopamine hydrochloride requires continuous blood pressure
        monitoring with an invasive or noninvasive device. The nurse may titrate the IV infusion to maintain a
        systolic blood pressure of 90 mm Hg. Administration of a pain medication concurrently with
        dopamine hydrochloride, which is a potent sympathomimetic with dose-related alpha-adrenergic
        agonist, beta 1-selective adrenergic agonist, and dopaminergic blocking effects, is not an essential
        nursing action for a client who is in shock with already low hemodynamic values. Arterial blood gas
        concentrations should be monitored according to the client’s respiratory status and acid-base balance
        status and are not directly related to the dopamine hydrochloride dosage. Monitoring for signs of
        infection is not related to the nursing action for the client receiving dopamine hydrochloride.
        CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 111

111. A client who has been taking warfarin has been admitted with severe acute rectal bleeding
     and the following laboratory results: International Normalized Ratio (INR), 8; hemoglobin, 11 g/dL
     (110 g/L); and hematocrit, 33% (0.33). In which order should the nurse implement the following
     physician prescriptions?
112. Give 1 unit fresh frozen plasma (FFP).
113. Administer vitamin K 2.5 mg by mouth.
114. Schedule client for sigmoidoscopy.
115. Administer IV dextrose 5% in 0.45% normal saline solution.

Answer 111

111.
4. Administer IV dextrose 5% in 0.45% normal saline solution.
1. Give 1 unit fresh frozen plasma (FFP)
2. Administer vitamin K 2.5 mg by mouth.
3. Schedule client for sigmoidoscopy.
Analysis of the client’s laboratory results indicate that an INR of 8 is increased beyond
therapeutic ranges. The client is also experiencing severe acute rectal bleeding and has a hemoglobin
level in the low range of normal and a hematocrit reflecting fluid volume loss. The nurse should first
establish an IV line and administer the dextrose in saline. Next the nurse should administer the FFP.
FFP contains concentrated clotting factors and provides an immediate reversal of the prolonged INR.
Vitamin K 2.5 mg PO should be given next because it reverses the warfarin by returning the PT to
normal values. However, the reversal process occurs over 1 to 2 hours. Last, the nurse can schedule
the client for the sigmoidoscopy.
CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 112

112. When assessing a client for early septic shock, the nurse should assess the client for which
of the following?
1. Cool, clammy skin.
2. Warm, flushed skin.
3. Increased blood pressure.
4. Hemorrhage.

Answer 112

112. 2. Warm, flushed skin from a high cardiac output with vasodilation occurs in warm shock or
        the hyperdynamic phase (first phase) of septic shock. Other signs and symptoms of early septic shock
        include fever with restlessness and confusion; normal or decreased blood pressure with tachypnea
        and tachycardia; increased or normal urine output; and nausea and vomiting or diarrhea. Cool,clammy skin occurs in the hypodynamic or cold phase (later phase). Hemorrhage is not a factor in
        septic shock.
        CN: Physiological adaptation; CL: Analyze

Question 113

113. A client with toxic shock has been receiving ceftriaxone sodium (Rocephin), 1 g every 12
     hours. In addition to culture and sensitivity studies, which other laboratory findings should the nurse
     monitor?
114. Serum creatinine.
115. Spinal fluid analysis.
116. Arterial blood gases.
117. Serum osmolality.

Answer 113

113. 1. The nurse monitors the blood levels of antibiotics, white blood cells, serum creatinine,
        and blood urea nitrogen because of the decreased perfusion to the kidneys, which are responsible for
        filtering out the Rocephin. It is possible that the clearance of the antibiotic has been decreased enough
        to cause toxicity. Increased levels of these laboratory values should be reported to the physician
        immediately. A spinal fluid analysis is done to examine cerebral spinal fluid, but there is no
        indication of central nervous system involvement in this case. Arterial blood gases are used to
        determine actual blood gas levels and assess acid-base balance. Serum osmolality is used to monitor
        fluid and electrolyte balance.
        CN: Pharmacological and parenteral therapies; CL: Analyze

Question 114

114. Which nursing intervention is most important in preventing septic shock?
115. Administering IV fluid replacement therapy as prescribed.
116. Obtaining vital signs every 4 hours for all clients.
117. Monitoring red blood cell counts for elevation.
118. Maintaining asepsis of indwelling urinary catheters.

Answer 114

114. 4. Maintaining asepsis of indwelling urinary catheters is essential to prevent infection.
        Preventing septic shock is a major focus of nursing care because the mortality rate for septic shock is
        as high as 90% in some populations. Very young and elderly clients (those younger than age 2 or older
        than age 65) are at increased risk for septic shock. Administering IV fluid replacement therapy,
        obtaining vital signs every 4 hours on all clients, and monitoring red blood cell counts for elevation
        do not pertain to septic shock prevention.
        CN: Safety and infection control; CL: Synthesize

Question 115

115. Which of the following is an indication of a complication of septic shock?1.
     2.
     3.
     4.
     Anaphylaxis.
     Acute respiratory distress syndrome (ARDS).
     Chronic obstructive pulmonary disease (COPD).
     Mitral valve prolapse.

Answer 115

115. 2. ARDS is a complication associated with septic shock. ARDS causes respiratory failure
        and may lead to death, even after the client has recovered from shock. Anaphylaxis is a type of
        distributive or vasogenic shock. COPD is a functional category of pulmonary disease that consists of
        persistent obstruction of bronchial airflow and involves chronic bronchitis and chronic emphysema.
        Mitral valve prolapse is a condition in which the mitral valve is pushed back too far during
        ventricular contraction.
        CN: Physiological adaptation; CL: Analyze

Question 116

Managing Care Quality and Safety
116. A nurse has two middle-aged clients who have a prescription to receive a blood transfusion
of packed red blood cells at the same time. The first client’s blood pressure dropped from the
preoperative value of 120/80 mm Hg to a postoperative value of 100/50. The second client is
hospitalized because he developed dehydration and anemia following pneumonia. After checking the
patency of their IV lines and vital signs, what should the nurse do next?
1. Call for both clients’ blood transfusions at the same time.
2. Ask another nurse to verify the compatibility of both units at the same time.
3. Call for and hang the first client’s blood transfusion.
4. Ask another nurse to call for and hang the blood for the second client.

Answer 116

Managing Care Quality and Safety
116. 3. When two clients are to receive blood at the same time, the nurse should call for and hang
the clients’ transfusions separately to avoid error. The nurse should call for and hang the first client’s
blood first because this client has experienced a change in blood pressure over a short period of time.
The nurse should next call and hang the second client’s blood transfusion as there is no indication that
this client is unstable at this time. The nurse should not call for both units of transfusions at the same
time due to the increased risk of misidentification. The nurse should not verify compatibility of both
units at the same time due to the increased risk of misidentification. It is not necessary to involve two
nurses because the second client can wait until the nurse has time to hang the blood.
CN: Management of care; CL: Synthesize

Question 117

117. When a blood transfusion is terminated following a reaction, the nurse must do which of the
     following? Select all that apply.
118. Send freshly collected urine samples to the laboratory.
119. Return the remainder of the blood component unit to the blood bank.
120. Return the intravenous administration set to the blood bank.
121. Alert Risk Management about the incident.
122. Report the incident to the Infection Control Manager.

Answer 117

117. 1, 2, 3, 4. If a blood transfusion is terminated, the nurse must send a freshly collected blood
     sample to the blood bank and a urine sample to the laboratory; the nurse must send the blood
     component unit with the attached administration set and completed Transfusion Reaction Form to the
     blood bank. It is not necessary to inform Infection Control, but the Risk Management department
     should be notified, since a transfusion reaction may be a significant liability issue.CN: Reduction of risk potential; CL: Synthesize

Question 118

118. The nurse is administering a medication to a client with myeloid leukemia and does not
     know the use, dose, or side effects. To obtain the most up-to-date information about this drug, the
     nurse should:
119. Check the Physician’s Drug Reference (PDR) at the nurses’ station.
120. Obtain a pharmacology textbook from the hospital library.
121. Consult the drug guide provided by the hospital on the computer or nurses’ internet accessible
     device
122. Review information at the drug manufacturer’s website.

Answer 118

118. 3. The most current pharmacology information is found on electronic sources that are
        frequently updated and can be transmitted to a handheld device or by logging into the internet or
        hospital’s intranet, if available. The PDR and pharmacology textbooks are outdated once published
        and, therefore, may not have current information. The manufacturer’s website has the potential for
        bias.
        CN: Safety and infection control; CL: Apply

Question 119

119. The charge nurse on a hematology/oncology unit is reviewing the policy for using
     abbreviations with the staff. The charge nurse should emphasize which of the following about why
     dangerous abbreviations need to be eliminated? Select all that apply.
120. To ensure efficient and accurate communication.
121. To prevent medication errors.
122. To ensure client safety.
123. To make it easier for clients to understand the medication prescriptions.
124. To make data entry into a computerized health record easier.

Answer 119

119. 1, 2, 3. Abbreviations can be misinterpreted and all health care professionals should avoid
     the use of easily misunderstood abbreviations. The purpose of avoiding abbreviations is not to make
     it easier for clients to understand the medication prescriptions or to make data entry easier.
     CN: Safety and infection control; CL: Synthesize