AH 2- Exam 5

Which is one of the causes of secondary osteoporosis? a. older age b. current smoking c. diabetes mellitus d. high alcohol intake

c. diabetes mellitus

Which type of transfusion reaction is characterized by disseminated intravascular coagulation? a. febrile b. bacterial c. hemolytic d. acute pain

c. hemolytic

1. Which client is at greatest risk for experiencing a hemolytic transfusion reaction? A. A 42-year-old client with allergies B. A 78-year-old client with arthritis C. A 58-year-old immune-suppressed client D. A 34-year-old client with type O blood

D Rationale: The client at greatest risk for experiencing a hemolytic transfusion reaction is the 34-year-old client with type O blood. Hemolytic transfusion reactions are caused by blood type or Rh incompatibility. When blood that contains antigens different from the client's own antigens is infused, antigen-antibody complexes are formed in the client's blood. Type O is considered the universal donor, but not the universal recipient.The client with allergies would be most susceptible to an allergic transfusion reaction. The older adult client with arthritis would be most susceptible to circulatory overload. The immune-suppressed client would be most susceptible to a transfusion-associated graft-versus-host disease.

The nurse is caring for a patient who has weakness, pallor, fatigue, reduced exercise tolerance, and fissures at the corners of the mouth. The nurse recognizes these symptoms are associated with which condition? a. aplastic anemia b. folic acid deficiency c. iron deficiency anemia d. vitamin b12 deficiency (pernicious) anemia

c. iron deficiency anemia

Which clinical manifestation is associated with a hemolytic transfusion reaction? a. vomiting b. anorexia c. low back pain d. thrombocytopenia

c. low back pain

Which part of the pelvis is non-weight bearing? a. sacrum b. pelvic ring c. pubic rami d. acetabulum

c. pubic rami

Which type of unrelated transplant donor matches are most difficult to find for African American patients? a. organ b.blood c. bone marrow d. blood products

c. bone marrow

Which change in a client's lab values will the nurse attribute to a blood transfusion? a. blood glucose decrease b. serum sodium 133 mEq/L c. serum potassium 5.2 mEq/L d. WBC count decrease to 4,000/mm3

c. serum potassium 5.2 mEq/L

Which term describes a patient who experiences continuous seizures for more than 6 minutes per episode? a. acute seizure b. chronic seizure c. status elipticus d. tonic-clonic seizure

c. status elipticus

Which amount of weight is the maximum that should be used for the pulling force when Buck traction is applied? a. 10 lbs b. 15 lbs c. 20 lbs d. 25 lbs

a. 10 lbs

A patient who needs a unit of packed RBCs is ordered by the physician to be premedicated with oral diphenhydramine and acetaminophen. You will administer these medications? a. 15 min before starting the transfusion b. immediately after starting the transfusion c. right before starting the transfusion d. 30 minutes before starting the transfusion

d. 30 min before starting the transfusion

A 7-year old male patient is being evaluated for seizures. While in the child's room talking with the child's parents, you notice that the child appears to be daydreaming. You time this event to be 10 seconds, the child appropriately responds and doesn't recall the event. This known as what type of seizure? a. Focal Impaired Awareness ) complex partial b. atonic c. tonic-clonic d. absence

d. absence

What definition relates to a myoclonic seizure? a. loss of consciousness or "blackout" for 1-3 minutes b. activity beginning in a part of one cerebral hemisphere c. sudden loss of muscle tone followed by a postictal confusion d. brief jerking or stiffening of extremities lasting a few seconds

d. brief jerking or stiffening of extremities lasting a few seconds

Which organism is commonly responsible for hospital acquired infections and is often the causative agent in osteomyelitis? a. streptococcus mutans b. streptococcus salivarius c. lactobacillus acidophilus d. methicillin-resistant staphylococcus aureus (MRSA)

d. methicillin-resistant staphylococcus aureus (MRSA)

Which description accurately defines a closed reduction? a. procedure that does not require general anesthesia b. commercial immobilizer that is used to keep the bone in place c. fiberglass synthetic cast used to immobilize an upper extremity d. process where the ends of the bones are manually pulled and realigned

d. process where the ends of the bones are manually pulled and realigned

A patient with bone cancer is susceptible to which type of fracture? a. stress fracture b. simple fracture c. compound fracture d. spontaneous fracture

d. spontaneous fracture

What is the first priority action the nurse will take to prevent harm when recognizing that a client is having a hemolytic transfusion reaction? a. flushing the blood tubing with normal saline b. initiating the Rapid Response Team c. applying oxygen via face mask d. stopping the transfusion

d. stopping the transfusion

1. A client has undergone an elective below-the-knee amputation of the right leg as a result of severe peripheral vascular disease. In postoperative care teaching, the nurse instructs the client to notify the health care provider immediately if which change occurs? A. Observation of a large amount of serosanguineous or bloody drainage B. Mild to moderate pain controlled with prescribed analgesics C. Absence of erythema and tenderness at the surgical site D. Ability to flex and extend the right knee

A Rationale: A large amount of serosanguineous or bloody drainage may indicate hemorrhage or, if an incision is present, that the incision has opened. This requires immediate attention.Mild to moderate pain controlled with prescribed analgesics would be a normal finding for this client. Absence of erythema and tenderness of the surgical site would also be normal findings for this client. The client would be able to flex and extend the right knee (limb) after surgery.

1. An older adult client has had an open reduction and internal fixation of a fractured right hip. Which intervention does the nurse implement for this client? A. Keep the client's heels off the bed at all times. B. Reposition the client every 3 to 4 hours. C. Administer preventive pain medication before deep-breathing exercises. Prohibit the use of antiembolic stockings

A Rationale: Because the client is an older adult and is more at risk for skin breakdown because of impaired circulation and sensation, the client's heels must be kept off the bed at all times to avoid constant pressure on this sensitive area.Repositioning the older adult client must be done every 2 hours, not every 3 to 4 hours, to prevent skin breakdown and to inspect the skin for any signs of breakdown. Pain medication would not be administered for deep-breathing exercises because this client typically would not experience pain upon breathing. Antiembolic stockings are not contraindicated for older adults; rather, they help prevent deep vein thrombosis.

1. The nurse is mentoring a recent graduate registered nurse (RN) about administering blood and blood products. What action does the nurse perform before starting the transfusion? A. Verify with another RN all of the data on blood products. B. Use a 22-gauge needle to obtain venous access when starting the infusion. C. Remain with the client who is receiving the blood for the first 5 minutes of the infusion. D. Obtain the client's initial set of vital signs (VS) within the first 10 minutes of the infusion.

A Rationale: Before administering blood and blood products, the nurse must verify with another RN all of the data on blood products. All data are checked by two RNs. Human error is the most common cause of ABO incompatibilities when administering blood and blood products.A 20-gauge needle (or a central line catheter) is used. The 22-gauge needle is too small. Initial VS must be recorded before the start of infusion of blood, not after it has begun. The nurse remains with the client for the first 15 to 30 minutes (not 5) of the infusion. This is the period when any transfusion reactions are likely to happen.

1. Which change in the cerebrospinal fluid (CSF) indicates to the nurse that a client may have bacterial meningitis? A. Cloudy, turbid CSF B. Decreased white blood cells C. Decreased protein D. Increased glucose

A Rationale: Cloudy, turbid CSF indicates to the nurse that the client may have bacterial meningitis.Clear fluid is a sign of viral meningitis. Increased white blood cells, increased protein, and decreased glucose are signs of bacterial meningitis.

1. Which nursing intervention helps to reduce the incidence of osteomyelitis for a client receiving hemodialysis? A. Instructing the client to brush teeth after every meal B. Maintaining clean dressing change technique for long-term IV catheters C. Using clean technique D. Using Standard Precautions

A Rationale: Proper dental hygiene helps prevent periodontal infection, which can be a causative factor in contiguous osteomyelitis in facial bones. Patients undergoing long-term hemodialysis and IV drug users are at risk for osteomyelitis.Long-term IV catheters can be a primary source of infection, so dressing changes are done using sterile not clean technique. All clients undergoing hemodialysis require careful sterile technique before needle cannulation. Standard Precautions must be used for all clients

1. Which task is appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP) working on a medical-surgical unit? A. Obtain vital signs on a client receiving a blood transfusion B. Assist a client with folic acid deficiency in making diet choices C. Administer erythropoietin to a client with myelodysplastic syndrome D. Assess skin integrity on an anemic client who fell during ambulation

A Rationale: The appropriate task for the nurse to delegate to a UAP is obtaining vital signs on a client receiving a blood transfusion. This activity is within the scope of practice for UAPs.Assisting with prescribed diet choices, administering medication, and assessing clients are complex actions that must be done by licensed nurses

1. The nurse is assessing several clients who are receiving transfusions of blood components. Which assessment finding requires immediate action by the nurse? A. Respiratory rate of 36 breaths/min in a client receiving red blood cells B. Temperature of 99.1°F (37.3°C) for a client with a platelet transfusion C. Sleepiness in a client who received diphenhydramine (Benadryl) as a premedication D. A partial thromboplastin time (PTT) that is 1.2 times normal in a client who received a transfusion of fresh-frozen plasma (FFP)

A Rationale: The assessment finding that requires immediate action by the nurse is a respiratory rate of 36 breaths/min in a client receiving red blood cells. An increased respiratory rate indicates a possible hemolytic transfusion reaction. The nurse must quickly stop the transfusion and assess the client further.Temperature elevations are not an indication of an allergic reaction to a platelet transfusion, although the nurse may administer acetaminophen (Tylenol) to decrease the fever. Sleepiness is expected when Benadryl is administered. Because FFP is not usually given until the PTT is 1.5 times above normal, a PTT that is 1.2 times normal indicates that the FFP has had the desired response.

1. A client is admitted with bacterial meningitis. Which nursing intervention is the highest priority for this client? A. Assessing neurologic status at least every 2-4 hours B. Decreasing environmental stimuli C. Managing pain through drug and nondrug methods D. Strict monitoring of hourly intake and output

A Rationale: The highest priority nursing intervention for the newly admitted client with bacterial meningitis is to accurately monitor and record the client's neurologic status every 2-4 hours. The neurologic status, vital signs, and vascular status must be assessed at least every 4 hours or more often, if clinically indicated, to rapidly determine any deterioration in status.Decreasing environmental stimuli is helpful for the client with bacterial meningitis but is not the highest priority. Clients with bacterial meningitis report severe headaches requiring pain management which may be accomplished through both pharmacologic and nonpharmacologic methods. Assessing fluid balance while preventing overload is not the highest priority however intake and output must be monitored.

1. A client with an open fracture of the left femur is admitted to the emergency department after a motorcycle crash. Which action is most essential for the nurse to take first? A. Check the dorsalis pedis pulses. B. Immobilize the left leg with a splint. C. Administer the prescribed analgesic. Place a dressing on the affected area

A Rationale: The most essential action should be to check the dorsalis pedis pulses. It is necessary to assess the circulatory status of the leg because the client is at risk for acute compartment syndrome, which can begin as early as 6 to 8 hours after an injury. Severe tissue damage can also occur if neurovascular status is compromised.Immobilization will be needed, but the nurse must assess the client's condition first. Administering an analgesic and placing a dressing on the affected area would both be done after the nurse has assessed the client

1. A client sustains a fracture of one arm and the provider applies a plaster cast to the extremity. What will the nurse teach the client to do during the first 24 hours after discharge from the emergency department? A. Monitor neuromuscular status for decreased circulation and sensation in the extremity. B. Apply a heating pad for 15 to 20 minutes four times daily to help with pain. C. Check the fit of the cast by inserting a tongue blade between the cast and the skin. D. Keep the cast covered with a soft towel to help it to dry quickly.

A Rationale: The most important intervention the nurse teaches the client is to monitor the neurovascular status during the first 24 hours after ED discharge.The client should apply ice for discomfort, not heat. The client should not place anything between the cast and the skin. In assessing fit, one finger should easily fit between the cast and the skin. To allow the cast to dry, it should remain uncovered.

1. A client who is receiving a blood transfusion suddenly tells the nurse, "I don't feel right!" What is the nurse's first action? A. Stop the transfusion. B. Call the Rapid Response Team. C. Slow the infusion rate of the transfusion. Obtain vital signs and continue to monitor

A Rationale: The nurse's first action when a client receiving a blood transfusion says, "I don't feel right," is to stop the transfusion. The client may be experiencing a transfusion reaction, so the nurse must stop the transfusion immediately.Calling the Rapid Response Team or obtaining vital signs is not the first thing that must be done. The nurse would not slow the infusion rate but would stop it altogether

Your patient is 2 hours post-op from a cast placement on the right leg. The patient has family in the room. Which action by the significant other requires you to re-educate the patient and family about cast care? A. Gently moving the cast with the fingertips of the hands every 2 hours to help with drying. B. Positioning the cast at heart level with pillows. C. Checking the color and temperature of the right foot. D. Using a hair dryer on the cool setting to help with drying.

A. Gently moving the cast with the fingertips of the hands every 2 hours to help with drying.

You have a patient who has a brain tumor and is at risk for seizures. In the patient's plan of care you incorporate seizure precautions. Select below all the proper steps to take in initiating seizures precautions. a. oxygen and suction at bedside b. bed in highest position c. remove all pillows from the patient's head d. have restraints on stand- by e. padded bed rails f. remove restrictive objects or clothing from patient's body g. IV access

A, E, F, G,

1. An 82-year-oldclient with anemia is prescribed 2 units of whole blood. Which assessment findings cause the nurse to discontinue the transfusion because it is unsafe for the client? SELECT ALL THAT APPLY A. Hypotension B. Hypertension C. Decreased pallor D. Rapid, bounding pulse E. Flattened superficial veins F. Capillary refill less than 3 seconds

A,B,D Rationale: The assessment findings that are unsafe for the nurse to continue the blood transfusion for the client are: hypotension, hypertension, and rapid, bounding pulse. In an older adult receiving a transfusion, low blood pressure is a sign of a transfusion reaction, hypertension is a sign of overload, and a rapid and bounding pulse is a sign of fluid overload. In this scenario, 2 units, or about a liter of fluid, could be problematic.Increased (not decreased) pallor and cyanosis are signs of a transfusion reaction, while swollen (not flattened) superficial veins are present in fluid overload in older adult clients receiving transfusions. Capillary refill time that is less than 3 seconds is considered to be normal and would not pose a problem.

1. A rock climber has sustained an open fracture of the right tibia after a 20-foot (6 meter) fall. The nurse plans to assess the client for which potential complications? SELECT ALL THAT APPLY A. Acute compartment syndrome (ACS) B. Fat embolism syndrome (FES) C. Congestive heart failure D. Urinary tract infection (UTI) E. Osteomyelitis

A,B,E Rationale: ACS is a serious condition in which increased pressure within one or more compartments reduces circulation to the area. A fat embolus is a serious complication in which fat globules are released from yellow bone marrow into the bloodstream within 12 to 48 hours after the injury. FES usually results from long bone fracture or fracture repair but is occasionally seen in clients who have received a total joint replacement. Bone infection, or osteomyelitis, is most common in open fractures.Congestive heart failure is not a potential complication for this client; pulmonary embolism is a potential complication of venous thromboembolism, which can occur with fracture. The client is at risk for wound infection resulting from orthopedic trauma, not a UTI

The nurse is assessing a patient diagnosed with ACUTE osteomyelitis. Which feature of this disorder does the nurse expect to find? Select all that apply. a. temperature above 101 F b. drainage from the affected area c. swelling around the affected area d. Erythema around the affected area e. pulsating pain that worsens with movement f. ulceration of the skin resulting in a sinus tract

A,C,D,E

What is the nurse's best first action to prevent harm when an older client, receiving the third unit of packed RBC's in the past 8 hours, has distended neck veins in the sitting position? a. slow the infusion rate b. discontinue the transfusion c. document the observation as the only action d. check the type of infusing blood with the client's blood type

A. slow the infusion rate Older clients are at risk for developing fluid overload during transfusion therapy, especially when receiving multiple units of packed RBCs.

1. The nurse has received report on a group of clients. Which client requires the nurse's attention first? A. Adult who is lethargic after a generalized tonic-clonic seizure B. Young adult who has experienced four tonic-clonic seizures within the past 30 minutes C. Middle-aged adult with absence seizures who is staring at a wall and does not respond to questions D. Older adult with a seizure disorder who has a temperature of 101.9° F (38.8° C)

B Rationale: After receiving report on a group of clients, the nurse first needs to attend to the young adult client who is experiencing repeated seizures over the course of 30 minutes. This client is in status epilepticus, which is a medical emergency and requires immediate intervention.The adult client who is lethargic and the middle-aged adult client with absence seizures do not require immediate attention. A fever of 101.9° F (38.8° C), although high, does not require immediate attention.

1. The nurse admits an older adult client who sustained a left hip fracture and is in considerable pain. The nurse anticipates that the client will be placed in which type of traction prior to surgical repair? A. Balanced skin traction B. Buck's traction C. Overhead traction D. Plaster traction

B Rationale: Buck's traction may be applied before surgery to help decrease pain associated with muscle spasm.Balanced skin traction is indicated for fracture of the femur or pelvis. Overhead traction is indicated for fracture of the humerus with or without involvement of the shoulder and clavicle. Plaster traction is indicated for wrist fracture.

1. The client has sustained a traumatic amputation of the left arm after a machine accident. In what order should the following nursing actions be taken? *1. Apply direct pressure to the amputated site. *2. Elevate the extremity above the client's heart. *3. Assess the client for breathing problems. *4. Examine the amputation site. A. 2, 4, 3, 1 B. 3, 4, 1, 2 C. 1, 4, 3, 2 D. 4, 1, 2, 3

B Rationale: First, the airway must be assessed for breathing problems. Second, the nurse should examine the amputation site. Third, the nurse should apply direct pressure to the amputated site. Finally, the extremity should be elevated above the client's heart to decrease bleeding.All of the other sequencing of options is incorrect.

A patient sustained a fracture to the femur. The patient has suddenly become confused, restless, and has a respiratory rate of 30 breaths per minute. Based on the location of fracture and the presenting symptoms, this patient may be experiencing what type of complication? A. Compartment Syndrome B. Osteomyelitis C. Fat embolism D. Hypovolemia

C. Fat Embolism

1. The nurse is transfusing 2 units of packed red blood cells to a postoperative client. What electrolyte imbalance would the nurse monitor for after the blood transfusion? A. Hyponatremia B. Hyperkalemia C. Hypercalcemia D. Hypomagnesemia

B Rationale: The electrolyte imbalance the nurse needs to monitor after transfusing 2 units of blood to a postoperative client is hyperkalemia. During transfusion, some cells are damaged. These cells release potassium, thus raising the client's serum potassium level (hyperkalemia). This complication is especially common with packed cells and whole-blood products.High serum calcium levels, low magnesium levels, or low sodium levels are not expected with blood transfusions

1. Which is the most effective way for a college student to minimize the risk for bacterial meningitis? A. Avoid large crowds. B. Get the meningococcal vaccine. C. Take a high dose vitamin C daily. D. Take prophylactic antibiotics.

B Rationale: The most effective way for a college student to minimize the risk for bacterial meningitis is to get the meningococcal vaccine. Individuals ages 16-21 years have the highest rates of meningococcal infection and need to be immunized against the virus.Avoiding large crowds is helpful, but is not practical for a college student. Taking a high dose of vitamin C every day does not minimize the risk of bacterial meningitis. However, maintaining a healthy lifestyle, with adequate sleep and nutrition, can improve immunity. Taking prophylactic antibiotics is inappropriate because it leads to antibiotic-resistant strains of microorganisms.

1. A client with thrombocytopenia is being discharged. Which instruction would the nurse include in a teaching plan for this client? A. "Avoid large crowds." B. "Use a soft-bristled toothbrush." C. "Drink at least 2 L of fluid per day." D. "Elevate your lower extremities when sitting."

B Rationale: Using a soft-bristled toothbrush reduces the risk for bleeding in the client with thrombocytopenia.Avoiding large crowds reduces the risk for infection but is not specific to the client with thrombocytopenia. Increased fluid intake reduces the risk for dehydration but is not particularly relevant to the client with thrombocytopenia. Elevating extremities reduces the risk for dependent edema but is not specific to the client with thrombocytopenia.

1. Which statement indicates to the nursing instructor that the nursing student understands the normal healing process of bone after a fracture? A. "A callus is quickly deposited and transformed into bone." B. "A hematoma forms at the site of the fracture." C. "Cellular and vascular proliferation surround the fracture site." D. "Granulation tissue reabsorbs the hematoma and deposits new bone."

B Rationale: With a stage 1 fracture, a hematoma forms at the site of the fracture within 24 to 72 hours, because bone is extremely vascular. This action helps prompt the formation of fibrocartilage, providing the foundation for bone healing.Stage 2 of bone healing occurs within 3 days to 2 weeks after the fracture, when granulation tissue begins to invade the hematoma. Stage 3 of bone healing occurs as a result of vascular and cellular proliferation. In stage 4 of a healing fracture, callus is gradually reabsorbed and transformed into bone

1. A client has been admitted with new-onset status epilepticus. Which seizure precautions does the nurse put in place? SELECT ALL THAT APPLY A. Bite block at the bedside B. Intravenous access (IV) C. Continuous sedation D. Suction equipment at the bedside E. side-rails raised

B,D,E Rationale: Seizure precautions the nurse institutes for an admitted client with new-onset status epilepticus include IV access, suctioning equipment at the bedside and raised siderails. IV access is needed to administer medications. Suctioning equipment must be available to suction secretions and facilitate an open airway during a seizure. Raised, padded siderails may be used to protect the client from falling out of bed during a seizure.Bite blocks or padded tongue blades would not be used because the client's jaw may clench, causing teeth to break and possibly obstructing the airway. Continuous sedation is a medical intervention and not a seizure precaution.

Which statement by a patient, who just received a cast on the right arm for a fracture, requires you to notify the physician immediately?* A. "It is really itchy inside my cast!" B. "My pain is so severe that it hurts to stretch or elevate my arm." C. "I can feel my fingers and move them." D. "I've been using ice packs to reduce swelling."

B. "My pain is so severe that it hurts to stretch or elevate my arm."

1. The nurse is transfusing a unit of whole blood to a client when the primary health care provider prescribes "Furosemide (Lasix) 20 mg IV push." Which intervention would the nurse perform? A. Piggyback the furosemide into the infusing blood. B. Give furosemide to the client intramuscularly (IM). C. Administer the furosemide after completion of the transfusion. D. Add furosemide to the normal saline that is infusing with the blood.

C Rationale: Completing the transfusion before administering furosemide is the best course of action in this scenario.Drugs are not to be administered with infusing blood products, because they can interact with the blood, causing risks for the client. Changing the admission route is not a nursing decision. Stopping the infusing blood to administer the drug and then restarting it is also not the best decision.

1. The nurse performs an assessment on a newly admitted client with thrombocytopenia. Which assessment finding requires immediate intervention by the nurse? A. Reports of pain B. Increased temperature C. Bleeding from the nose D. Decreased urine output

C Rationale: The assessment finding on a newly admitted client with thrombocytopenia that needs immediate intervention by the nurse is bleeding from the nose. The client with thrombocytopenia has a high risk for bleeding. The nosebleed would be attended to immediately.The client's report of pain, decreased urine output, and increased temperature are not the highest priority.

1. A client is in skeletal traction. Which nursing intervention ensures proper care of this client? A. Ensure that weights are placed on the floor. B. Ensure that pins are not loose and tighten as needed. C. Inspect the skin at least every 8 hours. D. Remove the traction weights only for bathing

C Rationale: The client's skin should be inspected at least every 8 hours for signs of irritation, inflammation, or actual skin breakdown.Weights must never rest on the floor because they will not be effective. They must hang freely at all times. Pin sites would be checked for signs and symptoms of infection and for security in their position to the fixation and the client's extremity. However, the nurse does not adjust the pins. Any loose pin site or alteration must be reported to the health care provider. Traction weights are not removed for bathing.

1. Which finding does the nurse expect to observe in a client with suspected common chronic osteomyelitis? A. Erythema of the affected area B. Fever; temperature usually above 101° F (38° C) C. Ulceration of the skin D. Constant, localized, and pulsating bone pain

C Rationale: The nurse expects to observe ulceration of the skin, which is a feature of chronic osteomyelitis.Erythema of the affected area; fever; and constant, localized, pulsating bone pain are features of acute osteomyelitis.

1. The nurse is providing medication instructions for a client for whom phenytoin (Dilantin) has been ordered for treatment of epilepsy. The nurse instructs the client to avoid which beverage? A. Apple juice B. Grape juice C. Grapefruit juice D. Prune juice

C Rationale: The nurse instructs the client taking phenytoin for epilepsy to avoid taking grapefruit juice. Some citrus fruits and juices, like grapefruit juice, can interfere with the metabolism of phenytoin potentially leading to an increased blood level and toxicity.Apple, grape, and prune juices are not contraindicated for a client taking phenytoin (Dilantin).

1. The nurse assesses the client with which hematologic condition first? A. A 32-year-old with pernicious anemia who needs a vitamin B12 injection B. A 67-year-old with acute myelocytic leukemia with petechiae on both legs C. An 81-year-old with thrombocytopenia and an increase in abdominal girth D. A 40-year-old with iron deficiency anemia who needs a Z-track iron injection

C Rationale: The nurse needs to first assess the 81-year-old client with thrombocytopenia and an increase in abdominal girth. An increase in abdominal girth in a client with thrombocytopenia indicates possible hemorrhage, and warrants further assessment immediately.The 32-year-old with pernicious anemia, the 67-year-old with acute myelocytic leukemia, and the 40-year-old with iron deficiency anemia do not indicate any acute complications, so the nurse can assess them after assessing the client with thrombocytopenia

1. A client admitted with cerebral edema suddenly begins to have a seizure while the nurse is in the room. What does the nurse do first? A. Administer phenytoin (Dilantin). B. Draw the client's blood. C. Establish an airway. D. Start an intravenous (IV) line.

C Rationale: When a client admitted with cerebral edema begins to have a seizure, the nurse must first establish an airway. The primary goal is to open and maintain an airway and then assess the client for the need of additional support during the seizure.Phenytoin (Dilantin) is administered to prevent the recurrence of seizures, not to treat a seizure already underway. Drawing blood or starting an IV is not the priority in this situation. Remember the ABCs during an emergency situation.

1. The nurse is administering the intake assessment for a newly admitted client with a history of seizures. The client suddenly begins to seize. What does the nurse do next? A. Documents the length and time of the seizure. B. Forces a tongue blade in the mouth. C. Positions the client on the side. Restrains the client

C Rationale: When a newly admitted client with a history of seizures begins to seize, the nurse must turn the client on his/her side. Turning the client on the side during a generalized tonic-clonic or complex partial seizure is indicated because he or she may lose consciousness resulting in potential loss of a patent airway.Documenting the length and time of seizures is important, but not the priority intervention. Both forcing a tongue blade in the mouth and restraining the client can cause injury.

1. A client is recovering from an above-the-knee amputation resulting from peripheral vascular disease. Which statement indicates that the client is coping well after the procedure? A. "My spouse will be the only person to change my dressing." B. "I can't believe that this has happened to me. I can't stand to look at it." C. "I do not want any visitors while I'm in the hospital." D. "It will take me some time to get used to this."

D Rationale: Acknowledging that it will take time to get used to the amputation indicates that the client is expressing acceptance and effective coping.Stating that the spouse will change the dressing indicates the client does not want to participate in self-care. Expressing disbelief and disgust over the amputation indicates the client is unwilling to address what has happened. The client who does not want to receive visitors is having difficulty coping with the change in body image

1. A client has had a sequestrectomy of the right fibula for osteomyelitis 1 day ago. Which assessment finding requires the nurse to immediately contact the surgeon? A. Swelling of the right lower extremity B. 1+ to 2+ bilateral palpable pedal pulses C. Pain of right lower extremity on movement D. Decreased sensation of right lower extremity

D Rationale: Decreased sensation of the right lower extremity indicates a neurovascular compromise that must be reported immediately to the surgeon. A sequestrectomy is performed to remove necrotic bone and allow revascularization of tissue. The excision of dead and infected bone often results in a sizable cavity, or bone defect.The client undergoing a sequestrectomy experiences increased swelling after the procedure, so the affected extremity should be elevated to increase venous return and thus control swelling. Palpable pulses of 1+ to 2+ bilaterally are a sign of adequate blood flow. Pain on movement of the right lower extremity is an expected finding.

1. Which information about a client who was admitted with a pelvic fracture after being crushed by a tractor is most important for the nurse to assess to monitor for serious complications from this type of injury? A. Skin to evaluate lacerations and abrasions. B. Lungs for bilateral normal breath sounds C. Pain score and level of alertness D. Urine dipstick for the presence of red blood cells.

D Rationale: It is most important for the nurse to monitor for the presence of blood in the urine as well as assessing the abdomen for rigidity. Clients with crushing injuries to the pelvis are at increased risk of internal hemorrhage. Pelvic injuries are the second cause of death from trauma after head injuries.Assessing the skin for external trauma and monitoring pain and alertness will be performed as part of the overall assessment but are not critical nursing actions at this time. Assessing lung sounds is more critical with chest injuries and rib fractures.

1. An older adult client has multiple tibia and fibula fractures of the left extremity after a motor vehicle crash. Which pain medication does the nurse anticipate will be requested for this client? A. Cyclobenzaprine (Flexeril) B. Ibuprofen (Advil) C. Meperidine (Demerol) D. Patient-controlled analgesia (PCA) with morphine

D Rationale: Morphine is an opioid narcotic analgesic and is given through PCA. It is the most appropriate mode of pain management for this type of acute pain associated with multiple injuries.Muscle relaxants such as cyclobenzaprine are effective for treating pain related to muscle spasms, but they are not adequate for this type of acute pain. Ibuprofen is a nonsteroidal anti-inflammatory drug that is used to treat mild to moderate pain. This bone pain is very acute, so ibuprofen would not be sufficient. Meperidine should never be used for older adults because it has toxic metabolites that can cause seizures.

1. A client with a fracture asks the nurse about the difference between an open fracture and a simple fracture. Which statement by the nurse is correct? A. "Simple fracture involves a break in the bone, with skin contusions." B. "An open fracture does not extend through the skin." C. "Simple fracture has an increased risk for infection and emboli." D. "An open fracture involves a break in the bone, with damage to the skin."

D Rationale: The correct statement made by the nurse states that an open fracture involves a break in the bone with damage to the skin.A simple fracture does not extend through the skin. An open fracture, not a simple fracture, has an increased risk for infection.

1. Which nursing intervention most effectively protects a client with thrombocytopenia? A. Take rectal temperatures B. Avoid the use of dentures C. Apply warm compresses on trauma sites D. Encourage the use of an electric shaver

D Rationale: The most effective nursing intervention that protects a client with thrombocytopenia is encouraging the client to use an electric shaver. This client must be advised to use an electric shaver instead of a razor. Any small cuts or nicks can cause problems because of the prolonged clotting time.To prevent rectal trauma, rectal thermometers would not be used. Oral or tympanic temperatures would be taken. Dentures may be used by clients with thrombocytopenia as long as they fit properly and do not rub. Ice (not heat) would be applied to areas of trauma.

1. The nurse is to administer packed red blood cells to a client. How does the nurse ensure proper client identification? A. Ask the client's name B. Check the client's armband C. Verify the client's room number D. Review all information with another registered nurse (RN)

D Rationale: With another registered nurse, all information must be reviewed. This process includes verifying the client by name and number, checking blood compatibility, and noting the expiration time. Human error is the most common cause of ABO incompatibility reactions, even for experienced nurses.Asking the client's name and checking the client's armband are not adequate for identifying the client before transfusion therapy. Using the room number to verify client identification is never appropriate.

What is the nurses best action when a client is having a generalized tonic-clonic seizure and becomes cyanotic? a. raise the head of the bed and apply oxygen by nasal cannula b. suction the client and alert the Rapid Response Team c. call the health care provider and obtain intubation equipment d. stay with the client because the cyanosis is usually self-limiting

D. stay with the client because the cyanosis is usually self-limiting

A patient has recently undergone surgery to treat osteomyelitis. Which sign of neurovascular compromise does the nurse assess for after the surgery? Select all that apply. A. paresthesia b. pulselessness c. purulent drainage d. uncontrollable pain e. paresis or paralysis f. presence of erythema

a,b,d,e

A patient with an osteoporotic vertebral fracture is prescribed raloxifene. Which information would the nurse include in the assessment of this patient? a. assess for a history of venous thromboembolism b. assess the patients CBC c. observe the patient for drowsiness, agitation, or anxiety d. perform an oral assessment before beginning treatment

a. assess for a history of venous thromboemolism

Which posttransfusion electrolyte imbalance would the nurse monitor for after transfusion 2 units of packed RBCs? a. hyperkalemia b. hypercalcemia c. hyponatremia d. hypomagnesemia

a. hyperkalemia

Which issue does the nurse consider a priority when caring for a client diagnosed with atonic seizures? a. possibility of injury related to falls b. limited mobility related to lack of tonicity of muscles c. confusion related to postictal period d. organ ischemia related to decreased perfusion

a. possibility of injury related to falls

Which fracture is most common in the ADULT population? a. rib fractures b . wrist fractures c. humeral fractures d. proximal femoral fractures

a. rib fractures

Which assessment is most important for the nurse to perform for the client receiving 1 unit of packed RBCs from an autologous donation? a. temperature b. blood pressure c. oxygen saturation d. IV site assessment for hives

a. temperature

A patient with a large, painless lymph node has a biopsy that reveals Reed-Sternberg cells. Which forms of cancer does this finding indicate? a. multiple myeloma b. Hodgkin lymphoma c. Non-Hodgkin lymphoma d. Acute myelogeneous leukemia

b. Hodgkin lymphoma

Which patient does the nurse consider at risk for folic acid deficiency anemia? a. patient with heart failure b. patient with Crohns disease c. patient recovering from fracture of the tibia d. patient with a basal skin cancer of the nose

b. a patient with Crohns disease

The nurse is caring for a patient with polycythemia vera. Which nursing intervention is a priority for this patient? a. flossing between the teeth b. elevating the feet while sitting c. applying shapewear for support d. encouraging the patient to drink 1 L of water daily

b. elevating the feet while sitting

Before initiating the blood transfusion, you obtain the patient's baseline vitals , which are : hr 100, bp 115/72, rr 18, temp 100.8 F. Your next action is to: a. administer the blood transfusion as ordered b. hold the blood transfusion and reassess vital signs in 1 hour c. notify the physician before starting the transfusion d. administer 200 mL of the blood and then reassess the patient's vital signs

b. hold the blood transfusion and reassess vital signs in 1 hour

A patient with a history of epilepsy is taking Phenytoin. The patient's morning labs are back, and the patient's Phenytoin level is 7 mcg/mL. Based on this finding, the nurse will? a. assess the patient for a rash b. initiate seizure precautions c. hold the next dose of Phenytoin d. continue to monitor the patient

b. initiate seizure precautions

Which is the minimum weight permitted for the pulling force in skeletal traction? a. 5 lbs b. 7 lbs c. 10 lbs d. 15 lbs

d. 15 lbs Rationale: Skeletal traction aids in bone realignment, allowing the use of longer traction time and heavier weights, usually 15 to 30 lbs. Any weight below 15 lbs may not align the fragments properly.

What disorder is classified by less than 150,000 platelets/mcL? a. leukemia b. hemophilia c. leukocytopenia d. thrombocytopenia

d. thrombocytopenia