MedSurg Test #3
47. The nurse is caring for a patient who is to receive a transfusion of two units of packed red blood cells. After obtaining the first unit from the blood bank, the nurse would ask which health team member in the nurses' station to assist in checking the unit before administration? 1. Unit secretary 2. A physician's assistant 3. Another registered nurse 4. An unlicensed assistive personnel
3. Another registered nurse Before hanging a transfusion, the registered nurse must check the unit with another RN or with a licensed practical (vocational) nurse, depending on agency policy. The unit secretary, physician's assistant, or unlicensed assistive personnel should not be asked.
50. The nurse notes a physician's order written at 10:00 AM for two units of packed red blood cells to be administered to a patient who is anemic as a result of chronic blood loss. If the transfusion is picked up at 11:30 AM, the nurse should plan to hang the unit no later than what time? 1. 11:45 AM 2. 12:00 noon 3. 12:30 PM 4. 3:30 PM
ANS 12:00 noon The nurse must hang the unit of packed red blood cells within 30 minutes of signing them out from the blood bank.
48. Before starting a transfusion of packed red blood cells for an older anemic patient, the nurse would arrange for a peer to monitor his or her other assigned patients for how many minutes when the nurse begins the transfusion? 1. 5 2. 15 3. 30 4. 60
ANS 15: As part of standard procedure, the nurse remains with the patient for the first 15 minutes after starting a blood transfusion. Patients who are likely to have a transfusion reaction will more often exhibit signs within the first 15 minutes that the blood is infusing. Monitoring during the transfusion will be every 30 to 60 minutes.
56. Which patient is most likely to experience anemia related to an increased destruction of red blood cells? 1. A 59-year-old man whose alcoholism has precipitated folic acid deficiency 2. A 23-year-old African American man who has a diagnosis of sickle cell disease 3. A 30-year-old woman with a history of "heavy periods" accompanied by anemia 4. A 3-year-old child whose impaired growth and development is attributable to thalassemi
ANS:A 23-year-old African American man who has a diagnosis of sickle cell disease A result of a sickling episode in sickle cell anemia involves increased hemolysis of the sickled cells. Thalassemias and folic acid deficiencies cause a decrease in erythropoiesis, whereas the anemia related to menstruation is a direct result of blood loss.
49. When preparing to administer an ordered blood transfusion, which IV solution does the nurse use when priming the blood tubing? 1. Lactated Ringer's 2. 5% dextrose in water 3. 0.9% sodium chloride 4. 0.45% sodium chloride
ANS: 0.9% sodium chloride The blood set should be primed before the transfusion with 0.9% sodium chloride, also known as normal saline. It is also used to flush the blood tubing after the infusion is complete to ensure the patient receives blood that is left in the tubing when the bag is empty. Dextrose and lactated Ringer's solutions cannot be used with blood as they will cause RBC hemolysis.
46. A 50-year-old man with an acute peptic ulcer and major blood loss requires an immediate transfusion with packed red blood cells. Which task is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)? 1. Confirm the IV solution is 0.9% saline. 2. Obtain the vital signs before the transfusion is initiated. 3. Monitor the patient for shortness of breath and back pain. 4. Double check the patient identity and verify the blood product.
ANS: 2 Obtain the vital signs before the transfusion is initiated. The registered nurse (RN) may delegate tasks such as taking vital signs to unlicensed assistive personnel (UAP). Assessments (e.g., monitoring for signs of a blood transfusion reaction [shortness of breath and back pain]) are within the scope of practice of the RN and may not be delegated to UAP. The RN must also assume responsibility for ensuring the correct IV fluid is used with blood products. Verification of the patient's identity and the blood product data must be completed by a licensed nurse.
5. A patient presents to the emergency department with the complaint of vomiting and diarrhea for the past 48 hours. The nurse anticipates which fluid therapy initially? a) 0.9% sodium chloride b) Dextrose 10% in water c) Dextrose 5% in water d) 0.45% sodium chloride
ANS: A
37. The nursing management of a patient in sickle cell crisis includes (select all that apply) a. monitoring CBC. b. optimal pain management and O2 therapy. c. blood transfusions if required and iron chelation. d. rest as needed and deep vein thrombosis prophylaxis. e. administration of IV iron and diet high in iron content.
ANS: a, b, c, d
44. A patient with pancytopenia of unknown origin is scheduled for the following diagnostic tests. The nurse will provide a consent form to sign for which test? a. ABO blood typing b. Bone marrow biopsy c. Abdominal ultrasound d. Complete blood count (CBC)
ANS: B A bone marrow biopsy is a minor surgical procedure that requires the patient or guardian to sign a surgical consent form. The other procedures do not require a signed consent by the patient or guardian.
38. During discharge teaching of a patient with newly diagnosed sickle cell disease, what should the nurse teach the patient to do? a. Limit fluid intake b. Avoid humid weather c. Eliminate exercise from the lifestyle d. Seek early medical intervention for upper respiratory infections
ANS: d. The patient with sickle cell disease is particularly prone to upper respiratory infection and infection can precipitate a sickle cell crisis.
41. The nurse instructs an African American man who has sickle cell disease about symptom management and prevention of sickle cell crisis. The nurse determines further teaching is necessary if the patient makes which statement? 1. "When I take a vacation, I should not go to the mountains." 2. "I should avoid contact with anyone who has a respiratory infection." 3. "When my vision is blurred, I will close my eyes and rest for an hour." 4. "I may experience severe pain during a crisis and need narcotic analgesics."
ANS: 3 "When my vision is blurred, I will close my eyes and rest for an hour." a. Blurred vision should be reported immediately and may indicate a detached retina or retinopathy. Hypoxia (at high altitudes) and infection are common causes of a sickle cell crisis. Severe pain may occur during a sickle cell crisis, and narcotic analgesics are indicated for pain management.
64. The nurse examines the lymph nodes of a patient during a physical assessment. Which assessment finding would be of most concern to the nurse? a. A 2-cm nontender supraclavicular node b. A 1-cm mobile and nontender axillary node c. An inability to palpate any superficial lymph nodes d. Firm inguinal nodes in a patient with an infected foot
ANS: A Enlarged and nontender nodes are suggestive of malignancies such as lymphoma. Firm nodes are an expected finding in an area of infection. The superficial lymph nodes are usually not palpable in adults, but if they are palpable, they are normally 0.5 to 1 cm and nontender.
26. The nurse assesses a patient who has numerous petechiae on both arms. Which question should the nurse ask the patient? a. Do you take salicylates? b. Are you taking any oral contraceptives? c. Have you been prescribed antiseizure drugs? d. How long have you taken antihypertensive drugs?
ANS: A Salicylates interfere with platelet function and can lead to petechiae and ecchymoses. Antiseizure drugs may cause anemia, but not clotting disorders or bleeding. Oral contraceptives increase a persons clotting risk. Antihypertensives do not usually cause problems with decreased clotting.
45. Which information shown in the accompanying figure about a patient who has just arrived in the emergency department is most urgent for the nurse to communicate to the health care provider? a. Platelet count b. White blood cell count c. History of abdominal pain d. Blood pressure and heart rate
ANS: A The platelet count is severely decreased and places the patient at risk for spontaneous bleeding. The other information is also pertinent, but not as indicative of the need for rapid treatment as the platelet count.
34. The complete blood count (CBC) indicates that a patient is thrombocytopenic. Which action should the nurse include in the plan of care? a. Avoid intramuscular injections. b. Encourage increased oral fluids. c. Check temperature every 4 hours. d. Increase intake of iron-rich foods.
ANS: A Thrombocytopenia is a decreased number of platelets, which places the patient at high risk for bleeding. Neutropenic patients are at high risk for infection and sepsis and should be monitored frequently for signs of infection. Encouraging fluid intake and iron-rich food intake is not indicated in a patient with thrombocytopenia.
13. A postoperative patient who has been receiving nasogastric suction for 3 days has a serum sodium level of 125 mEq/L (125 mmol/L). Which of these prescribed therapies that the patient has been receiving should the nurse question? a. Infuse 5% dextrose in water at 125 ml/hr. b. Administer IV morphine sulfate 4 mg every 2 hours PRN. c. Give IV metoclopramide (Reglan) 10 mg every 6 hours PRN for nausea. d. Administer 3% saline if serum sodium drops to less than 128 mEq/L.
ANS: A Infuse 5% dextrose in water at 125 ml/hr. Because the patient's gastric suction has been depleting electrolytes, the IV solution should include electrolyte replacement. Solutions such as lactated Ringer's solution would usually be ordered for this patient. The other orders are appropriate for a postoperative patient with gastric suction.
12. When caring for a patient admitted with hyponatremia, which actions will the nurse anticipate taking? a. Restrict patient's oral free water intake. b. Avoid use of electrolyte-containing drinks. c. Infuse a solution of 5% dextrose in 0.45% saline. d. Administer vasopressin (antidiuretic hormone, [ADH]).
ANS: A Restrict patient's oral free water intake. To help improve serum sodium levels, water intake is restricted. Electrolyte-containing beverages will improve the patient's sodium level. Administration of vasopressin or hypotonic IV solutions will decrease the serum sodium level further.
23. The nurse obtains all of the following assessment data about a patient with deficient fluid volume caused by a massive burn injury. Which of the following assessment data will be of greatest concern? a. The blood pressure is 90/40 mm Hg. b. Urine output is 30 ml over the last hour. c. Oral fluid intake is 100 ml for the last 8 hours. d. There is prolonged skin tenting over the sternum.
ANS: A The blood pressure is 90/40 mm Hg. The blood pressure indicates that the patient may be developing hypovolemic shock as a result of fluid loss. This will require immediate intervention to prevent the complications associated with systemic hypoperfusion. The poor oral intake, decreased urine output, and skin tenting all indicate the need for increasing the patient's fluid intake but not as urgently as the hypotension.
10. Which assessment finding about a patient who has a serum calcium level of 7.0 mEq/L is most important for the nurse to report to the health care provider? a. The patient is experiencing laryngeal stridor. b. The patient complains of generalized fatigue. c. The patient's bowels have not moved for 4 days. d. The patient has numbness and tingling of the lips.
ANS: A The patient is experiencing laryngeal stridor. Laryngeal stridor may lead to respiratory arrest and requires rapid action to correct the patient's calcium level. The other data also are consistent with hypocalcemia, but do not indicate a need for immediate action.
16. The nurse in the outpatient clinic who notes that a patient has a decreased magnesium level should ask the patient about a. daily alcohol intake. b. intake of dietary protein. c. multivitamin/mineral use. d. use of over-the-counter (OTC) laxatives.
ANS: A daily alcohol intake. Hypomagnesemia is associated with alcoholism. Protein intake would not have a significant effect on magnesium level. OTC laxatives (such as milk of magnesia) and use of multivitamin/mineral supplements would tend to increase magnesium level.
57. When teaching a patient with renal failure about a low phosphate diet, the nurse will include information to restrict a. ingestion of dairy products. b. the amount of high-fat foods. c. the quantity of fruits and juices. d. intake of green, leafy vegetables.
ANS: A ingestion of dairy products. Foods high in phosphate include milk and other dairy products, so these are restricted on low-phosphate diets. Green, leafy vegetables; high-fat foods; and fruits/juices are not high in phosphate and are not restricted.
1. A patient is receiving 3% NaCl solution for correction of hyponatremia. During administration of the solution, the most important assessment for the nurse to monitor is a. lung sounds. b. urinary output. c. peripheral pulses. d. peripheral edema.
ANS: A lung sounds. Hypertonic solutions cause water retention, so the patient should be monitored for symptoms of fluid excess. Crackles in the lungs may indicate the onset of pulmonary edema and are the most serious of the symptoms of fluid excess listed. Bounding peripheral pulses, peripheral edema, or changes in urine output also are important to monitor when administering hypertonic solutions, but they do not indicate acute respiratory or cardiac decompensation.
14. A patient who has been receiving diuretic therapy is admitted to the emergency department with a serum potassium level of 3.1 mEq/L. Of the following medications that the patient has been taking at home, the nurse will be most concerned about a. oral digoxin (Lanoxin) 0.25 mg daily. b. ibuprofen (Motrin) 400 mg every 6 hours. c. metoprolol (Lopressor) 12.5 mg orally daily. d. lantus insulin 24 U subcutaneously every evening.
ANS: A oral digoxin (Lanoxin) 0.25 mg daily Hypokalemia increases the risk for digoxin toxicity, which can cause serious dysrhythmias. The nurse also will need to do more assessment regarding the other medications, but there is not as much concern with the potassium level.
33. The nurse is reviewing laboratory results and notes an aPTT level of 28 seconds. The nurse should notify the health care provider in anticipation of adjusting which medication? a. Aspirin b. Heparin c. Warfarin d. Erythropoietin
ANS: B Activated partial thromboplastin time (aPTT) assesses intrinsic coagulation by measuring factors I, II, V, VIII, IX, X, XI, XII. aPTT is increased (prolonged) in heparin administration. aPTT is used to monitor whether heparin is at a therapeutic level (needs to be greater than the normal range of 25 to 35 sec). Prothrombin time (PT) and international normalized ratio (INR) are most commonly used to test for therapeutic levels of warfarin (Coumadin). Aspirin affects platelet function. Erythropoietin is used to stimulate red blood cell production.
42. It is important for the nurse providing care for a patient with sickle cell crisis to a. limit the patient's intake of oral and IV fluids. b. evaluate the effectiveness of opioid analgesics. c. encourage the patient to ambulate as much as tolerated. d. teach the patient about high-protein, high-calorie foods.
ANS: B Pain is the most common clinical manifestation of a crisis and usually requires large doses of continuous opioids for control. Fluid intake should be increased to reduce blood viscosity and improve perfusion. Rest is usually ordered to decrease metabolic requirements. Patients are instructed about the need for dietary folic acid, but high-protein, high-calorie diets are not emphasized.
30. A patients complete blood count (CBC) shows a hemoglobin of 19 g/dL and a hematocrit of 54%. Which question should the nurse ask to determine possible causes of this finding? a. Have you had a recent weight loss? b. Do you have any history of lung disease? c. Have you noticed any dark or bloody stools? d. What is your dietary intake of meats and protein?
ANS: B The hemoglobin and hematocrit results indicate polycythemia, which can be associated with chronic obstructive pulmonary disease (COPD). The other questions would be appropriate for patients who are anemic.
58. Which action will the nurse include in the plan of care for a patient who has a central venous access device (CVAD)? a. Avoid using friction when cleaning around the CVAD insertion site. b. Use the push-pause method to flush the CVAD after giving medications. c. Obtain an order from the health care provider to change CVAD dressing. d. Have the patient turn the head toward the CAVD during injection cap changes.
ANS: B Use the push-pause method to flush the CVAD after giving medications. The push-pause enhances the removal of debris from the CVAD lumen and decreases the risk for clotting. To decrease infection risk, friction should be used when cleaning the CVAD insertion site. The dressing should be changed whenever it becomes damp, loose, or visibly soiled and the patient should turn away from the CVAD during cap changes.
8. A patient who has been hospitalized for 2 days has been receiving normal saline IV at 100 ml/hr, has a nasogastric tube to low suction, and is NPO. Which assessment finding by the nurse is the priority to report to the health care provider? a. Serum sodium level of 138 mEq/L (138 mmol/L) b. Gradually decreasing level of consciousness (LOC) c. Oral temperature of 100.1° F with bibasilar lung crackles d. Weight gain of 2 pounds (1 kg) above the admission weight
ANS: B Gradually decreasing level of consciousness (LOC) The patient's history and change in LOC could be indicative of several fluid and electrolyte disturbances: extracellular fluid (ECF) excess, ECF deficit, hyponatremia, hypernatremia, hypokalemia, or metabolic alkalosis. Further diagnostic information will be ordered by the health care provider to determine the cause of the change in LOC and the appropriate interventions. The weight gain, elevated temperature, crackles, and serum sodium level also will be reported, but do not indicate a need for rapid action to avoid complications.
20. Intravenous potassium chloride (KCl) 60 mEq is prescribed for treatment of a patient with severe hypokalemia. Which action should the nurse take? a. Administer the KCl as a rapid IV bolus. b. Infuse the KCl at a rate of 20 mEq/hour. c. Give the KCl only through a central venous line. d. Add no more than 40 mEq/L to a liter of IV fluid.
ANS: B Infuse the KCl at a rate of 20 mEq/hour. Intravenous KCl is administered at a maximal rate of 20 mEq/hr. Rapid IV infusion of KCl can cause cardiac arrest. Although the preferred concentration for KCl is no more than 40 mEq/L, concentrations up to 80 mEq/L may be used for some patients. KCl can cause inflammation of peripheral veins, but it can be administered by this route.
7. Which of these actions can the nurse who is caring for a critically ill patient with multiple intravenous (IV) lines delegate to an experienced LPN? a. Administer IV antibiotics through the implantable port. b. Monitor the IV sites for redness, swelling, or tenderness. c. Remove the patient's nontunneled subclavian central venous catheter. d. Adjust the flow rate of the 0.9% normal saline in the peripheral IV line.
ANS: B Monitor the IV sites for redness, swelling, or tenderness. An experienced LPN has the education, experience, and scope of practice to monitor IV sites for signs of infection. Administration of medications, adjustment of infusion rates, and removal of central catheters in critically ill patients require RN level education and scope of practice.
19. A patient with advanced lung cancer is admitted to the emergency department with urinary retention caused by renal calculi. Which of these laboratory values will require the most immediate action by the nurse? a. Arterial blood pH is 7.32. b. Serum calcium is 18 mEq/L. c. Serum potassium is 5.1 mEq/L. d. Arterial oxygen saturation is 91%.
ANS: B Serum calcium is 18 mEq/L. The serum calcium is well above the normal level and puts the patient at risk for cardiac dysrhythmias. The nurse should initiate cardiac monitoring and notify the health care provider. The potassium, oxygen saturation, and pH also are abnormal, and the nurse should notify the health care provider about these values as well, but they are not immediately life-threatening.
3. The following data are obtained by the nurse when assessing a pregnant patient with eclampsia who is receiving IV magnesium sulfate. Which finding is most important to report to the health care provider immediately? a. The bibasilar breath sounds are decreased. b. The patellar and triceps reflexes are absent. c. The patient has been sleeping most of the day. d. The patient reports feeling "sick to my stomach."
ANS: B The patellar and triceps reflexes are absent. The loss of the deep tendon reflexes indicates that the patient's magnesium level may be reaching toxic levels. Nausea and lethargy also are side effects associated with magnesium elevation and should be reported, but they are not as significant as the loss of deep tendon reflexes. The decreased breath sounds suggest that the patient needs to cough and deep breathe to prevent atelectasis.
24. When the nurse is evaluating the fluid balance for a patient admitted for hypovolemia associated with multiple draining wounds, the most accurate assessment to include is a. skin turgor. b. daily weight. c. presence of edema. d. hourly urine output.
ANS: B daily weight. Daily weight is the most easily obtained and accurate means of assessing volume status. Skin turgor varies considerably with age. Considerable excess fluid volume may be present before fluid moves into the interstitial space and causes edema. Hourly urine outputs do not take account of fluid intake or of fluid loss through insensible loss, sweating, or loss from the gastrointestinal tract or wounds.
27. The home health nurse notes that an elderly patient has a low serum protein level. The nurse will plan to assess for a. pallor. b. edema. c. confusion. d. restlessness.
ANS: B edema. Low serum protein levels cause a decrease in plasma oncotic pressure and allow fluid to remain in interstitial tissues, causing edema. Confusion, restlessness, and pallor are not associated with low serum protein levels.
25. When caring for an alert and oriented elderly patient with a history of dehydration, the home health nurse will teach the patient to increase fluid intake a. in the late evening hours. b. if the oral mucosa feels dry. c. when the patient feels thirsty. d. as soon as changes in level of consciousness (LOC) occur.
ANS: B if the oral mucosa feels dry. An alert, elderly patient will be able to self-assess for signs of oral dryness such as thick oral secretions or dry-appearing mucosa. The thirst mechanism decreases with age and is not an accurate indicator of volume depletion. Many older patients prefer to restrict fluids slightly in the evening to improve sleep quality. The patient will not be likely to notice and act appropriately when changes in LOC occur.
60. Following a thyroidectomy, a patient complains of "a tingling feeling around my mouth." The nurse will immediately check for a. an elevated serum potassium level. b. the presence of Chvostek's sign. c. a decreased thyroid hormone level. d. bleeding on the patient's dressing.
ANS: B the presence of Chvostek's sign. The patient's symptoms indicate possible hypocalcemia, which can occur secondary to parathyroid injury/removal during thyroidectomy. There is no indication of a need to check the potassium level, the thyroid hormone level, or for bleeding.
40. Which instruction will the nurse plan to include in discharge teaching for the patient admitted with a sickle cell crisis? a. Take a daily multivitamin with iron. b. Limit fluids to 2 to 3 quarts per day. c. Avoid exposure to crowds when possible. d. Drink only two caffeinated beverages daily.
ANS: C Exposure to crowds increases the patient's risk for infection, the most common cause of sickle cell crisis. There is no restriction on caffeine use. Iron supplementation is generally not recommended. A high-fluid intake is recommended
63. The nurse assesses a patient with pernicious anemia. Which assessment finding would the nurse expect? a. Yellow-tinged sclerae b. Shiny, smooth tongue c. Numbness of the extremities d. Gum bleeding and tenderness
ANS: C Extremity numbness is associated with cobalamin (vitamin B12) deficiency or pernicious anemia. Loss of the papillae of the tongue occurs with chronic iron deficiency. Yellow-tinged sclera is associated with hemolytic anemia and the resulting jaundice. Gum bleeding and tenderness occur with thrombocytopenia or neutropenia.
43. A patient who had a total hip replacement had an intraoperative hemorrhage 14 hours ago. Which laboratory result would the nurse expect to find? a. Hematocrit of 46% b. Hemoglobin of 13.8 g/dL c. Elevated reticulocyte count d. Decreased white blood cell (WBC) count
ANS: C Hemorrhage causes the release of reticulocytes (immature red blood cells) from the bone marrow into circulation. The hematocrit and hemoglobin levels are normal. The WBC count is not affected by bleeding.
51. A postoperative patient receiving a transfusion of packed red blood cells develops chills, fever, headache, and anxiety 35 minutes after the transfusion is started. After stopping the transfusion, what action should the nurse take? a. Draw blood for a new crossmatch. b. Send a urine specimen to the laboratory. c. Administer PRN acetaminophen (Tylenol). d. Give the PRN diphenhydramine (Benadryl).
ANS: C The patient's clinical manifestations are consistent with a febrile, nonhemolytic transfusion reaction. The transfusion should be stopped and antipyretics administered for the fever as ordered. A urine specimen is needed if an acute hemolytic reaction is suspected. Diphenhydramine (Benadryl) is used for allergic reactions. This type of reaction does not indicate incorrect crossmatching
36. The health care providers progress note for a patient states that the complete blood count (CBC) shows a shift to the left. Which assessment finding will the nurse expect? a. Cool extremities b. Pallor and weakness c. Elevated temperature d. Low oxygen saturation
ANS: C The term shift to the left indicates that the number of immature polymorphonuclear neutrophils (bands) is elevated and that finding is a sign of infection. There is no indication that the patient is at risk for hypoxemia, pallor/weakness, or cool extremities.
28. The long-term care nurse is evaluating the effectiveness of protein supplements on a patient who has low serum total protein level. Which of these data indicate that the patient's condition has improved? a. Hematocrit 28% b. Good skin turgor c. Absence of peripheral edema d. Blood pressure 110/72 mm Hg
ANS: C Absence of peripheral edema Edema is caused by low oncotic pressure in individuals with low serum protein levels; the absence of edema indicates an improvement in the patient's protein status. Good skin turgor is an indicator of fluid balance, not protein status. A low hematocrit could be caused by poor protein intake. Blood pressure does not provide a useful clinical tool for monitoring protein status.
17. A patient receiving isoosmolar continuous tube feedings develops restlessness, agitation, and weakness. Which laboratory result is most important to report to the health care provider? a. K+ 3.4 mEq/L (3.4 mmol/L) b. Ca+2 7.8 mg/dl (1.95 mmol/L) c. Na+ 154 mEq/L (154 mmol/L) d. PO4-3 4.8 mg/dl (1.55 mmol/L)
ANS: C Na+ 154 mEq/L (154 mmol/L) The elevated serum sodium level is consistent with the patient's neurologic symptoms and indicates a need for immediate action to prevent further serious complications such as seizures. The potassium and calcium levels vary slightly from the normal but do not require any immediate action by the nurse. The phosphate level is within the normal parameters.
18. A patient with renal failure who has been taking aluminum hydroxide/magnesium hydroxide suspension (Maalox) at home for indigestion is somnolent and has decreased deep tendon reflexes. Which action should the nurse take first? a. Notify the patient's health care provider. b. Withhold the next scheduled dose of Maalox. c. Review the magnesium level on the patient's chart. d. Check the chart for the most recent potassium level.
ANS: C Review the magnesium level on the patient's chart. The patient has a history and symptoms consistent with hypermagnesemia; the nurse should check the chart for a recent serum magnesium level. Notification of the health care provider will be done after the nurse knows the magnesium level. The Maalox should be held, but more immediate action is needed to correct the patient's decreased deep tendon reflexes (DTRs) and somnolence. Monitoring of potassium levels also is important for patients with renal failure, but the patient's current symptoms are not consistent with hyperkalemia.
11. A recently admitted patient has a small cell carcinoma of the lung, which is causing the syndrome of inappropriate antidiuretic hormone (SIADH). The nurse will monitor carefully for a. increased total urinary output. b. elevation of serum hematocrit. c. decreased serum sodium level. d. rapid and unexpected weight loss.
ANS: C decreased serum sodium level. SIADH causes water retention and a decrease in serum sodium level. Weight loss, increased urine output, and elevated serum hematocrit may be associated with excessive loss of water, but not with SIADH and water retention.
9. When assessing a patient with increased extracellular fluid (ECF) osmolality, the priority assessment for the nurse to obtain is a. skin turgor. b. heart sounds. c. mental status. d. capillary refill.
ANS: C mental status. Changes in ECF osmolality lead to swelling or shrinking of cells in the central nervous system, initially causing confusion, which may progress to coma or seizures. Although skin turgor, capillary refill, and heart sounds also may be affected by ECF osmolality changes and resultant fluid shifts, these are signs that occur later and do not have as immediate an impact on patient outcomes.
2. A patient who has an infusion of 50% dextrose prescribed asks the nurse why a peripherally inserted central catheter must be inserted. Which explanation by the nurse is correct? a. The prescribed infusion can be given much more rapidly when the patient has a central line. b. There is a decreased risk for infection when 50% dextrose is infused through a central line. c. The 50% dextrose is hypertonic and will be more rapidly diluted when given through a central line. d. The required blood glucose monitoring is more accurate when samples are obtained from a central line.
ANS: C. The 50% dextrose is hypertonic and will be more rapidly diluted when given through a central line. Shrinkage of red blood cells can occur when solutions with dextrose concentrations greater than 10% are administered intravenously. Blood glucose testing is not more accurate when samples are obtained from a central line. The infection risk is higher with a central catheter than with peripheral IV lines. Hypertonic or concentrated IV solutions are not given rapidly.
6. Which assessment finding should cause a nurse to question administering a sodium-containing isotonic intravenous fluid? a) Blood pressure 102/58 b) Dry mucous membranes c) Poor skin turgor d) Pitting edema
ANS: D
Which of the following nursing actions included in the care plan for a patient with neutropenia is appropriate for the RN to delegate to an LPN/LVN who is assisting with patient care? a. Assessing the patient for signs and symptoms of infection b. Teaching the patient the purpose of neutropenic precautions c. Developing a discharge teaching plan for the patient and family d. Administering the ordered subcutaneous filgrastim (Neupogen) injection
ANS: D Administration of medications is included in LPN/LVN education and scope of practice. Patient education, assessment, and developing the plan of care require RN level education and scope of practice.
35. A patient who has been receiving a heparin infusion and warfarin (Coumadin) for a deep vein thrombosis (DVT) is diagnosed with heparin-induced thrombocytopenia (HIT) when her platelet level drops to 110,000/µL. Which action will the nurse include in the plan of care? a. Use low-molecular-weight heparin (LMWH) only. b. Administer the warfarin (Coumadin) at the scheduled time. c. Teach the patient about the purpose of platelet transfusions. d. Discontinue heparin and flush intermittent IV lines using normal saline.
ANS: D All heparin is discontinued when the HIT is diagnosed. The patient should be instructed to never receive heparin or LMWH. Warfarin is usually not given until the platelet count has returned to 150,000/µL. The platelet count does not drop low enough in HIT for a platelet transfusion, and platelet transfusions increase the risk for thrombosis.
39. Which statement by a patient indicates good understanding of the nurse's teaching about prevention of sickle cell crisis? a. "Home oxygen therapy is frequently used to decrease sickling." b. "There are no effective medications that can help prevent sickling." c. "Routine continuous dosage narcotics are prescribed to prevent a crisis." d. "Risk for a crisis is decreased by having an annual influenza vaccination."
ANS: D Because infection is the most common cause of a sickle cell crisis, influenza, Haemophilus influenzae, pneumococcal pneumonia, and hepatitis immunizations should be administered. Although continuous dose opioids and oxygen may be administered during a crisis, patients do not receive these therapies to prevent crisis. Hydroxyurea (Hydrea) is a medication used to decrease the number of sickle cell crises.
29. A nurse reviews the laboratory data for an older patient. The nurse would be most concerned about which finding? a. Hematocrit of 35% b. Hemoglobin of 11.8 g/dL c. Platelet count of 400,000/L d. White blood cell (WBC) count of 2800/L
ANS: D Because the total WBC count is not usually affected by aging, the low WBC count in this patient would indicate that the patients immune function may be compromised and the underlying cause of the problem needs to be investigated. The platelet count is normal. The slight decrease in hemoglobin and hematocrit are not unusual for an older patient.
65. The health care provider orders a liver/spleen scan for a patient who has been in a motor vehicle accident. Which action should the nurse take before this procedure? a. Check for any iodine allergy. b. Insert a large-bore IV catheter. c. Place the patient on NPO status. d. Assist the patient to a flat position.
ANS: D During a liver/spleen scan, a radioactive isotope is injected IV and images from the radioactive emission are used to evaluate the structure of the spleen and liver. An indwelling IV catheter is not needed. The patient is placed in a flat position before the scan.
31. When assessing a newly admitted patient, the nurse notes pallor of the skin and nail beds. The nurse should ensure that which laboratory test has been ordered? a. Platelet count b. Neutrophil count c. White blood cell count d. Hemoglobin (Hgb) level
ANS: D Pallor of the skin or nail beds is indicative of anemia, which would be indicated by a low Hgb level. Platelet counts indicate a persons clotting ability. A neutrophil is a type of white blood cell that helps to fight infection.
61. The nurse is caring for a patient who is being discharged after an emergency splenectomy following an automobile accident. Which instructions should the nurse include in the discharge teaching? a. Watch for excess bruising. b. Check for swollen lymph nodes. c. Take iron supplements to prevent anemia. d. Wash hands and avoid persons who are ill.
ANS: D Splenectomy increases the risk for infection, especially with gram-positive bacteria. The risks for lymphedema, bleeding, and anemia are not increased after a person has a splenectomy.
32. The nurse reviews the complete blood count (CBC) and white blood cell (WBC) differential of a patient admitted with abdominal pain. Which information will be most important for the nurse to communicate to the health care provider? a. Monocytes 4% b. Hemoglobin 13.6 g/dL c. Platelet count 168,000/L d. White blood cells (WBCs) 15,500/L
ANS: D The elevation in WBCs indicates that the patient has an inflammatory or infectious process ongoing, which may be the cause of the patients pain, and that further diagnostic testing is needed. The monocytes are at a normal level. The hemoglobin and platelet counts are normal.
52. A patient in the emergency department complains of back pain and difficulty breathing 15 minutes after a transfusion of packed red blood cells is started. The nurse's first action should be to a. administer oxygen therapy at a high flow rate. b. obtain a urine specimen to send to the laboratory. c. notify the health care provider about the symptoms. d. disconnect the transfusion and infuse normal saline.
ANS: D The patient's symptoms indicate a possible acute hemolytic reaction caused by the transfusion. The first action should be to disconnect the transfusion and infuse normal saline. The other actions also are needed but are not the highest priority.
62. A patient with pancytopenia has a bone marrow aspiration from the left posterior iliac crest. Which action would be important for the nurse to take after the procedure? a. Elevate the head of the bed to 45 degrees. b. Apply a sterile 2-inch gauze dressing to the site. c. Use a half-inch sterile gauze to pack the wound. d. Have the patient lie on the left side for 1 hour.
ANS: D To decrease the risk for bleeding, the patient should lie on the left side for 30 to 60 minutes. After a bone marrow biopsy, the wound is small and will not be packed with gauze. A pressure dressing is used to cover the aspiration site. There is no indication to elevate the patients head.
22. Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a patient as a diuretic.Which statement by the patient indicates that the teaching about this medication has been effective? a. "I will try to drink at least 8 glasses of water every day." b. "I will use a salt substitute to decrease my sodium intake." c. "I will increase my intake of potassium-containing foods." d. "I will drink apple juice instead of orange juice for breakfast."
ANS: D "I will drink apple juice instead of orange juice for breakfast." Since spironolactone is a potassium-sparing diuretic, patients should be taught to choose low potassium foods such as apple juice rather than foods that have higher levels of potassium, such as citrus fruits. Because the patient is using spironolactone as a diuretic, the nurse would not encourage the patient to increase fluid intake. Teach patients to avoid salt substitutes, which are high in potassium.
59. A postoperative patient who is receiving nasogastric suction is complaining of anxiety and incisional pain. The patient's respiratory rate is 32 breaths/minute and the arterial blood gases (ABGs) indicate respiratory alkalosis. Which action should the nurse take first? a. Discontinue the nasogastric suctions for a few hours. b. Notify the health care provider about the ABG results. c. Teach the patient about the need to take slow, deep breaths. d. Give the patient the PRN morphine sulfate 4 mg intravenously.
ANS: D Give the patient the PRN morphine sulfate 4 mg intravenously. The patient's respiratory alkalosis is caused by the increased respiratory rate associated with pain and anxiety. The nurse's first action should be to medicate the patient for pain. Although the nasogastric suction may contribute to the alkalosis, it is not appropriate to discontinue the tube when the patient needs gastric suction. The health care provider may be notified about the ABGs but is likely to instruct the nurse to medicate for pain. The patient will not be able to take slow, deep breaths when experiencing pain.
4. The nurse has administered 3% saline to a patient with hyponatremia. Which one of these assessment data will require the most rapid response by the nurse? a. The patient's radial pulse is 105 beats/minute. b. There is sediment and blood in the patient's urine. c. The blood pressure increases from 120/80 to 142/94. d. There are crackles audible throughout both lung fields.
ANS: D There are crackles audible throughout both lung fields. Crackles throughout both lungs suggest that the patient may be experiencing pulmonary edema, a life-threatening adverse effect of hypertonic solutions. The increased pulse rate and blood pressure and the appearance of the urine also should be reported, but they are not as dangerous as the presence of fluid in the alveoli.
15. A patient with hypercalcemia is being cared for on the medical unit. Nursing actions included on the care plan will include a. maintaining the patient on bed rest. b. auscultating lung sounds every 4 hours. c. monitoring for Trousseau's and Chvostek's signs. d. encouraging fluid intake up to 4000 ml every day.
ANS: D encouraging fluid intake up to 4000 ml every day. To decrease the risk for renal calculi, the patient should have an intake of 3000 to 4000 ml daily. Ambulation helps decrease the loss of calcium from bone and is encouraged in patients with hypercalcemia. Trousseau's and Chvostek's signs are monitored when there is a possibility of hypocalcemia. There is no indication that the patient needs frequent assessment of lung sounds, although these would be assessed every shift.
21. A patient is taking a potassium-wasting diuretic for treatment of hypertension. The nurse will teach the patient to report symptoms of adverse effects such as a. personality changes. b. frequent loose stools. c. facial muscle spasms. d. generalized weakness.
ANS: D generalized weakness. Generalized weakness progressing to flaccidity is a manifestation of hypokalemia. Facial muscle spasms might occur with hypocalcemia. Loose stools are associated with hyperkalemia. Personality changes are not associated with electrolyte disturbances, although changes in mental status are common manifestations with sodium excess or deficit.
55. A pregnant woman tells the nurse that there is a history of sickle cell disease in her family and she is afraid that the baby will have the disease. The nurse provides the client with which of the following information? 1.Sickle cell is a male disease and would be passed on by the baby's father. 2.The baby needs only one parent to be a carrier to be affected. 3.Both the mother and father must carry the gene for the baby to be affected. 4.Genetic testing will be needed to determine if the baby is affected.
Answer: 3 Both the mother and father must carry the gene for the baby to be affected. Rationale: Sickle cell is inherited as an autosomal recessive disorder. Both parents must carry the gene for the baby to be affected. The other statements are inaccurate.
53. The nursing management of a patient in sickle cell crisis includes (select all that apply) a. monitoring CBC. b. optimal pain management and O2 therapy. c. blood transfusions if required and iron chelation. d. rest as needed and deep vein thrombosis prophylaxis. e. administration of IV iron and diet high in iron content.
→ ANS: a, b, c, d
54. A pediatric nursing instructor asks a nursing student to describe the cause of the clinical manifestations that occur in sickle cell disease. The student responds correctly by telling the instructor that 1. Sickled cells increase the blood flow through the body and cause a great deal of pain. 2. sickled cells mix with the unsickled cells and cause the immune system to become depressed. 3. bone marrow depression occurs because of the development of sickled cells. 4. sickled cells are unable to flow easily through the microvasculature and their clumping obstructs blood flow.
→ Answer: 4 Rationale: all of the clinical manifestations of sickle cell disease result from the sickled cells being unable to flow easily through the microvasculature, and their clumping obstructs blood flow. With re-oxygenation, most of the sickled red blood cells resume their normal shape. Options 1, 2, and 3 are incorrect statements.
