Lippincott Questions Exam 3

Which signs and symptoms of leukemia would lead the nurse to suspect the client has thrombocytopenia? Select all that apply. 1. fever 2. petechiae 3. epistaxis 4. anorexia 5. bone pain 6. shortness of breath

,3. Children with acute lymphocytic leukemia have a reduced platelet count (thrombocytopenia), reduced red blood cell count (anemia), and reduced white blood cell count (neutropenia) because of unrestricted proliferation of immature white blood cell. Chemotherapy is used to treat leukemia and contributes to thrombocytopenia, neutropenia, and anemia. Clients with thrombocytopenia are at risk for bleeding. Petechiae (small red or purple spots on the skin) and epistaxis (nose bleeds) are both signs of bleeding. A fever is a result of a decreased white blood cell count. Anorexia and shortness of breath are a result of a decreased red blood cell count. Bone pain is a result of stress on the bone related to the unrestricted proliferation of the leukemic blast cells.

A nurse is developing a care plan for a client with hepatic encephalopathy. Which are goals for the care for this client? Select all that apply. 1. Prevent constipation. 2. Administer lactulose to reduce blood ammonia levels. 3. Monitor coordination while walking. 4. Check the pupil reaction. 5. Provide food and fluids high in carbohydrate. 6. Encourage physical activity.

1,2,3,4,5. Constipation leads to increased ammonia production. Lactulose is a hyperosmotic laxative that reduces blood ammonia by acidifying the colon contents, which retards diffusion of nonionic ammonia from the colon to the blood while promoting its migration from the blood to the colon. Hepatic encephalopathy is considered a toxic or metabolic condition that causes cerebral edema; it affects a person's coordination and pupil reaction to light and accommodation. Food and fluids high in carbohydrates should be given because the liver is not synthesizing and storing glucose. Because exercise produces ammonia as a by-product of metabolism, physical activity should be limited, not encouraged.

A client with a Sengstaken-Blakemore tube has a sudden drop in SpO2 and an increase in respiratory rate to 40 breaths/min. What should the nurse do in order from first to last? All options must be used. 1. Affirm airway obstruction by the tube. 2. Remove the tube. 3. Deflate the tube by cutting with bedside scissors. 4. Apply oxygen via face mask.

1,3,2,4. The nurse should first assess the client to determine if the tube is obstructing the airway; assessment is done by assessing airflow. Once obstruction is established, the tube should be deflated and then quickly removed. A set of scissors should always be at the bedside to allow for emergency deflation of the balloon. Oxygen via face mask should then be applied once the tube is removed.

Which position would be appropriate for a client with severe ascites? 1. Fowler's 2. side-lying 3. reverse Trendelenburg 4. Sims

1. Ascites can compromise the action of the diaphragm and increase the client's risk of respiratory problems. Ascites also greatly increases the risk of skin breakdown. Frequent position changes are important, but the preferred position is Fowler's. Placing the client in Fowler's position helps facilitate the client's breathing by relieving pressure on the diaphragm. The other positions do not relieve pressure on the diaphragm.

A client had a liver biopsy 1 hour ago. The nurse should first: 1. auscultate lung sounds. 2. check for fever. 3. obtain a CBC. 4. apply packing to the biopsy site.

1. Because the biopsy needle insertion site is close to the lung, there is a risk of lung puncture and pneumothorax; therefore, immediately after the procedure, the nurse should determine diminished or absent lung sounds in the right lung. Although fever indicates infection, a rise in temperature is not seen immediately. A CBC is warranted if the vital signs and client symptoms indicate potential hemorrhage. The needle insertion site is covered with a pressure dressing; there is no need for a dressing requiring packing.

A client with cirrhosis is receiving lactulose. The nurse notes the client is more confused and has asterixis. The nurse should: 1. assess for gastrointestinal (GI) bleeding. 2. withhold the lactulose. 3. increase protein in the diet. 4. monitor serum bilirubin levels.

1. Clients with cirrhosis can develop hepatic encephalopathy caused by increased ammonia levels. Asterixis, a flapping tremor, is a characteristic symptom of increased ammonia levels. Bacterial action on increased protein in the bowel will increase ammonia levels and cause the encephalopathy to worsen. GI bleeding and protein consumed in the diet increase protein in the intestine and can elevate ammonia levels. Lactulose is given to reduce ammonia formation in the intestine and should not be held since neurological

Which dietary instruction would be appropriate for the nurse to give a client who is recovering from acute pancreatitis? 1. Avoid crash dieting. 2. Restrict carbohydrate intake. 3. Eat six small meals a day. 4. Decrease sodium in the diet.

1. Crash dieting or bingeing may cause an acute attack of pancreatitis and should be avoided. Carbohydrate intake should be increased because carbohydrates are less stimulating to the pancreas. There is no need to maintain a dietary pattern of six meals a day; the client can eat whenever desired. There is no need to place the client on

The nurse should question which prescription for medications for a client with acute pancreatitis? 1. furosemide 20 mg IV push 2. imipenem 500 mg IV 3. morphine sulfate 2 mg IV push 4. famotidine 20 mg IV push

1. Furosemide can cause pancreatitis. Additionally, hypovolemia can develop with acute pancreatitis, and furosemide will further deplete fluid volume. Imipenem is indicated in the treatment of acute pancreatitis with necrosis and infection. Research no longer supports meperidine over other opiates. Morphine and hydromorphone are opiates of choice in acute pancreatitis to get pain under control. Famotidine is a histamine-2 receptor antagonist used to decrease acid secretion and prevent stress or peptic ulcers.

The nurse is preparing a client for a paracentesis. The nurse should: 1. have the client void immediately before the procedure. 2. place the client in a side-lying position. 3. initiate an IV line to administer sedatives. 4. place the client on nothing-by-mouth (NPO) status 6 hours before the procedure.

1. Immediately before a paracentesis, the client should empty the bladder to prevent perforation. The client will be placed in a high Fowler's position or seated on the side of the bed for the procedure. IV sedatives are not usually administered. The client does not need to be NPO.

A client with cirrhosis who has ascites receives 100 mL of 25% serum albumin IV. Which finding would best indicate that the albumin is having its desired effect? 1. reduced ascites 2. increased serum albumin level 3. decreased anorexia 4. increased ease of breathing

1. Normal serum albumin is administered to reduce ascites. Hypoalbuminemia, a mechanism underlying ascites formation, results in decreased colloid osmotic pressure. Administering serum albumin increases the plasma colloid osmotic pressure, which causes fluid to flow from the tissue space into the plasma. Increased urine output is the best indication that the albumin is having the desired effect. An increased serum albumin level and increased ease of breathing may indirectly imply that the administration of albumin is effective in relieving the ascites. However, it is not as direct an indicator as increased urine output and reduced ascites. Anorexia is not affected by the administration of albumin.

A client is receiving propantheline bromide in the management of acute pancreatitis. Which finding would indicate that the nurse should discuss withholding the medication with the healthcare provider (HCP)? 1. absent bowel sounds 2. increased urine output 3. diarrhea 4. decreased heart rate

1. Propantheline is an anticholinergic, antispasmodic medication that decreases vagal stimulation and pancreatic secretions. It is contraindicated in paralytic ileus; therefore, the nurse should be concerned with the absent bowel sounds. Side effects are urinary retention, constipation, and tachycardia.

A client with peptic ulcer disease reports being nauseated most of the day and now feeling light-headed and dizzy. Based upon these findings, which nursing actions would be most appropriate for the nurse to take? Select all that apply. 1. administering an antacid hourly until nausea subsides 2. monitoring the client's vital signs 3. notifying the healthcare provider (HCP) of the client's symptoms 4. initiating oxygen therapy 5. reassessing the client in an hour

2,3. The symptoms of nausea and dizziness in a client with peptic ulcer disease may be indicative of hemorrhage and should not be ignored. The appropriate nursing actions at this time are for the nurse to monitor the client's vital signs and notify the HCP of the client's symptoms. To administer an antacid hourly or to wait 1 hour to reassess the client would be inappropriate; prompt intervention is essential in a client who is potentially experiencing a gastrointestinal hemorrhage. The nurse would notify the HCP of assessment findings and then initiate oxygen therapy if prescribed by the HCP.

The nurse is caring for a client who has had a gastroscopy. Which findings indicate that the client is developing a complication related to the procedure? Select all that apply. 1. The client has a sore throat. 2. The client has a temperature of 100°F (37.8°C). 3. The client appears drowsy following the procedure. 4. The client has epigastric pain. 5. The client experiences hematemesis.

2,4,5. Following a gastroscopy, the nurse should monitor the client for complications, which include perforation and the potential for aspiration. An elevated temperature, epigastric pain, or the vomiting of blood (hematemesis) are all indications of a possible perforation and should be reported promptly. A sore throat is a common occurrence following a gastroscopy. Clients are usually sedated to decrease anxiety, and the nurse would anticipate that the client will be drowsy following the procedure.

A 15-year-old has been admitted to the hospital with the diagnosis of acute lymphocytic leukemia. Which signs and symptoms require the most immediate nursing intervention? 1. fatigue and anorexia 2. fever and petechiae 3. swollen neck lymph glands and lethargy 4. enlarged liver and spleen

2. Fever and petechiae associated with acute lymphocytic leukemia indicate a suppression of normal white blood cells and thrombocytes by the bone marrow and put the client at risk for other infections and bleeding. The nurse should initiate infection control and safety precautions to reduce these risks. Fatigue is a common symptom of leukemia due to red blood cell suppression. Although the client should be told about the need for rest and meal planning, such teaching is not the priority intervention. Swollen glands and lethargy may be uncomfortable, but they do not require immediate intervention. An enlarged liver and spleen do require safety precautions that prevent injury to the abdomen; however, these precautions are not the priority.

A client with acute pancreatitis has a blood pressure of 88/40 mm Hg, heart rate of 128 bpm, respirations of 28/min, and Grey Turner's sign. What prescription should the nurse implement first? 1. Initiate intake/output record. 2. Place an intravenous line. 3. Position on the left side. 4. Insert a nasogastric tube.

2. Grey Turner's sign is a bluish discoloration in the flank area caused by retroperitoneal bleeding. The vital signs are showing hemodynamic instability. IV access should be obtained to provide immediate volume replacement. The urine output will provide information on the fluid status. A nasogastric tube is indicated for clients with uncontrolled nausea and vomiting or gastric distension. Repositioning the client may be considered for pain management once the client's vital signs are stable.

After teaching the parents of a child newly diagnosed with leukemia about the disease, which description if given by the parent best indicates understanding the nature of leukemia? 1. "The disease is an infection resulting in increased white blood cell production." 2. "The disease is a type of cancer characterized by an increase in immature white blood cells." 3. "The disease is an inflammation associated with enlargement of the lymph nodes." 4. "The disease is an allergic disorder involving increased circulating antibodies in the blood."

2. Leukemia is a neoplastic, or cancerous, disorder of blood-forming tissues that is characterized by a proliferation of immature white blood cells. Leukemia is not an infection, inflammation, or allergic disorder.

The nurse explains to the parents of a 1-year-old child admitted to the hospital in sickle cell crisis that the local tissue damage the child has on admission is caused by which factor? 1. autoimmune reaction complicated by hypoxia 2. lack of oxygen in the red blood cells 3. obstruction to circulation 4. elevated serum bilirubin concentration

3. Characteristic sickle cells tend to cause "log jams" in capillaries. This results in poor circulation to local tissues, leading to ischemia and necrosis. The basic defect in sickle cell disease is an abnormality in the structure of the red blood cells. The erythrocytes are sickle shaped, rough in texture, and rigid. Sickle cell disease is an inherited disease, not an autoimmune reaction. Elevated serum bilirubin concentrations are associated with jaundice, not sickle cell disease.

The nurse is providing discharge instructions for a client with cirrhosis. Which statement best indicates that the client has understood the teaching? 1. "I should eat a high-protein, high-carbohydrate diet to provide energy." 2. "It is safer for me to take acetaminophen for pain instead of aspirin." 3. "I should avoid constipation to decrease chances of bleeding." 4. "If I get enough rest and follow my diet, it is possible for my cirrhosis to be cured."

3. Clients with cirrhosis should be instructed to avoid constipation and straining at stool to prevent hemorrhage. The client with cirrhosis has bleeding tendencies because of the liver's inability to produce clotting factors. A lowprotein and high-carbohydrate diet is recommended. Clients with cirrhosis should not take acetaminophen, which is potentially hepatotoxic. Aspirin also should be avoided if esophageal varices are present. Cirrhosis is a chronic disease.

A client with ascites and peripheral edema is at risk for impaired skin integrity. To prevent skin breakdown, the nurse should: 1. institute range-of-motion (ROM) exercise every 4 hours. 2. massage the abdomen once a shift. 3. use an alternating air pressure mattress. 4. elevate the lower extremities.

3. Edematous tissue is easily traumatized and must receive meticulous care. An alternating air pressure mattress will help decrease pressure on the edematous tissue. ROM exercises are important to maintain joint function, but they do not necessarily prevent skin breakdown. When abdominal skin is stretched taut due to ascites, it must be cleaned very carefully. The abdomen should not be massaged. Elevation of the lower extremities promotes venous return and decreases swelling.

The nurse is assessing a client with cirrhosis who has developed hepatic encephalopathy. The nurse should notify the healthcare provider (HCP) of a decrease in which serum lab value that is a potential precipitating factor for hepatic encephalopathy? 1. aldosterone 2. creatinine 3. potassium 4. protein

3. Hypokalemia is a precipitating factor in hepatic encephalopathy. A decrease in creatinine results from muscle atrophy; an increase in creatinine would indicate renal insufficiency. With liver dysfunction, increased aldosterone levels are seen. A decrease in serum protein will decrease colloid osmotic pressure and promote edema.

Which medication prescription to help relieve pain in a child with leukemia should the nurse question? 1. hydromorphone 2. acetaminophen with codeine 3. ibuprofen 4. acetaminophen with hydrocodone

3. Ibuprofen prolongs bleeding time and is contraindicated in clients with leukemia. Nonnarcotic drugs other than ibuprofen or aspirin, such as acetaminophen, may be prescribed to control pain and may be used in combination with codeine or hydrocodone if pain is more severe. Hydromorphone may also be used for severe pain.

A client's serum ammonia level is elevated, and the healthcare provider (HCP) prescribes 30 mL of lactulose. Which effect is common for this drug? 1. increased urine output 2. improved level of consciousness 3. increased bowel movements 4. nausea and vomiting

3. Lactulose increases intestinal motility, thereby trapping and expelling ammonia in the feces. An increase in the number of bowel movements is expected as an adverse effect. Lactulose does not affect urine output. Any improvements in mental status would be the result of increased ammonia elimination, not an adverse effect of the drug. Nausea and vomiting are not common adverse effects of lactulose.

A client is to take one daily dose of ranitidine at home to treat a peptic ulcer. The client understands proper drug administration of ranitidine when the client will take the drug: 1. before meals. 2. with meals. 3. at bedtime. 4. when pain occurs.

3. Ranitidine blocks secretion of hydrochloric acid. Clients who take only one daily dose of ranitidine are usually advised to take it at bedtime to inhibit nocturnal secretion of acid. Clients who take the drug twice a day are advised to take it in the morning and at bedtime. It is not necessary to take the drug before meals. The client should take the drug regularly, not just when pain occurs.

A client with peptic ulcer disease (PUD) is admitted to the hospital for a gastric resection. The client reports a sudden sharp pain in the midepigastric area that radiates to the shoulder. The nurse should first: 1. establish an IV line. 2. administer pain medication. 3. notify the surgeon. 4. call for a stat ECG.

3. The sharp, sudden midepigastric pain indicates the client may have a perforated ulcer. The nurse notifies the surgeon and may then obtain prescriptions for pain medication and IV fluids. It is not necessary to first obtain an ECG because the pain from ulcer perforation is different from that of chest pain that may indicate coronary artery syndrome (crushing pain radiating to the jaw).

A client admitted to the hospital with peptic ulcer disease tells the nurse about having black, tarry stools. The nurse should: 1. encourage the client to increase fluid intake. 2. advise the client to avoid iron-rich foods. 3. place the client on contact precautions. 4. report the finding to the healthcare provider (HCP).

4. Black, tarry stools are an important warning sign of bleeding in peptic ulcer disease. Digested blood in the stool causes it to be black; the odor of the stool is very offensive. The nurse should instruct the client to report the incidence of black stools promptly to the HCP. Increasing fluids or avoiding iron-rich foods will not change the stool color or consistency if the stools contain digested blood. Until other information is available, it is not necessary to initiate contact precautions.

A client with peptic ulcer disease is taking ranitidine. What is the expected outcome of this drug? 1. heal the ulcer 2. protect the ulcer surface from acids 3. reduce acid concentration 4. limit gastric acid secretion

4. Histamine-2 (H2) receptor antagonists, such as ranitidine, reduce gastric acid secretion. Antisecretories, or proton pump inhibitors, such as omeprazole, help ulcers heal quickly in 4 to 8 weeks. Cytoprotective drugs, such as sucralfate, protect the ulcer surface against acid, bile, and pepsin. Antacids reduce acid concentration and help reduce symptoms.

The parents of a child with sickle cell disease ask the nurse why their child's hemoglobin was normal at birth but now the child has S hemoglobin. Which response by the nurse is appropriate? 1. "The placenta bars passage of the hemoglobin S from the mother to the fetus." 2. "The red bone marrow does not begin to produce hemoglobin S until several months after birth." 3. "Antibodies transmitted from you to the fetus provide the newborn with temporary immunity." 4. "The newborn has a high concentration of fetal hemoglobin in the blood for some time after birth."

4. Sickle cell disease is an inherited disease that is present at birth. However, 60% to 80% of a newborn's hemoglobin is fetal hemoglobin, which has a structure different from that of hemoglobin S or hemoglobin A. Sickle cell symptoms usually occur about 4 months after birth, when hemoglobin S begins to replace the fetal hemoglobin. The gene for sickle cell disease is transmitted at the time of conception, not passed through the placenta. Some hemoglobin S is produced by the fetus near term. The fetus produces all its own hemoglobin from the earliest production in the first trimester. Passive immunity conferred by maternal antibodies is not related to sickle cell disease, but this transmission of antibodies is important to protect the infant from various infections during early infancy.

A client is admitted to the hospital after vomiting bright red blood and is diagnosed with a bleeding duodenal ulcer. The client develops a sudden, sharp pain in the midepigastric region along with a rigid, board-like abdomen. After obtaining the client's vital signs, what should the nurse do next? 1. Administer pain medication as prescribed. 2. Raise the head of the bed. 3. Prepare to insert a nasogastric tube. 4. Notify the healthcare provider (HCP).

4. The client is experiencing a perforation of the ulcer, and the nurse should notify the HCP immediately. The body reacts to perforation of an ulcer by immobilizing the area as much as possible. This results in board-like abdominal rigidity, usually with extreme pain. Perforation is a medical emergency requiring immediate surgical intervention because peritonitis develops quickly after perforation. Administering pain medication is not the first action, although the nurse later should institute measures to relieve pain. Elevating the head of the bed will not minimize the perforation. A nasogastric tube may be used following surgery.

The nurse is caring for a client with esophageal varices. The nurse should discuss which laboratory report finding with the healthcare provider (HCP)? 1. normal serum albumin 2. decreased ammonia 3. slightly decreased levels of calcium 4. elevated PT/INR

4. The client with esophageal varices is at even higher risk for bleeding with elevated PT/INR. The nurse and HCP collaborate to prevent bleeding. The other laboratory findings are not as life threatening. A decreased serum albumin can cause fluid to move into the interstitial tissues. Increased ammonia levels are toxic to the brain. Calcium loss is more common to pancreatitis.

A client diagnosed with peptic ulcer disease (PUD) has an H. pylori infection. The client is following a 2-week drug regimen that includes clarithromycin along with omeprazole and amoxicillin. The nurse should instruct the client to: 1. alternate the use of the drugs. 2. take the drugs at different times during the day. 3. discontinue all drugs if nausea occurs. 4. take the drugs for the entire 2-week period.

4. The use of the triple-therapy approach to the H. pylori infection has proved effective; therefore, the nurse advises the client to take the drugs as prescribed for the duration of the prescription. The nurse instructs the client to avoid alternating the use of the drugs and to take all medication at the same time, three times a day unless otherwise noted by the healthcare provider (HCP) . Drugs have very few side effects; however, the nurse instructs the client to continue taking medications and contact the HCP if adverse effects occur.

The nurse is assessing a client who is in the early stages of cirrhosis of the liver. Which focused assessment is appropriate? 1. peripheral edema 2. ascites 3. anorexia 4. jaundice

3. Early clinical manifestations of cirrhosis are subtle and usually include gastrointestinal symptoms, such as anorexia, nausea, vomiting, and changes in bowel patterns. These changes are caused by the liver's altered ability to metabolize carbohydrates, proteins, and fats. Peripheral edema, ascites, and jaundice are later signs of liver failure and portal hypertension.

The nurse is reviewing the chart information for a client with increased ascites. The data include the following: temperature 98.9°F (37.2°C), heart rate 118 bpm, shallow respirations 26/min, blood pressure 128/76 mm Hg, and SpO2 89% on room air. The nurse should first: 1. assess heart sounds. 2. obtain a prescription for blood cultures. 3. prepare for a paracentesis. 4. raise the head of the bed.

4. Elevating the head of the bed will allow for increased lung expansion by decreasing the ascites pressing on the diaphragm. The client requires reassessment. A paracentesis is reserved for symptomatic clients with ascites with impaired respiration or abdominal pain not responding to other measures such as sodium restriction and diuretics. There is no indication for blood cultures. Heart sounds are assessed with the routine physical assessment.