Medsurg Test 6

A patient with hypercalcemia needs to drink at least 3 L of fluid per day. Today, he has had 1 measuring cup of coffee, 1 L of water, a can of soda that says it has 355 mL, and a half cup of juice. How many milliliters has he had so far today? (Fill in the blank) Answer:_________ mL

1715

The recommended dose of filgrastim (Neupogen) is 10 mcg/kg/day. It is supplied as 300 mcg/mL. A patient who weighs 132 lb should receive ____________________ mL.

2

A nurse is assisting with the care of a client who asks why her provider prescribed a daily aspirin. Which of the following is an appropriate response by the nurse? A) "Aspirin reduces the formation of blood clots that could cause a heart attack." B) "Aspirin relieves the pain due to myocardial ischemia." C) "Aspirin dissolves clots that are forming in your coronary arteries." D) "Aspirin relieves headaches that are caused by other medications."

A) "Aspirin reduces the formation of blood clots that could cause a heart attack."

A patient diagnosed with lymphoma is being discharged from the hospital. Which of the following statements should the nurse include in the patient teaching? A) "It is important to avoid crowds to reduce your risk of infection." B) "Taking a walk outside will help reduce your stress level." C) "It it important for you to increase your dietary intake of iron." D) "Your disease often affects the eyes, so television viewing should be minimized."

A) "It is important to avoid crowds to reduce your risk of infection."

The nurse is teaching the parent of a child with hemophilia. Which of the following statement by the parent demonstrates understanding about preventing bleeding episodes? A) "My son will have to avoid contact sports." B) "My son will have to avoid irritating foods in his diet." C) "My son will have to grow a beard." D) "My son will always have to live near a major hospital."

A) "My son will have to avoid contact sports."

A nurse is reinforcing discharge teaching with a client who has heart failure and a fluid restriction of 2,000 mL/day. The client asks the nurse how to determine the amount of fluids he is allowed. Which of the following statements is an appropriate response by the nurse? A) "Pour the amount of fluid you drink into an empty 2-liter bottle to keep track of how much you drink." B) "Each glass contains 8 ounces. There are 30 milliliters per ounce, so you can have a total of 8 glasses or cups of fluid each day." C) "This is the same as 2 quarts, or about the same as two pots of coffee." D) "Take sips of water or ice chips so you will not take in too much fluid."

A) "Pour the amount of fluid you drink into an empty 2-liter bottle to keep track of how much you drink."

A patient with terminal lymphoma says to the nurse, "I'm tired of being so fatigued all the time. Can't you just give me a big shot of morphine and help me end this suffering?" Which response by the nurse is most appropriate? A) "You sound frustrated. It must be difficult to feel so tired all the time." B) "Are you sure that is what you want me to do? Maybe you should think about it first." C) "That is really not appropriate to ask. Would you like a shot just to take away the pain?" D) "You have orders for morphine 10 to 15 mg. I don't think that's enough to end your suffering."

A) "You sound frustrated. It must be difficult to feel so tired all the time."

A nurse is reinforcing discharge teaching with a client who had a gastrectomy due to stomach cancer. Which of the following statements should the nurse make? A) "You will need a monthly injection of vitamin B12 for the rest of your life." B) "Using the nasal spray form of vitamin B12 on a daily basis can be an option." C) "an oral supplement of vitamin B12 taken on a daily basis can be an option." D) "You should increase your intake of animal proteins, legumes, and dairy products to increase vitamin B12 in your diet." E) "Add soy milk fortified with Vitamin B12 to your fiet to decrease the risk of pernicious anemia."

A) "You will need a monthly injection of vitamin B12 for the rest of your life." B) "Using the nasal spray form of vitamin B12 on a daily basis can be an option."

The nurse is assisting with the preparation of a blood transfusion for a patient. Which type of fluid should the nurse select to transfuse with the blood? A) 0.9% normal saline B) Dextrose 5% and water C) Dextrose 5% and 0.9% normal saline D) Dextrolse 5% and 0.45% normal saline

A) 0.9% normal saline

A nurse is reinforcing teaching with a client who has heart failure about the need to limit sodium in the diet to 2,000 mg daily. Which of the following foods should the nurse recommend for the client? (Select all that apply.) A) 1 slice cheddar cheese B) 1 medium beef hot dog C) 3 oz Atlantic salmon D) 3 oz roasted chicken breast E) 2 oz lean baked ham

A) 1 slice cheddar cheese C) 3 oz Atlantic salmon D) 3 oz roasted chicken breast

A nurse is caring for a group of clients. Which of the following clients is at risk for development of a dysrhythmia? (Select all that apply.) A) A client who has metabolic acidosis B) A client who has a serum potassium level of 4.3 mEq/L C) A client who has an SaO2 of 96% D) A client who has COPD E) A client who underwent stent placement in a coronary artery

A) A client who has metabolic acidosis D) A client who has COPD E) A client who underwent stent placement in a coronary artery

The nurse is assisting in the development of a care plan for a patient with anemia. Which nursing diagnosis is most common in a patient with anemia? A) Activity Intolerance related to tissue hypoxia B) Ineffective Airway Clearance related to dyspnea C) Chronic Pain related to bone marrow dysfunction D) Risk for Infection related to reduction in circulating WBCs

A) Activity Intolerance related to tissue hypoxia

The nurse is collecting information about sickle cell disease for an upcoming seminar. What should the nurse include as common triggers for a sickle cell crisis? (Select all that apply.) A) Anesthesia B) Chemotherapy C) Severe infection D) Strenuous exercise E) Use of nasal oxygen F) Blood loss during surgery

A) Anesthesia C) Severe infection D) Strenuous exercise F) Blood loss during surgery

A nurse is reinforcing teaching with a client who has a new prescription for clopidogrel. Which of the following instructions should the nurse include in the teaching? (Select all that apply.) A) Avoid consuming grapefruit while taking this medication. B) Monitor for black, tarry stools. C) Use an electric razor when shaving. D) Take the medication when you have pain. E) Limit food sources containing vitamin K while taking this medication.

A) Avoid consuming grapefruit while taking this medication. B) Monitor for black, tarry stools. C) Use an electric razor when shaving.

Which of the following nursing interventions are appropriate for a patient with thromboctyopenia? (Select all that apply.) A) Avoid intramuscular injections. B) Keep visitors who are ill away from the patient. C) Encourage 4 L of fluid daily. D) Avoid use of aspirin and NSAIDs. E) Allow rest between activities. F) Encourage use of shoes or slippers.

A) Avoid intramuscular injections. D) Avoid use of aspirin and NSAIDs. F) Encourage use of shoes or slippers.

The nurse is caring for a patient scheduled for tests to confirm the diagnosis of lymphoma. For which diagnostic tests should the nurse prepare the patient? (Select all that apply.) A) CT scan B) Cerebral angiogram C) Lymph node biopsy D) Lymphangiography E) Complete blood count

A) CT scan C) Lymph node biopsy D) Lymphangiography E) Complete blood count

A nurse is assisting with the plan of care for a client following a surgical placement of a synthetic graft to repair an aneurysm. Which of the following interventions should be included in the plan of care? (Select all that apply.) A) Check pedal pulses. B) Monitor for an increase in pain below the graft site. C) Maintain the client in high-Fowler's position. D) Administer antiplatelet agents. E) Report hourly urine output of 60 mL.

A) Check pedal pulses. B) Monitor for an increase in pain below the graft site. D) Administer antiplatelet agents.

A nurse is reviewing a client's laboratory test results. The nurse should identify that which of the following results indicates the client is at risk for heart disease? (Select all that apply.) A) Cholesterol (total) 245 mg/dL B) HDL 90 mg/dL C) LDL 140 mg/dL D) Triglycerides 125 mg/dL E) Troponin 1 0.02 ng/mL

A) Cholesterol (total) 245 mg/dL C) LDL 140 mg/dL

A nurse is collecting data on a client who has a new diagnosis of a thoracic aortic aneurysm. Which of the following manifestations should the nurse expect? (Select all that apply.) A) Cough B) Shortness of breath C) Upper chest pain D) Diaphoresis E) Altered swallowing

A) Cough B) Shortness of breath E) Altered swallowing

A female patient's hematocrit level is 50% and oxygen saturation is 98% on room air. What should the nurse suspect as being the cause for this patient's hematocrit level? A) Dehydration B) Chronic renal failure C) Bone marrow suppression D) Bleeding esophageal varices

A) Dehydration

A nurse is assisting with data collection from a client who has left-sided valvular heart disease. Which of the following data are risk factors for this condition? (Select all that apply.) A) Dyspnea on exertion B) Client report of fatigue C) Bradycardia D) Pleural friction rub E) Peripheral edema

A) Dyspnea on exertion B) Client report of fatigue E) Peripheral edema

Which of the following interventions can help minimize complications related to hypercalcemia? A) Encourage 3 to 4 L of fluid daily. B) Have the patient cough and deep breathe every 2 hours. C) Place the patient on bedrest. D) Apply heat to painful areas.

A) Encourage 3 to 4 L of fluid daily.

A patient with multiple myeloma is at risk for hypercalcemia. Which nursing intervention is most important for the patient with hypercalcemia? A) Encourage fluids. B) Offer citrus juices and fruits. C) Place the patient on a low-sodium diet. D) Discourage intake of alcoholic beverages.

A) Encourage fluids.

A nurse is assisting in the care of a client who underwent defibrillation. Which of the following should be included in the documentation of this procedure? (Select all that apply.) A) Follow-up ECG B) Energy settings used C) IV fluid intake D) Urinary output E) Skin condition under electrodes

A) Follow-up ECG B) Energy settings used E) Skin condition under electrodes

During a home visit, the nurse becomes concerned that a child is developing idiopathic thrombocytopenic purpura (ITP). Which health problems could have precipitated the development of this disorder in the child? (Select all that apply.) A) HIV B) Rubella C) Hepatitis C D) Chickenpox E) Cystic fibrosis

A) HIV B) Rubella C) Hepatitis C D) Chickenpox

The nurse is caring for a patient with PV. Which laboratory study should the nurse monitor to help evaluate the effectiveness of treatment for this patient? A) Hematocrit B) Total protein C) Blood urea nitrogen (BUN) D) WBC differential

A) Hematocrit

A patient with iron-deficiency anemia has been taking oral iron supplements. Which test should the nurse review to determine the effectiveness of this intervention? A) Hemoglobin and hematocrit B) WBC and platelet counts C) Electrolytes, blood urea nitrogen (BUN), and creatinine D) Thrombin clotting time (TCT) and prothrombin time (PT)

A) Hemoglobin and hematocrit

Which of the following nursing interventions is a priority for the patient with multiple myeloma found in the ribs and femur? A) Implement safety measures to prevent falls. B) Assist with all ADLs. C) Provide a high-protein, low-sodium diet. D) Institute neutropenic precautions.

A) Implement safety measures to prevent falls.

A nurse is collecting data from a client who has splinter hemorrhages in the nail beds and reports a fever. The nurse should identify these findings as manifestations of which of the following disorders? A) Infective endocarditis B) Pericarditis C) Myocarditis D) Rheumatic endocarditis

A) Infective endocarditis

A patient is diagnosed with anemia and asks the nurse what nutrients are important for RBC formation. The nurse bases an answer on the understanding that which nutrients are essential for production of healthy red cells? A) Iron, folic acid, and vitamin B12 B) Vitamin C, vitamin D, and selenium C) Vitamin A, calcium, and phosphorus D) Aluminum, vitamin E, and beta carotene

A) Iron, folic acid, and vitamin B12

A patient is admitted to determine why red blood cells are being quickly destructed in the body. What finding should the nurse associate with this patient's health problem? A) Jaundice B) Bleeding C) Diarrhea D) Cyanosis

A) Jaundice

A nurse is reinforcing discharge teaching with a client who has a prescription for furosemide 40 mg PO daily. The client should take this medication at which of the following times of day? A) Morning B) Immediately after lunch C) Immediately before dinner D) Bedtime

A) Morning

A comatose patient is admitted to the emergency department after an automobile accident. The nurse notes a Medic-Alert identification bracelet that states the patient has hemophilia. What should the nurse do first? A) Notify the physician of the bracelet. B) Tape the bracelet to the patient's arm. C) Call the phone number on the bracelet. D) Remove the bracelet, and give it to the patient's family member.

A) Notify the physician of the bracelet.

A patient who has had a splenectomy complains of malaise. The nurse checks the patient's temperature and finds it is 102°F (39°C). Which action by the nurse should take priority? A) Notify the physician. B) Encourage fluids to reduce fever and prevent dehydration. C) Administer acetaminophen to reduce fever and relieve discomfort. D) Explain to the patient that low-grade fevers are common after splenectomy because the spleen is part of the immune system.

A) Notify the physician.

The nurse is caring for a patient having a bone marrow biopsy. What nursing action is the most important following the biopsy? A) Observe for bleeding. B) Encourage oral fluids. C) Administer an analgesic for pain. D) Monitor the puncture site for infection.

A) Observe for bleeding.

Which of the following is an early sign of anemia? A) Palpitations B) Glossitis C) Pallor D) Weight loss

A) Palpitations

The nurse is caring for a patient with a bleeding disorder. Which manifestation might first alert the nurse to the possibility of disseminated intravascular coagulation? A) Petechiae B) Absence of pulses in extremities C) Weakness or paralysis on one side D) Increasing blood pressure and pulse

A) Petechiae

The nurse is preparing to provide care to a patient recovering from surgery. What nursing action is the best way to prevent infection in a postoperative patient? A) Practice good hand washing. B) Encourage 2 L of fluid daily. C) Change wound dressings daily. D) Assess vital signs every 4 hours.

A) Practice good hand washing.

A nurse is contributing to the plan of care for a client who has a Hgb of 7.5 g/dL and a Hct if 21.5%. Which of the following interventions should the nurse include? (Select all that apply.) A) Provide assistance with ambulation. B) Monitor oxygen saturation. C) Weigh the client weekly. D) Obtain stool specimen for occult blood. E) Schedule daily rest periods.

A) Provide assistance with ambulation. B) Monitor oxygen saturation. D) Obtain stool specimen for occult blood. E) Schedule daily rest periods.

The nurse is assessing a patient with a bleeding disorder and finds large purplish areas in the skin and oral mucosa. Which term should the nurse use to document this finding? A) Purpura B) Bleeding C) Petechiae D) Hemorrhage

A) Purpura

During a home visit, the nurse becomes concerned that a patient recovering from a splenectomy is at risk for infection. What did the nurse observe to come to this conclusion? (Select all that apply.) A) Received a manicure and pedicure B) Washed hands before preparing lunch C) Poured a cup of tea after petting the cat D) Had a hot tub installed on the back patio E) Planting tomato plants in an outside garden

A) Received a manicure and pedicure C) Poured a cup of tea after petting the cat D) Had a hot tub installed on the back patio E) Planting tomato plants in an outside garden

The nurse is explaining the role of red blood cells with oxygen transport in the body with a nursing student. Which term should the nurse use to describe hemoglobin that has given up its oxygen to the body's cells? A) Reduced B) Detached C) Oxyhemoglobin D) Hypoxyhemoglobin

A) Reduced

A patient has a platelet count of 75,000 /mm3. What action should the nurse take to support this patient? A) Restrict blood draws. B) Place in protective isolation. C) Wear a mask when entering the room. D) Document rectal temperatures to be taken.

A) Restrict blood draws.

A patient with multiple myeloma is being cared for at home. Which nursing diagnosis should guide the nurse when teaching the family how to provide care for the patient? A) Risk for Injury related to compromised bone integrity B) Ineffective Tissue Perfusion related to vascular occlusion C) Risk for Deficient Fluid Volume related to bleeding disorder D) Ineffective Airway Clearance related to cervical lymphadenopathy

A) Risk for Injury related to compromised bone integrity

The nurse is providing education to an individual with sickle cell anemia. Which activities should the nurse instruct the patient to avoid? (Select all that apply.) A) Scuba diving B) Contact sports C) Sexual activity D) Long-distance driving E) Skiing in the mountains F) Standing for long periods

A) Scuba diving E) Skiing in the mountains

A patient is diagnosed with a folic acid deficiency. On what dietary changes should the nurse instruct this patient? (Select all that apply.) A) Snack on peanuts. B) Eat breads fortified with folic acid. C) Add green leafy vegetables to meals. D) Increase the intake of milk each day. E) Prepare soups with dried peas and beans.

A) Snack on peanuts. B) Eat breads fortified with folic acid. C) Add green leafy vegetables to meals. E) Prepare soups with dried peas and beans.

A nurse is assisting with admission of a client who has a suspected myocardial infarction (MI) and a history of angina. Which of the following findings will help the nurse distinguish angina from an MI? A) Stable angina can be relieved with rest and nitroglycerin. B) The pain of an MI resolves in less than 15 minutes. C) The type of activity that causes an MI can be identified. D) Stable angina can occur for longer than 30 minutes.

A) Stable angina can be relieved with rest and nitroglycerin.

A nurse is caring for a client who is receiving a blood transfusion. Which of the following actions should the nurse take if an allergic transfusion reaction is suspected? (Select all that apply.) A) Stop the transfusion. B) Monitor for hypertension. C) Maintain an IV infusion with 0.9% sodium chloride. D) Position the client in an upright position with the feet lower than the heart. E) Administer diphenhydramine.

A) Stop the transfusion. C) Maintain an IV infusion with 0.9% sodium chloride. E) Administer diphenhydramine.

While receiving a unit of packed red blood cells, the patient begins to experience hives around the neck and upper chest. What actions should the nurse perform because of this reaction? (Select all that apply.) A) Stop the transfusion. B) Notify the health care provider (HCP). C) Return the blood to the blood bank. D) Administer prescribed antihistamines. E) Restart the infusion and carefully monitor.

A) Stop the transfusion. B) Notify the health care provider (HCP). D) Administer prescribed antihistamines. E) Restart the infusion and carefully monitor.

A patient receiving a unit of packed red blood cells as treatment for anemia begins to vomit and experience extreme gastrointestinal cramping. What should the nurse do? (Select all that apply.) A) Stop the transfusion. B) Administer intravenous (IV) heparin. C) Prepare to provide cardiopulmonary resuscitation (CPR) if necessary. D) Stay with the patient and call for help. E) Flush the blood tubing with normal saline.

A) Stop the transfusion. C) Prepare to provide cardiopulmonary resuscitation (CPR) if necessary. D) Stay with the patient and call for help.

A patient with a bleeding disorder is considering surgery to have the spleen removed. What should the nurse explain as being functions of the spleen in a healthy adult? (Select all that apply.) A) Storage of platelets B) Formation of bilirubin C) Production of red blood cells D) Production of neutrophils and eosinophils E) Production of lymphocytes and monocytes F) Phagocytosis of worn blood cells and platelets

A) Storage of platelets B) Formation of bilirubin E) Production of lymphocytes and monocytes F) Phagocytosis of worn blood cells and platelets

A nurse is reviewing the health record of a client who is being evaluated for possible valvular heart disease. Which of the following data are risk factors for this condition? (Select all that apply.) A) Surgical repair of an atrial septal defect at age 2 B) Measles infection during childhood C) Hypertension for 5 years D) Weight gain of 10 lb in 1 year E) Diastolic murmur

A) Surgical repair of an atrial septal defect at age 2 C) Hypertension for 5 years E) Diastolic murmur

A nurse is assisting with the admission data collection of a client who has suspected pulmonary edema. Which of the following manifestation are expected findings? (Select all that apply.) A) Tachypnea B) Persistent cough C) Increased urinary output D) Thick yellow sputum E) Orthopnea

A) Tachypnea B) Persistent cough E) Orthopnea

What assessment data will best help the nurse determine if interventions for neutropenia have been effective? A) Temperature B) Fatigue level C) Oxygen saturation D) Hemoglobin level

A) Temperature

A patient is admitted for a splenectomy. Why is an injection of vitamin K ordered before surgery? A) To correct clotting problems B) To promote healing C) To prevent postoperative infection D) To dry secretions

A) To correct clotting problems

A nurse is assisting in the care of a client who began having chest pain 2 hr ago. Which of the following laboratory findings should the nurse identify as an indication the client has sustained injury to the heart? A) Troponin T 0.8 ng/mL B) Creatine kinase (MB) 100 units/L C) Myoglobin 80 mcg/L D) Triglycerides 120 mg/dL

A) Troponin T 0.8 ng/mL

A patient has hand-foot syndrome related to sickle cell anemia. What findings does the nurse expect to see as the patient is examined? A) Unequal growth of the fingers and toes B) Webbing between fingers and toes C) Purplish discoloration of hands and feet D) Deformities of the wrists and ankles

A) Unequal growth of the fingers and toes

A patient reports severe abdominal cramping and diarrhea. Assessment reveals a temperature of 102°F (38.8°C) and pulse of 82 beats/min. Results of a complete blood count reveal lower than normal segmented and banded neutrophils and higher than normal lymphocytes. Which type of infection does the nurse suspect this patient is most likely experiencing? A) Viral B) Fungal C) Parasitic D) Bacterial

A) Viral

The nurse is staying with a patient who has been started on a blood transfusion. Which assessment should the nurse perform during a blood product infusion to detect a reaction? A) Vital signs B) Skin turgor C) Bowel sounds D) Pupil reactivity

A) Vital signs

The nurse is preparing teaching for a patient with Hodgkin's disease. Which beverage should the nurse instruct this patient to avoid? A) Wine B) Coffee C) Ginger ale D) Orange juice

A) Wine

A nurse is reinforcing teaching with a client who is scheduled for a bone marrow biopsy of the iliac crest. Which of the following statements by the client indicates an understanding of the teaching? A) "This test will be preformed while I am lying flat on my back." B) "I will need to stay in bed for about an hour after the test." C) "this test will determine which antibiotic I should take for treatment." D) "I will receive general anesthesia for the test."

B) "I will need to stay in bed for about an hour after the test."

A nurse is reinforcing teaching with a client scheduled for cardioversion. Which of the following client statements should the nurse identify as an indication the teaching has been understood? A) "I should stop taking my warfarin 1 week prior to the procedure." B) "I will receive an electrocardigram following the procedure." C) "Mechanical ventilation will be required during the procedure." D) "Palpitations are an expected effect following the procedure."

B) "I will receive an electrocardigram following the procedure."

A nurse is reinforcing teaching with a client who has a new diagnosis of hypertension and a new prescription for spironolactone 25 mg/day. Which of the following statements by the client indicates an understanding of the teaching? A) "I should eat a lot of fruits and vegetables, especially bananas and potatoes." B) "I will report any changes in heart rate to my provider." C) "I should replace the salt shaker on my table with a salt substitute." D) "I will decrease the dose of this medication when I no longer have headaches and facial redness."

B) "I will report any changes in heart rate to my provider."

A nurse is caring for a patient admitted with gastrointestinal tract bleeding and a hemoglobin level of 6 g/dL. The patient asks the nurse why the low hemoglobin causes shortness of breath. Which response is best? A) "Anemia prevents your lungs from absorbing oxygen effectively." B) "You do not have enough hemoglobin to carry oxygen to your tissues." C) "You don't have enough blood to feed your cells." D) "You have lost a lot of blood, and that has damaged your lungs."

B) "You do not have enough hemoglobin to carry oxygen to your tissues."

A nurse in an outpatient clinic is reinforcing discharge instructions with a client who has a new prescription for erythropoietin. Which of the following statements should the nurse make? A) "You will need an erythrocyte sedimentation rate (ESR) test weekly." B) "You should have your hemoglobin level checked twice per week." C) "Your oxygen saturation levels should be monitored." D) "Your folic acid production will increase."

B) "You should have your hemoglobin level checked twice per week."

A nurse is reinforcing teaching with a client who is scheduled for a stress test. Which of the following statements should the nurse include in the teaching? A) "You should not have anything to eat or drink for 8 hours prior to the test." B) "You will exercise your heart by walking on a treadmill." C) "A chest x-ray will be obtained following the test." D) "The test will be delayed if your troponin 1 level is less than 0.5 ng/mL."

B) "You will exercise your heart by walking on a treadmill."

A nurse is reinforcing discharge teaching with a client who has heart failure and is encouraged to increase potassium in his diet. Which of the following food selections should the nurse include as having the highest source of potassium? A) 1 medium apple B) 1 medium baked potato C) 1 slice toast with 1 tbsp peanut butter D) 1 large scrambled egg

B) 1 medium baked potato

Which of the following is a normal hemoglobin value? A) 38% to 48% B) 12 to 18 g/100 mL C) 48 to 54 mg % D) 27 to 36 g/dL

B) 12 to 18 g/100 mL

The nurse is preparing to assist the physician with a bone marrow biopsy. Which of the following interventions is most important for the nurse to carry out before the procedure? A) Explain the procedure to the patient's family. B) Administer an analgesic to the patient. C) Observe the patient for bleeding. D) Drape the biopsy site.

B) Administer an analgesic to the patient.

The nurse is reviewing the contents of blood plasma prior to participating in a seminar for nursing students. What should the nurse include as proteins in the plasma? (Select all that apply.) A) Iron B) Albumin C) Globulin D) Fibrinogen E) Electrolytes F) Hemoglobin

B) Albumin C) Globulin D) Fibrinogen

The nurse is teaching a patient with sickle cell anemia how to prevent crises. Which foods should the nurse teach the patient to avoid? A) Citrus fruits B) Alcoholic beverages C) Chocolates and colas D) Whole grain products

B) Alcoholic beverages

The nurse is evaluating laboratory values for a group of patients. Which values should the nurse identify as being within normal limits? (Select all that apply.) A) An adult male with Hct = 35% B) An adult female with Hct = 40% C) An adult male with Hgb = 12.8 g/100 mL D) An adult female with Hgb = 11.5 g/100 mL E) An adult male with RBC = 4 million/mm3 F) An adult female with RBC = 5 million/mm3

B) An adult female with Hct = 40% F) An adult female with RBC = 5 million/mm3

Which of the following conditions places a patient at risk for respiratory complications following splenectomy? A) A low platelet count B) An incision near the diaphragm C) Early ambulation D) Early discharge

B) An incision near the diaphragm

A nurse is caring for a client who has chronic venous insufficiency and a prescription for thigh-high compression stockings. Which of the following actions should the nurse take? A) Elevate the legs for 10 minutes, 2 to 3 times daily which wearing the stockings. B) Apply the stockings in the morning upon awakening and before getting out of bed. C) Roll the stocking down to the knees to relieve discomfort on the legs. D) Cross on leg over the other when sitting or reclining.

B) Apply the stockings in the morning upon awakening and before getting out of bed.

A nurse is caring for a client who has heart failure and reports increased shortness of breath. The nurse increases the client's oxygen per protocol. Which of the following should the nurse take first? A) Weigh the client. B) Assist the client into high-Fowler's position. C) Auscultate lung sounds. D) Check oxygen saturation with pulse oximeter.

B) Assist the client into high-Fowler's position.

A nurse is caring for a client following peripheral bypass graft surgery of the left lower extremity. Which of the following findings pose an immediate concern? (Select all that apply.) A) Trace of bloody drainage on dressing B) Capillary refill of affected limb of 6 seconds C) Mottled appearance of the limb D) Throbbing pain of affected limb that is decreased following IV bolus analgesic E) Pulse of 2+ in the affected limb

B) Capillary refill of affected limb of 6 seconds C) Mottled appearance of the limb

A patient has a bone marrow aspiration from the posterior iliac crest. Before the procedure, the patient's vital signs were: blood pressure 132/82 mm Hg and pulse 88 beats/min. One hour after the procedure, the blood pressure is 108/70 mm Hg and pulse is 96 beats/min. Which assessment is the least important for the patient at this time? A) Observe the puncture site. B) Check the patient's most recent complete blood count report. C) Ask the patient about feelings of lightheadedness or dizziness. D) Determine if the patient had any medications before the procedure.

B) Check the patient's most recent complete blood count report.

A nurse is screening a client for hypertension. Which of the following actions by the client increases the risk for hypertension? (Select all that apply.) A) Drinking 8 oz nonfat milk daily B) Eating popcorn at the movie theater C) Walking 1 mile daily at 12 min/mile pace D) Consuming 36 oz beer daily E) Getting a massage once a week

B) Eating popcorn at the movie theater D) Consuming 36 oz beer daily

A 27-year-old African American is admitted in sickle cell crisis. Which of the following events most likely contributed to the onset of the crisis? A) He started a new job last week. B) He walked home in a cold rain yesterday. C) He has seafood for dinner last night. D) He has not exercised for a week.

B) He walked home in a cold rain yesterday.

A nurse is caring for a client who is receiving warfarin anticoagulation therapy. Which of the following laboratory test results indicates that the client needs an increase in the dosage? A) aPTT 38 seconds B) INR 1.1 C) PT 22 seconds D) D-dimer negative

B) INR 1.1

The nurse is caring for a patient with thrombocytopenia. Which activity should be avoided? A) Ambulation B) Intramuscular injections C) Visits from family members D) Eating fresh fruits and vegetables

B) Intramuscular injections

The nurse suspects a patient is experiencing manifestations of Hodgkin's disease. Which are characteristics of this health disorder? (Select all that apply.) A) Visual changes occur. B) It is the most curable of all lymphomas. C) Skeletal pain is a common symptom. D) It is distinguished by the presence of Reed-Sternberg cells. E) Painless swelling of cervical, axillary, or inguinal nodes occurs. F) It is distinguished by the presence of Philadelphia chromosome.

B) It is the most curable of all lymphomas. D) It is distinguished by the presence of Reed-Sternberg cells. E) Painless swelling of cervical, axillary, or inguinal nodes occurs.

Which of the following foods will best help provide dietary iron for a patient who has iron-deficiency anemia? A) Fresh fruits B) Lean red meats C) Dairy products D) Breads and cereals

B) Lean red meats

A nurse is assisting with the administration of a unit of packed RBCs to a client who has a Hgb of 8 g/dL. Which of the following actions should the nurse plan to take during the first 15 minutes of the transfusion? A) Verify the client has given informed consent for the transfusion B) Monitor for an acute hemolytic reaction. C) Explain the transfusion procedure to the client. D) Obtain blood culture specimens to send to the lab.

B) Monitor for an acute hemolytic reaction.

A patient is on warfarin (Coumadin) therapy and has an INR of 1.6. Which action by the nurse is appropriate? A) Observe the patient for abnormal bleeding. B) Notify the physician and expect an order to increase the warfarin dose. C) Advise the patient to double today's dose of warfarin. D) Administer vitamin k per protocol.

B) Notify the physician and expect an order to increase the warfarin dose.

A patient with a history of hemophilia A arrives in the emergency department with a "funny feeling" in his elbow. The patient states that he thinks he is bleeding into the joint. Which response by the nurse is correct? A) Palpate the patient's elbow to assess for swelling. B) Notify the physician immediately and expect an order for factor VIII. C) Prepare the patient for an x-ray examination to determine whether the bleeding is occurring. D) Apply heat to the elbow and wait for the physician to examine the patient.

B) Notify the physician immediately and expect an order for factor VIII.

Which of the following items are transported in blood plasma? (Select all that apply.) A) Oxygen B) Nutrients C) Carbon dioxide D) Hormones E) Wastes F) Electrolytes

B) Nutrients C) Carbon dioxide D) Hormones E) Wastes F) Electrolytes

A nurse is caring for a client who is on telemetry. The nurse recognizes the client's heart rate is 46/min and notifies the provider. The nurse should anticipate that which of the following management strategies will be used for this client? A) Defibrillation B) Pacemaker insertion C) Synchronized cardioversion D) Administration of amiodarone PO

B) Pacemaker insertion

The nurse notes that a patient's gaping wound is developing a blood clot. Which body substance is responsible for this clot formation? A) Plasma B) Platelets C) Red blood cells D) White blood cells

B) Platelets

An older adult patient is receiving a transfusion of packed red blood cells after being injured in a car accident. On assessment, the nurse notes a new finding of bounding pulse, crackles, and increasing dyspnea. What should the nurse do first, after stopping the transfusion? A) Assess vital signs. B) Raise the head of the bed. C) Encourage the patient to deep breathe and cough. D) Administer prn diphenhydramine (Benadryl) as ordered.

B) Raise the head of the bed.

A patient with abdominal injuries from a motor vehicle crash is scheduled for surgery to remove the spleen. What bodily function will be affected by the removal of this organ? A) Filtration of waste products B) Removal of old red blood cells from circulation C) Clearance of mucous in the tracheobronchial tree D) Facilitation of glucose to be used by the cell for energy

B) Removal of old red blood cells from circulation

A nurse is collecting data from a client who has anemia. Which of the following integumenatry findings should the nurse expect? A) Absent turgor B) Spoon-shaped nails C) Shiny, hairless legs D) Yellow mucous membranes

B) Spoon-shaped nails

The nurse is collaborating on discharge teaching needed for a patient recovering from a splenectomy. What follow-up care is most important for the nurse to emphasize with this patient? A) Monthly coagulation studies B) Yearly influenza vaccination C) Oral analgesics for pain control D) Routine transfusion of packed RBCs to prevent anemia

B) Yearly influenza vaccination

A patient is admitted in sickle cell crisis with symptoms of dyspnea and leg pain. The patient's significant other asks, "I don't really understand why he is hurting so badly." Which response by the nurse is best? A) "The pain is due to a disturbance in cellular metabolism." B) "The bone marrow is expanding with the sickled cells and that causes pain." C) "Clumping of abnormal red blood cells blocks the flow of blood through the capillaries." D) "Bleeding in the joints occurs because red blood cells are being rapidly destroyed by the bone marrow."

C) "Clumping of abnormal red blood cells blocks the flow of blood through the capillaries."

A nurse is reinforcing discharge teaching with a client following an atherectomy using the right femoral artery as an access. Which of the following statements indicates an understanding of the teaching? A) "I should expect moderate swelling of the insertion site on my right groin." B) "I will limit fluid intake for the first 24 hours following the procedure." C) "I should restrict lifting to 5 pounds." D) "I can resume high-impact aerobic exercises right away."

C) "I should restrict lifting to 5 pounds."

The nurse is providing dietary teaching to an individual with iron-deficiency anemia. Which patient statement indicates that teaching has been effective? A) "I know I need to eat more green vegetables and dairy products." B) "Berries and natural cereals are good for me because of my low iron levels." C) "I'm going to drink orange juice for breakfast and increase red meats in my diet." D) "Yellow vegetables and green tea will be important to help build up my blood levels."

C) "I'm going to drink orange juice for breakfast and increase red meats in my diet."

A nurse is caring for a client who has a deep-vein thrombosis (DVT) and has been taking unfractionated heparin for 1 week. Two days ago, the provider also prescribed warfarin. The client asks the nurse about receiving both heparin and warfarin at the same time. Which of the following statements should the nurse give? A) "I will remind your provdier that you are already receiving heparin." B) "Your laboratory findings indicated that two anticoagulants were needed." C) "It takes 3 to 4 days before the therapeutic effects of warfarin are achieved, and then the heparin can be discontinued." D) "Only one of these medications is being given to treat your deep-vein thrombosis."

C) "It takes 3 to 4 days before the therapeutic effects of warfarin are achieved, and then the heparin can be discontinued."

A patient with aplastic anemia is to receive an injection of erythropoietin (Epogen). The patient asks what the injection is intended to do. Which should the nurse respond to the patient? A) "It will inhibit the protein that is attacking your blood cells." B) "It works like a blood transfusion to give you extra red blood cells." C) "It will stimulate your body to produce more of its own red blood cells." D) "It will increase your energy while your body is recovering from the anemia."

C) "It will stimulate your body to produce more of its own red blood cells."

A patient is having difficulty coping with a new diagnosis of leukemia. Which response by the nurse is most helpful initially? A) "Don't worry. You'll be okay." B) "The treatments you are receiving will make you feel better very soon." C) "Who do you usually go to when you have a problem?" D) "Have you made end-of-life decisions?"

C) "Who do you usually go to when you have a problem?"

A nurse is reinforcing preoperative teaching with a client who requests aoutologous donation in preparation for a scheduled orthopedic surgical procedure. Which of the following statements should the nurse make? A) "You should make an appointment to donate blood 8 weeks prior to the surgery." B) "If you need an aoutologous transfusion, the blood your brother donates can be used." C) "You can donate blood each week if your hemoglobin is stable." D) "Any unused blood that is donated can be used for other clients."

C) "You can donate blood each week if your hemoglobin is stable."

The nurse is reviewing the activated partial thromboplastin time for a patient receiving heparin. Which value indicates that the medication is within the therapeutic range? A) 2.5 to 9.5 minutes B) 9.5 to 11.3 seconds C) 1.5 to 2.0 times normal D) 2.0 to 3.0 times normal

C) 1.5 to 2.0 times normal

A patient with anemia and a nursing diagnosis of activity intolerance due to tissue hypoxia and dyspnea is attempting to increase activity tolerance. What percentage of increase in pulse and respiratory rate should the nurse use to determine if the activity is too strenuous for the patient? A) 5% B) 10% C) 20% D) 30%

C) 20%

The nurse is preparing teaching materials for a patient with PV. How many liters of fluid should the nurse instruct the patient to consume each day? A) 1 B) 2 C) 3 D) 4

C) 3

The nurse is reviewing the results of a patient's arterial blood gas analysis. What should the nurse recognize as being a normal blood pH? A) 7.29 B) 7.31 C) 7.38 D) 7.48

C) 7.38

The nurse is reviewing the current patient census on a care area. Which individual is most likely to present with signs or symptoms of sickle cell anemia? A) A 1-month-old boy who is Hispanic B) A 5-year-old girl of Hispanic origin C) A 1-year-old boy who is African American D) A 3-month-old girl who is African American

C) A 1-year-old boy who is African American

A nurse is assisting with the care of a client who has a possible dissecting abdominal aortic aneurysm. Which of the following actions is the priority for the nurse to take? A) Administer pain medication. B) Provide a warm environment. C) Administer IV fluids. D) Initiate a 12-lead ECG.

C) Administer IV fluids.

The nurse is reviewing the care plan for a patient with disseminated intravascular coagulation. Which nursing intervention is most likely to cause an acute complication in this patient? A) Placing the patient on strict bedrest B) Providing a diet that is high in fat and sodium C) Administering intramuscular meperidine (Demerol) for pain D) Allowing a family member with a respiratory infection to visit

C) Administering intramuscular meperidine (Demerol) for pain

The nurse is caring for a patient admitted with pancytopenia with complaints of dyspnea upon exertion. This symptom would be most directly related to which condition? A) Pain B) Thrombocytopenia C) Anemia D) Neutropenia

C) Anemia

A nurse is caring for a client following an angioplasty through the femoral artery. While turning the client, the nurse discovers blood underneath the client's lower back. Which of the following complications should the nurse suspect? A) Retroperitoneal bleeding B) Cardiac tamponade C) Bleeding from the incisional site D) Heart failure

C) Bleeding from the incisional site

A patient is being tested for possible leukemia. With which diagnostic test should the nurse anticipate assisting? A) Liver biopsy B) Thoracentesis C) Bone marrow biopsy D) Arterial blood gas analysis

C) Bone marrow biopsy

The nurse is assessing a patient with chronic lung disease. Which finding indicates long-term hypoxia? A) Pallor B) Dyspnea C) Clubbed fingertips D) Pulmonary crackles

C) Clubbed fingertips

The nurse is caring for a patient with a clotting disorder. Which blood product should the nurse anticipate being prescribed? A) Albumin B) Normal saline C) Cryoprecipitates D) Packed WBCs

C) Cryoprecipitates

A patient is prescribed to receive 2 units of packed red blood cells. What approach should the nurse use to ensure that the correct blood will be provided to this patient? A) Check the patient's arm band. B) Check the order on the medical record. C) Follow the organization's verification process. D) Assume the correct blood was provided by the blood bank.

C) Follow the organization's verification process.

A nurse is reinforcing teaching with a client who has a new prescription for ferrous sulfate. Which of the following information should the nurse include? A) Stools will be dark red. B) Take with a glass of milk if gastrointestinal distress occurs. C) Foods high in vitamin C will promote absorption. D) Take for 14 days.

C) Foods high in vitamin C will promote absorption.

A nurse is monitoring a client who began receiving a unit of packed RBCs 10 minutes ago. Which of the following findings should the nurse identify as an indication of a febrile transfusion reaction? (Select all that apply.) A) Temperature change from 37 degrees Celsius (98.6 degrees Fahrenheit) pretransfusion to 37.2 degrees Celsius (99.0 degrees Fahrenheit) B) Blood pressure 178/90 mm Hg C) Heart rate change from 88/min pretransfusion to 120/min D) Client report of itching E) Flushed appearance

C) Heart rate change from 88/min pretransfusion to 120/min E) Flushed appearance

A patient with hemophilia A is bleeding. Which treatment should the nurse anticipate being prescribed for this patient? A) IV infusion of factor IX B) IM injection of factor IX C) IV infusion of factor VIII D) IM injection of factor VIII

C) IV infusion of factor VIII

A nurse is assisting with the admission of a client who has a suspected occlusion of a graft of the abdominal aorta. Which of the following manifestations should the nurse expect? A) Increase in urine output B) Bounding pedal pulse C) Increase in abdominal girth D) Redness of the lower extremities

C) Increase in abdominal girth

A patient is being prepared for splenectomy. What is the purpose of the order for a vitamin K injection? A) It corrects a dietary deficiency. B) It helps correct underlying anemia. C) It corrects clotting factor deficiencies. D) It replaces vitamin K lost during night sweats.

C) It corrects clotting factor deficiencies.

A patient has an altered level of T and B cells. The nurse realizes that these cells are members of which cell type? A) Platelets B) Eosinophils C) Lymphocytes D) Red blood cells

C) Lymphocytes

A nurse is assisting with the care of a client who is admitted to the emergency department with a blood pressure of 266/147 mm Hg. The client reports a headache and double vision. The client reports running out of diltiazem 3 days ago, and inability to purchase more. Which of the following actions should the nurse take first? A) Administer aceteminophen for headache. B) Reinforce teaching regarding the importance of not abruptly stopping the antihypertensive. C) Obtain IV access and ask the charge nurse to administer an IV antihypertensive. D) Call social services for a referral for financial assistance in obtaining prescribed medication.

C) Obtain IV access and ask the charge nurse to administer an IV antihypertensive.

Which laboratory study is monitored for the patient receiving heparin therapy? A) International normalized ratio (INR) B) Prothrombin time (PT) C) Partial thromboplastin time (PTT) D) Bleeding time

C) Partial thromboplastin time (PTT)

A patient walks into the urgent care clinic, stating that he has hemophilia and that he is bleeding. The triage nurse does a quick assessment and sees no signs of active bleeding. Several patients are already in the waiting area. Which action by the nurse is most appropriate? A) Palpate the suspected area for tenderness and edema. B) Ask the patient to sit in the waiting room until his name is called. C) Place the patient in an examination room and tell the physician that the patient may be bleeding. D) Send the patient for routine x-rays according to clinic protocol to look for a source of bleeding, and then place him in an examination room.

C) Place the patient in an examination room and tell the physician that the patient may be bleeding.

A nurse is preparing to assist with a bone marrow biopsy. Which anatomical site should the nurse anticipate will be used to obtain the specimen? A) Ribs B) Humerus C) Posterior iliac crest D) Long bones in the legs

C) Posterior iliac crest

What discharge teaching is most important to help the patient who has had a splenectomy prevent infection? A) Avoid showering for 1 week. B) Sleep in a semi-Fowler's position. C) Receive a yearly flu vaccine. D) Stay on antibiotics for life.

C) Receive a yearly flu vaccine.

The nurse is caring for a patient with anemia. Which blood component is deficient in this patient? A) Plasma B) Platelets C) Red blood cells (RBCs) D) White blood cells (WBCs)

C) Red blood cells (RBCs)

A patient is prescribed a transfusion of washed packed red blood cells. What should the nurse realize as being the rationale for the using this type of blood? A) Reduces the risk of hypothermia B) Cleans the blood cells of impurities C) Reduces the risk of a febrile reaction D) Removes potential harmful particles from the blood

C) Reduces the risk of a febrile reaction

A nurse is teaching a patient with sickle cell anemia about activities to avoid. Which of the following activities the patient plans to do shows that more teaching is needed? A) Going to the beach B) Taking a long car trip C) Running in a marathon D) Listening to a concert

C) Running in a marathon

A patient receiving a transfusion of packed RBCs reports chest and back pain. How should the nurse respond? A) Do a complete head-to-toe examination. B) Ask the patient to rate the pain on a 0 to 10 scale. C) Stop the transfusion and call the RN stat depending on agency policy. D) Administer an analgesic, as needed (prn).

C) Stop the transfusion and call the RN stat depending on agency policy.

A patient with Hodgkin's disease has cervical lymph node enlargement. Which symptom should the nurse attend to first? A) Pain B) Fever C) Stridor D) Fatigue

C) Stridor

A nurse is in an urgent care clinic is obtaining a history from a client who has type 2 diabetes mellitus and a recent diagnosis of hypertension. This is the second time in 2 weeks that the client experienced hypoglycemia. Which of the following client data should the nurse report to the provider? A) Takes psyllium daily as a fiber laxative B) Drinks skim milk daily as a bedtime snack C) Takes metoprolol daily after meals D) Drinks grapefruit juice daily with breakfast

C) Takes metoprolol daily after meals

The nurse is providing care for a patient who has had a splenectomy. Which nursing action has the highest priority? A) Assess pain every shift. B) Provide a diet rich in fruits and vegetables. C) Teach the patient to cough and deep breathe every hour. D) Encourage the patient to look at the incision during dressing changes.

C) Teach the patient to cough and deep breathe every hour.

A patient with lymphoma wants to attend a family member's wedding but is extremely fatigued. The nurse develops a plan for Activity Intolerance related to symptoms of lymphoma. How will the nurse know if the plan has been effective? A) The patient is able to sleep 8 hours at night. B) The patient can list three ways to combat fatigue. C) The patient attends the family member's wedding. D) The patient verbalizes understanding of the importance of gradually increasing activity.

C) The patient attends the family member's wedding.

The nurse has taught a patient with thrombocytopenia how to prevent bleeding. Which of the following is the best evidence that the teaching has been effective? A) The patient states the importance of avoiding injury. B) The patient can list signs and symptoms of bleeding. C) The patient uses an electric razor instead of a safety razor. D) The patient lists symptoms that should be reported to the doctor.

C) The patient uses an electric razor instead of a safety razor.

A patient is admitted to the hospital with hypertension and vertigo related to polycythemia vera (PV). For which treatment should the nurse prepare the patient? A) Myelogram B) Splenectomy C) Therapeutic phlebotomy D) Injection of colony-stimulating factors

C) Therapeutic phlebotomy

A nurse is observing a cardioversion procedure and hears the team leader call out, "Stand clear." The purpose of this action is to alert personnel of which of the following? A) The cardioverter is being charged to the appropriate setting. B) They should initiate CPR due to pulseless electrical activity. C) They cannot be in contact with the equipment connected to the client. D) A time-out is being called to verify correct protocols.

C) They cannot be in contact with the equipment connected to the client.

A nurse is assisting with a community education program on recommended lifestyle changes to prevent angina and myocardial infarction. Which of the following changes should the nurse recommend be made first? A) Diet modification B) Relaxation exercises C) Tobacco cessation D) Exercise routine

C) Tobacco cessation

A patient is planning to have an allogeneic bone marrow transplant. What will the patient most likely have completed before this transplant occurs? (Select all that apply.) A) Electrophoresis B) Peritoneal dialysis C) Total body irradiation D) High-dose chemotherapy E) Massive blood transfusions

C) Total body irradiation D) High-dose chemotherapy

A nurse is reviewing the laboratory findings of a client who has myocardial infarction (MI) and reports that dyspnea began 2 weeks ago. Which of the following cardiac enzymes would confirm the MI occurred 14 days ago? A) CK_MB B) Troponin 1 C) Troponin T D) Myoglobin

C) Troponin T

A patient with type O+ blood is to receive 4 units of packed red blood cells. Which type of blood should the nurse expect to see prepared for this patient? (Select all that apply.) A) Type A+ B) Type AB- C) Type O+ D) Type O- E) Type B- F) Type A-

C) Type O+ D) Type O-

A patient receiving chemotherapy for chronic myelocytic leukemia has irritated mucous membranes. Which mouth care intervention should the nurse include in the plan of care? A) Brush teeth twice a day with a firm toothbrush. B) Use waxed floss between meals and at bedtime. C) Use sponge Toothettes to clean teeth after meals. D) Swab teeth and mucous membranes four times daily with lemon-glycerin swabs.

C) Use sponge Toothettes to clean teeth after meals.

The nurse is determining the effectiveness of treatment prescribed for a patient with anemia. Which question should the nurse use to make this evaluation? A) "Is your appetite improving?" B) "Are you sleeping all night?" C) "Are you requiring many analgesics?" D) "Are you keeping up with your work schedule?"

D) "Are you keeping up with your work schedule?"

The family of a patient with DIC has questions about the bleeding that is occurring. Which statement by the nurse is the best response to explain why the patient is bleeding? A) "He is bleeding because he does not have enough RBCs." B) "He is bleeding because his white cells are depleted." C) "He is bleeding because his blood pressure is so high that is forces blood from mucous membranes." D) "He is bleeding because his body's blotting factors have all been used up."

D) "He is bleeding because his body's clotting factors have all been used up."

A nurse is reinforcing teaching with a client who has angina about a new prescription for metoprolol. Which of the following statements by the client indicates understanding of the teaching? A) "I should place the tablet under my tongue." B) "I should have my clotting time checked weekly." C) "I will report any ringing in my ears." D) "I will call my doctor if my pulse rate is less than 60."

D) "I will call my doctor if my pulse rate is less than 60."

A nurse is reinforcing teaching with a client who has a new diagnosis of an aneurysm. The client asks the nurse what causes an aneurysm to rupture. Which of the following statements should the nurse give? A) "This happens when the wall of an artery becomes thin and flexible." B) "This happens when there is turbulence in the blood flow in the artery." C) "It is due to abdominal enlargement." D) "It is due to hypertension."

D) "It is due to hypertension."

A patient who underwent lymphangiography the day before asks the licensed practical nurse (LPN), "Why does my urine look blue?" What should the LPN respond to this patient's concern? A) "It is nothing to be concerned about." B) "I will notify the RN and physician immediately." C) "This indicates that the procedure found abnormal results." D) "The dye used in the procedure may cause bluish skin and urine for 2 days."

D) "The dye used in the procedure may cause bluish skin and urine for 2 days."

A nurse is reinforcing teaching with a client who is scheduled for an echocardigram. Which of the following statements should the nurse include in the teaching? A) "You may experience a warm feeling when the dye is injected." B) "The test will require 2 hours to complete." C) "You will be placed onto your right side during the procedure." D) "The test allows us to see how your heart valves work."

D) "The test allows us to see how your heart valves work."

A nurse is reinforcing teaching with a client who is scheduled for an angiography. Which of the following statements should the nurse include in the teaching? A) "You should have nothing to eat or drink for 4 hours prior to the procedure." B) "You will be given general anesthesia during the procedure." C) "You should not have this procedure done if you are allergic to eggs." D) "You will need to keep your affected leg straight following the procedure."

D) "You will need to keep your affected leg straight following the procedure."

The nurse is monitoring a patient receiving a blood product and is concerned that the blood is going to deteriorate before it is complete infused. What is the maximum time that blood can hang during infusion before it begins to deteriorate? A) 1 hour B) 2 hours C) 3 hours D) 4 hours

D) 4 hours

A patient with thrombocytopenia is having pain. If each of the following medications is ordered, which should the nurse choose to administer? A) Morphine SQ B) Meperidine (Demerol) IM C) Oxycodone with aspirin (Percodan) PO D) Acetaminophen with codeine (Tylenol No. 3) PO

D) Acetaminophen with codeine (Tylenol No. 3) PO

A patient who is taking warfarin (Coumadin) 5 mg daily has an international normalized ratio (INR) of 2.5. It is time to administer the next dose of Coumadin. What should the nurse do? A) Notify the physician STAT. B) Hold the dose of Coumadin. C) Prepare to administer vitamin K. D) Administer the daily Coumadin as ordered.

D) Administer the daily Coumadin as ordered.

The nurse is assisting with the collection of data from a patient with a hematologic disorder. On which body system should the nurse expect to focus when collecting this data? A) Respiratory B) Genitourinary C) Cardiovascular D) All body systems

D) All body systems

The nurse is providing care for patients on a medical surgical unit. Which of the following patients is at risk for an infection? A) A 57-year-old whose WBC count = 6500/mm3 B) A 63-year-old with a platelet count = 110,000/mm3 C) A 49-year-old with a hematocrit = 44% D) An 88-year-old with a neutrophil count of 32%

D) An 88-year-old with a neutrophil count of 32%

A patient is being prepared to receive a prescribed blood transfusion. What is the best way that the LPN can assist the health team to prevent a transfusion reaction? A) Monitor vital signs every 15 minutes. B) Warm blood to 98.6°F (37°C) before infusion. C) Administer diphenhydramine (Benadryl) before the infusion. D) Assist the registered nurse (RN) to identify correctly the patient and the blood product.

D) Assist the registered nurse (RN) to identify correctly the patient and the blood product.

What is the mineral necessary for chemical clotting? A) Iron B) Sodium C) Potassium D) Calcium

D) Calcium

A patient receiving blood complains of dyspnea. The nurse auscultates the patient's lungs and finds crackles that were not present before the start of the transfusion. Which type of reaction should the nurse suspect? A) Urticarial B) Hemolytic C) Anaphylactic D) Circulatory overload

D) Circulatory overload

A 50-year-old African American patient is diagnosed with anemia. Where can the nurse best observe pallor? A) Scalp B) Axillae C) Chest D) Conjunctivae

D) Conjunctivae

Which blood product replaces missing clotting factors in the patient who has a bleeding disorder? A) Platelets B) Packed RBCs C) Albumin D) Cryoprecipitate

D) Cryoprecipitate

A nurse is collecting data on a client who has chronic peripheral arterial disease (PAD). Which of the following findings should the nurse expect? A) Edema around the ankles and feet B) Ulceration around the medial malleoli C) Brownish discoloration of the lower legs and ankles D) Dependent rubbor with pallor following limb evaluation

D) Dependent rubbor with pallor following limb evaluation

The nurse is reviewing laboratory results for a patient with a blood disorder. Reduced fibrinogen and platelet levels, increased thrombin time, and reduced factor assays are laboratory results associated with which hematological disorders? A) Aplastic anemia B) Sickle cell anemia C) PV D) Disseminated intravascular coagulation

D) Disseminated intravascular coagulation

The nurse is documenting findings after completing data collection with a patient. What term should the nurse use to document a large area of discoloration from hemorrhage under the skin? A) Pallor B) Rubor C) Petechiae D) Ecchymosis

D) Ecchymosis

The nurse is planning discharge teaching for a patient with polycythemia. Which nursing intervention should the nurse consider to help prevent complications in this patient? A) Monitor intake and output. B) Avoid use of injections for pain. C) Maintain bedrest during treatment. D) Encourage 3 L of water intake daily.

D) Encourage 3 L of water intake daily.

Patients are at risk for overwhelming postsplenectomy infection (OPSI) following splenectomy. Which of the following symptoms alerts the nurse to this possibility? A) Bruising around the operative site B) Irritability C) Pain D) Fever

D) Fever

A nurse is collecting data from a client who has pericarditis. Which of the following findings should the nurse expect? A) Petechiae B) Murmur C) Rash D) Friction rub

D) Friction rub

A patient with a new diagnosis of lymphoma is experiencing fatigue. Which of the following is the best way to assess the fatigue? A) Observe the patient's activity level. B) Monitor for changes in vital signs. C) Monitor hemoglobin and hematocrit values. D) Have the patient rate the fatigue on a scale of 0 to 10.

D) Have the patient rate the fatigue on a scale of 0 to 10.

The nurse is caring for a patient in sickle cell crisis. What is the rationale for providing warm compresses and blankets for this patient? A) Sickle cell crisis causes shivering and discomfort. B) Heat helps prevent the cells from becoming sickled. C) Heat speeds production of new healthy RBCs. D) Heat prevents vasoconstriction and impaired circulation.

D) Heat prevents vasoconstriction and impaired circulation.

A nurse in a clinic is caring for a client who has suspected anemia. Which of the following laboratory test results should the nurse expect? A) Iron 90 mcg/dL B) RBC 6.5 million/uL C) WBC 4,800 mm3 D) Hgb 10 g/L

D) Hgb 10 g/L

A nurse is contributing to the plan of care for a client who has transferred from the coronary care unit following coronary artery bypass graft surgery. Which of the following interventions should the nurse include? A) Provide percussion chest physiotherapy to loosen pulmonary secretions. B) Report urinary output less than 300 mL in 8 hr. C) Limit administration of opioid analgesics for pain ratings greater than 7 out of 10. D) Instruct the client to splint chest when deep breathing.

D) Instruct the client to splint chest when deep breathing.

The nurse is identifying approaches to reduce the risk of infection in a patient with leukemia. Why is it important for the nurse to institute infection control measures for this patient? A) Infection can precipitate hemorrhage in the patient with leukemia. B) The drugs needed to fight infection have life-threatening side effects. C) Infection in the patient with leukemia can lead to permanent neurological damage. D) Leukemia seriously impairs the leukocytes and the body's ability to fight infection.

D) Leukemia seriously impairs the leukocytes and the body's ability to fight infection.

Which circumstance places the patient at most risk for postoperative pneumonia following a splenectomy? A) Disturbance of clotting factors B) Nothing by mouth (NPO) status C) Need for frequent dressing changes D) Location of surgical incision

D) Location of surgical incision

A newly licensed nurse is assisting a charge murse with the administration of a blood transfusion to an older adult client. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure? A) Ensures the insertion of an 18-gauge IV catheter in the client B) Verifies blood compatibility and expiration date of the blood with another PN C) Ensures the administration of dextrose 5% in 0.9% sodium chloride IV with transfusion D) Obtains vital signs every 15 min throughout the procedure

D) Obtains vital signs every 15 min throughout the procedure

For which of the following problems should the nurse monitor in the patient with multiple bleeding? A) Uncontrolled bleeding B) Respiratory distress C) Liver engorgement D) Pathological fractures

D) Pathological fractures

A nurse is reinforcing teaching with a client who has a new diagnosis of severe peripheral arterial disease. Which of the following instructions should the nurse include? A) Wear tightly fitted insulated socks with shoes when going outside. B) Elevate both legs above the heart when resting. C) Apply a heating pad to both legs for comfort. D) Place both legs in dependent position while sleeping.

D) Place both legs in dependent position while sleeping.

A patient has a platelet count of 20,000/mm3. What action should the nurse take? A) Assist out of bed to a chair B) Draw another blood sample C) Measure a rectal temperature D) Place on bleeding precautions

D) Place on bleeding precautions

The nurse is preparing to give an injection of iron (Imferon) to a patient with anemia. What is the rationale for using the Z-track method for injection? A) Prevent pain at the site B) Prevent tissue damage at the site C) Promote absorption of the medication D) Prevent discoloration of tissue at the site

D) Prevent discoloration of tissue at the site

The nurse is reviewing the parts of the complete blood count and differential with a patient. Where should the nurse state that neutrophils, eosinophils, and basophils are produced? A) Spleen B) Thymus C) Lymph nodes D) Red bone marrow

D) Red bone marrow

A nurse is collecting data from a client who will undergo peripheral bypass graft surgery on the left leg. Which of the following findings should the nurse expect? A) Rubor of the affected leg when elevated B) 3+ dorsal pedal pulse in the left foot C) Thin, peeling toenails of the left foot D) Report of intermittent claudication in the affected leg

D) Report of intermittent claudication in the affected leg

Through which of the following does lymph return to the blood? A) Carotid arteries B) Aorta C) Inferior vena cava D) Subclavian veins

D) Subclavian veins

Which family member should be restricted from visiting a patient with newly diagnosed leukemia? A) The one who has a new baby at home B) The one who has a history of asthma C) The one who has received recent radiation treatment for cancer D) The one who has a runny nose

D) The one who has a runny nose

The nurse is caring for a patient who has a white blood cell (WBC) count of 8000/mm3. What concern should the nurse have about this finding? A) The patient has an infection. B) The patient is at risk for infection. C) The patient has a hematological disorder. D) There is no concern; this is a normal finding.

D) There is no concern; this is a normal finding.

A nurse is assisting with the admission of a client who has suspected rheumatic endocarditis. The nurse should expect a prescription for which of the following laboratory tests to assist in confirmation of this diagnosis? A) Arterial blood gases B) Serum albumin C) Liver enzymes D) Throat culture

D) Throat culture