POST-OP QUIZ - UPREP
Acute pain can be distinguished from chronic pain by assessing which characteristic? A. Acute pain responds poorly to drug therapy. B. Chronic pain diminishes with healing. C. Acute pain is specific and localized. D. Chronic pain is symptomatic of primary injury.
C. Acute pain is specific and localized. Explanation: Acute pain is specific and localized. Acute pain responds well to drug therapy. Acute pain usually diminishes with healing. Acute pain is symptomatic of primary injury. Reference: Chapter 12: Pain Management - Page 225
A client has hereditary hemochromatosis. Laboratory test results indicate an elevated serum iron level, high transferrin saturation, and normal complete blood count (CBC). What is most important action for the nurse to take? Remove the prescribed one unit of blood. Instruct the client to limit iron intake in the diet. Inform the client to limit ingestion of alcohol. Educate about precautions to follow after a liver biopsy.
Remove the prescribed one unit of blood. Explanation: Treatment for hemochromatosis is phlebotomy or removal of whole blood from a vein to reduce iron. Limiting dietary intake of iron is not an effective treatment. The client needs to perform activities to protect the liver, such as limiting alcohol ingestion. The definitive test for hemochromatosis had been a liver biopsy, but now genetic testing is performed. A liver biopsy could be performed to determine liver damage. However, this does not address the most immediate problem of too high iron. Reference: Chapter 33: Management of Patients With Nonmalignant Hematologic Disorders - Page 944
A nurse practitioner reviewed the blood work of a male client suspected of having microcytic anemia. The nurse suspected occult bleeding. Which laboratory result would indicate an initial stage of iron deficiency? Serum iron: 100 g/dL Serum ferritin: 15 ng/mL Hemoglobin: 16 g/dL Total iron-binding capacity: 300 g/dL
Serum ferritin: 15 ng/mL Explanation: Microcytic anemia is characterized by small RBCs due to insufficient hemoglobin. Serum ferritin levels correlate to iron deficiency and decrease as an initial response to anemia before hemoglobin and serum iron levels drop. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018.
A patient comes into the clinic frequently with complaints of pain. What would the nurse recognize as chronic benign pain in a patient? A. A migraine headache B. An exacerbation of rheumatoid arthritis C. Low back pain D. Sickle cell crisis
C. Low back pain Explanation: Acute pain differs from chronic pain primarily in its duration. For example, tissue damage as a result of surgery, trauma, or burns produces acute pain, which is expected to have a relatively short duration and resolve with normal healing. Chronic pain is subcategorized as being of cancer or noncancer origin and can be time limited (e.g., may resolve within months) or persist throughout the course of a person's life. Examples of noncancer pain include peripheral neuropathy from diabetes, back or neck pain after injury, and osteoarthritis pain from joint degeneration. Reference: Chapter 12: Pain Management - Page 226
Which of the following clinical manifestations increase the risk for evisceration in the postoperative client?
Valsalva maneuver Explanation: The Valsalva maneuver produces tension on abdominal wounds, which increases the risk for evisceration. Chapter 19: Postoperative Nursing Management - Page 470
All nurses care for clients who are grieving. It is important for the nurse to understand the grieving process for which reason? A. Allows for the nurse to facilitate the grieving process B. Allows for the nurse to take the client through in the appropriate order C. Allows for the nurse to understand when the grieving process should be concluded D. Allows the nurse to express his or her feelings
Allows for the nurse to facilitate the grieving process Explanation: Grieving is a painful yet normal reaction that helps clients cope with loss and leads to emotional healing. The nurse is responsible for facilitating the grieving process and helping the client and family deal with their emotions. Reference: Chapter 16: End-of-Life Care - Page 410
A nurse administers blood products to a client with Hodgkin disease. During the administration, the nurse notes the client has a fever and diffuse reddened skin rash. From what condition does the nurse suspect the client is suffering? Creutzfeld-Jakob disease Delayed hemolytic reaction Graft-versus-host disease Bacterial contamination
Graft-versus-host disease Explanation: Graft-versus-hold disease (GVHD) occurs in only severely immunocompromised recipients (such as those with Hodgkin disease). The transfused lymphocytes attack the host lymphocytes or body tissues; symptoms or signs may include fever, diffuse reddened skin rash, nausea, vomiting, and diarrhea. The other answer choices are complications that can occur as a result of blood transfusion; however, these do not present with a diffuse reddened skin rash. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 32: Assessment of Hematologic Function and Treatment Modalities, p. 922. Chapter 32: Assessment of Hematologic Function and Treatment Modalities - Page 922
Question 12 See full question43sReport this Question A postoperative client is moving from the bed to a chair when blood drips from the dressing. The nurse assesses the incision and notes evisceration. What does the nurse do first? A. Moisten sterile gauze with normal saline and place on the protruding organ. B. Have the client continue to stand at the edge of the bed C. Place a pressure dressing over the opening and secure. D. Use dry or pressure dressings to cover the protruding organ.
A. Moisten sterile gauze with normal saline and place on the protruding organ. Explanation: A wound evisceration occurs when the wound completely separates, and the internal organs protrude. The first action by the nurse would be to cover the protruding organs with sterile dressings moistened with normal saline. Once the client is safe, the nurse can notify the physician. The client is positioned in a manner that places the least stress on the organs. Dry or pressure dressings are not placed over the protruding organ. Reference: Chapter 19: Postoperative Nursing Management - Page 474
Which phase of pain transmission occurs when the brain experiences pain at a conscious level? A. Transmission B. Modulation C. Transduction D. Perception
D. Perception EXPLANATION: Perception is the phase of impulse transmission during which the brain experiences pain at a conscious level, but many concomitant neural activities occur almost simultaneously. Transmission is the phase during which peripheral nerve fibers from synapses with neurons in the spinal cord. Modulation is the last phase of pain impulse transmission, during which the brain interacts with the spinal nerves in a downward fashion to alter the pain experience. Transduction is the conversion of chemical information in the cellular environment to electrical impulses that move toward the spinal cord. Chapter 12: Pain Management - Page 229
Which of the following describes a red blood cell (RBC) that has pale or lighter cellular contents? Hypochromic Normocytic Microcytic Hyperchromic
Hypochromic Explanation: An RBC that has pale or lighter cellular contents is hypochromic. A normocytic RBC is normal or average in size. A microcytic RBC is smaller than normal. Hyperchromic is used to describe an RBC that has darker cellular contents. Reference: Chapter 33: Management of Patients With Nonmalignant Hematologic Disorders - Page 941
After cancer chemotherapy, a client experiences nausea and vomiting. The nurse should assign highest priority to which intervention? A. Serving small portions of bland food B. Encouraging rhythmic breathing exercises C. Administering metoclopramide and dexamethasone as ordered D. Withholding fluids for the first 4 to 6 hours after chemotherapy administration
Question 1 See full question3m 52sReport this Correct response: C. Administering metoclopramide and dexamethasone as ordered Explanation: The nurse should assign highest priority to administering an antiemetic, such as metoclopramide, and an anti-inflammatory agent, such as dexamethasone, because it may reduce the severity of chemotherapy-induced nausea and vomiting. This intervention, in turn, helps prevent dehydration, a common complication of chemotherapy. Serving small portions of bland food, encouraging rhythmic breathing exercises, and withholding fluids for the first 4 to 6 hours are less likely to achieve this outcome.
A postoperative client is experiencing a flash pulmonary edema. What finding in the client's sputum is consistent with this problem? A. Copious red blood in the sputum B. Pink color C. Viscous yellow sputum D. Orange tinged
You Selected: Copious red blood in the sputum Correct response: Pink color Explanation: Flash pulmonary edema that occurs when protein and fluid accumulate in the alveoli unrelated to elevated pulmonary artery occlusive pressure. Signs and symptoms include agitation, tachypnea, tachycardia, decreased pulse oximetry readings, frothy, pink sputum, and crackles on auscultation. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 19: Postoperative Nursing Management, p. 464.
A client develops a hemorrhage one hour post surgery. The nurse knows this is most likely an intermediary hemorrhage from a vein because it occurred: A. at a suture site, and the blood appears intermittently in spurts. B. during surgery. C. after a drainage tube dislodged. D. within the first few hours, and has darkly colored blood that flows quickly.
D. within the first few hours, and has darkly colored blood that flows quickly. Explanation: An intermediary hemorrhage appears within the first few hours following surgery. Darkly colored blood that flows out quickly indicates a venous hemorrhage. A hemorrhage that occurs during surgery is classified as a primary hemorrhage. A bright red color indicates that a hemorrhage's source is an artery. Secondary hemorrhages occur when sutures slip or drainage tubes dislodge insecure vessels. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 19: Postoperative Nursing Management, Types of Hemmorhage, p. 459.
The nurse is caring for a client with hypoxia. What does the nurse understand is true regarding the client's oxygen level and the production of red blood cells? The kidneys sense low oxygen levels in the blood and stimulate erythropoietin, stimulating the marrow to produce more red blood cells. The bone marrow is stimulated by low oxygen levels in the blood and stimulates erythropoietin, maturing the red blood cells. The brain senses low oxygen levels in the blood and stimulates hemoglobin, which binds to more red blood cells. The kidneys sense low oxygen levels in the blood and stimulate hemoglobin, stimulating the marrow to produce more red blood cells.
The kidneys sense low oxygen levels in the blood and stimulate erythropoietin, stimulating the marrow to produce more red blood cells. Explanation: If the kidney detects low levels of oxygen, as occurs when fewer red cells are available to bind oxygen (as with anemia), erythropoietin levels increase, stimulating the marrow to produce more erythrocytes (red blood cells). Reference: Chapter 32: Assessment of Hematologic Function and Treatment Modalities - Page 906 Add a
The nurse recognizes that the most common cause of iron deficiency anemia in an adult is lack of dietary iron. iron malabsorption. bleeding. chronic alcoholism.
bleeding. Explanation: Iron deficiency in adults generally indicates blood loss (e.g., from bleeding in the gastrointestinal (GI) tract or heavy menstrual flow). Lack of dietary iron is rarely the sole cause of iron deficiency anemia in adults. The source of iron deficiency should be investigated promptly because iron deficiency in an adult may be a sign of bleeding in the GI tract or colon cancer. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 32: Assessment of Hematologic Function and Treatment Modalities, p. 906. Chapter 32: Assessment of Hematologic Function and Treatment Modalities - Page 906
e following steps in order when determining the type and severity of a transfusion reaction. Use all options. 1Send the tubing and container to the blood banK 5Stop the transfusion. 2Assess the client. 3Notify the blood bank. 4Notify the health care provider.
5. Stop the transfusion. 2. Assess the client. 4. Notify the health care provider. 3. Notify the blood bank. 1. Send the tubing and container to the blood bank. Explanation: It is important for the nurse to take the proper steps when determining the type and severity of a transfusion reaction. The priority action is to stop the infusion and then assess the client. Next, the health care provider will be notified, followed by the blood bank. Finally, the nurse should send the tubing and container to the blood bank for analysis. Reference: Chapter 32: Assessment of Hematologic Function and Treatment Modalities - Page 922
A nurse is reviewing the various manifestations of anemia across the lifespan and notes a significant difference in how the older adult client responds to anemia versus a younger individual. Which concepts related to aging and the response to anemia does the nurse recognize? Select all that apply. Cardiac output increases more than in younger clients. Fatigue is often greater than in younger clients. Heart rate does not increase as much as in younger clients. Dyspnea is not reported as often as in younger clients. Confusion is often greater than in younger clients.
A nurse is reviewing the various manifestations of anemia across the lifespan and notes a significant difference in how the older adult client responds to anemia versus a younger individual. Which concepts related to aging and the response to anemia does the nurse recognize? Select all that apply. You Selected: Dyspnea is not reported as often as in younger clients. Fatigue is often greater than in younger clients. Confusion is often greater than in younger clients. Heart rate does not increase as much as in younger clients. Correct response: Fatigue is often greater than in younger clients. Heart rate does not increase as much as in younger clients. Confusion is often greater than in younger clients. Explanation: In the older adult client, fatigue, dyspnea, and confusion associated with anemia may be seen more readily versus a younger client. Cardiac output and heart rate compensatory mechanisms do not increase as much with older adult clients versus younger clients with anemia. Fatigue, dyspnea, and confusion related to anemia is often greater in the older adult client versus the younger client. Reference: Chapter 33: Management of Patients With Nonmalignant Hematologic Disorders - Page 927 Add a Note
A patient with chronic renal failure is examined by the health care provider for anemia. Which laboratory results will the nurse monitor? Decreased level of erythropoietin Decreased total iron-binding capacity Increased mean corpuscular volume Increased reticulocyte count
A patient with chronic renal failure is examined by the health care provider for anemia. Which laboratory results will the nurse monitor? You Selected: Decreased total iron-binding capacity Correct response: Decreased level of erythropoietin Explanation: As renal function decreases, erythropoietin, which is produced by the kidney, also decreases. Because erythropoietin is produced outside the kidney, some erythropoiesis continues, even in patients whose kidneys have been removed. However, the number of red blood cells produced is small and the degree of erythropoiesis is inadequate. Reference: Chapter 33: Management of Patients With Nonmalignant Hematologic Disorders - Page 927
What intervention should the nurse provide to reduce the incidence of renal damage when a patient is taking a chemotherapy regimen? A. Encourage fluid intake to dilute the urine. B. Take measures to acidify the urine and prevent uric acid crystallization. C. Withhold medication when the blood urea nitrogen level exceeds 20 mg/dL. D. Limit fluids to 1,000 mL daily to prevent accumulation of the drug's end products after cell lysis.
A. Encourage fluid intake to dilute the urine. Explanation: The nurse should ensure adequate fluid hydration before, during, and after drug administration and assess intake and output. Adequate fluid volume dilutes drug levels, which can help prevent renal damage. Reference: Chapter 15: Management of Patients with Oncologic Disorders - Page 345
For a client diagnosed with idiopathic thrombocytopenia purpura (ITP), which nursing intervention is appropriate? Teaching coughing and deep-breathing techniques to help prevent infection Administering platelets, as ordered, to maintain an adequate platelet count Giving aspirin, as ordered, to control body temperature Administering stool softeners, as ordered, to prevent straining during defecation
Administering stool softeners, as ordered, to prevent straining during defecation Explanation: The nurse should take measures to prevent bleeding because the client with ITP is at increased risk for bleeding. Straining at stool causes the Valsalva maneuver, which may raise intracranial pressure (ICP), thus increasing the risk for intracerebral bleeding. Therefore, the nurse should give stool softeners to prevent straining, which may result from constipation. Teaching coughing techniques would be inappropriate because coughing raises ICP. Platelets rarely are transfused prophylactically in clients with ITP because the cells are destroyed, providing little therapeutic benefit. Aspirin interferes with platelet function and is contraindicated in clients with ITP. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 33: Management of Patients With Nonmalignant Hematologic Disorders, Nursing Management, p. 951. Chapter 33: Management of Patients With Nonmalignant Hematologic Disorders - Page 951
Corticosteroids have which effect on wound healing? A. cause hemorrhage or protein-calorie depletion. B. mask the presence of infection C, reduce blood supply. D, cause hemorrhage or protein-calorie depletion.
B. Mask the presence of infection Explanation: Corticosteroids may mask the presence of infection by impairing the normal inflammatory response. Edema may reduce blood supply. Corticosteroids do not cause hemorrhage or protein-calorie depletion. Chapter 19: Postoperative Nursing Management - Page 470
A client, who had an above the knee amputation of the left leg related to peripheral vascular disease from uncontrolled diabetes, complains of pain in the left lower extremity. What type of pain is the client experiencing? A. Breakthrough pain B. Neuropathic pain C. Visceral pain D. Referred pain
B. Neuropathic pain Explanation: An example of neuropathic pain is phantom limb pain or phantom limb sensation, in which individuals with an amputated arm or leg perceive that the limb still exists and that sensation such as burning, itching, and deep pain are located in tissues that have been surgically removed. Chronic pain sufferers may have periods of acute pain, which is referred to as breakthrough pain. Visceral pain arises from internal organs such as the heart, kidneys, and intestine that are diseased or injured. Referred pain is a term used to describe discomfort that is perceived in a general area of the body but not in the exact site where an organ is anatomically located. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 12: Pain Management, Table 12-2: Classification of Pain by Inferred Pathology, p. 227. Chapter 12: Pain Management - Page 227
A nurse cares for a client with megaloblastic anemia who had a total gastrectomy three years ago. What statement will the nurse include in the client's teaching regarding the condition? A. "The condition is likely caused by a folate deficiency." B. "The condition causes abnormally small red blood cells." C. "The condition is likely caused by a vitamin B12 deficiency." D. "The condition causes abnormally rigid red blood cells."
Correct response: "The condition is likely caused by a vitamin B12 deficiency." Explanation: Vitamin B12 combines with intrinsic factor produced in the stomach. The vitamin B12 -intrinsic factor complex is absorbed in the distal ileum. Clients who have had a partial or total gastrectomy may have limited amounts of intrinsic factor, and the absorption of vitamin B12 may be diminished. Megaloblastic anemia may be caused by a folate deficiency; however, the client's history of gastrectomy indicates the likely cause is a vitamin B12 deficiency. Megaloblastic anemia causes large erythrocytes (RBCs), not small or rigid. Reference: Chapter 32: Assessment of Hematologic Function and Treatment Modalities - Page 906
How should the administration of analgesics be scheduled to provide a uniform level of pain relief to a client? A. Administering the analgesics on a regular basis B. Administering the analgesics intravenously C. Administering the analgesics on an as-needed per client request D. Administering analgesics with increased dosage
Correct response: A. Administering the analgesics on a regular basis Explanation: Routine scheduling of the administration of analgesics, rather than on an as-needed basis, often affords a uniform level of pain relief. Administering the analgesics intravenously or with increased dosage is not advisable unless prescribed by the physician. Reference: Chapter 12: Pain Management - Page 234
A patient with chronic renal failure is examined by the health care provider for anemia. Which laboratory results will the nurse monitor? Decreased level of erythropoietin Decreased total iron-binding capacity Increased mean corpuscular volume Increased reticulocyte count
Decreased level of erythropoietin Explanation: As renal function decreases, erythropoietin, which is produced by the kidney, also decreases. Because erythropoietin is produced outside the kidney, some erythropoiesis continues, even in patients whose kidneys have been removed. However, the number of red blood cells produced is small and the degree of erythropoiesis is inadequate. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 33: Management of Patients With Nonmalignant Hematologic Disorders, Assessment and Diagnostic Findings, p. 927.
The nurse is educating a patient with iron deficiency anemia about food sources high in iron and how to enhance the absorption of iron when eating these foods. What can the nurse inform the client would enhance the absorption? Eating calf's liver with a glass of orange juice Eating leafy green vegetables with a glass of water Eating apple slices with carrots Eating a steak with mushrooms
Eating calf's liver with a glass of orange juice Explanation: Food sources high in iron include organ meats (e.g., beef or calf's liver, chicken liver), other meats, beans (e.g., black, pinto, and garbanzo), leafy green vegetables, raisins, and molasses. Taking iron-rich foods with a source of vitamin C (e.g., orange juice) enhances the absorption of iron. Reference: Chapter 33: Management of Patients With Nonmalignant Hematologic Disorders - Page 931 Add a Note
A client is receiving platelets. In order to decreased the risk of circulatory overload in this client, what action should the nurse take? Administer each unit slowly over 3-4 hours. Infuse each unit over 30-60 minutes per client tolerance. Monitor vital signs closely before transfusion and once per shift. Flush the intravenous line with a liter of saline between units.
Infuse each unit over 30-60 minutes per client tolerance. Explanation: Infuse each unit of FFP over 30-60 minutes per client tolerance. Platelet clumping will occur if administered too slowly. Vital signs should be monitored before and throughout the transfusion, not just once per shift. A liter of saline is too large an amount to flush the intravenous line and would contribute to fluid overload. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 32: Assessment of Hematologic Function and Treatment Modalities, Chart 32-3, p. 918. Chapter 32: Assessment of Hematologic Function and Treatment Modalities - Page 918
The clinic nurse is caring for a client who has just been diagnosed with a tumor. The client says to the nurse "The doctor says my tumor is benign. What does that mean?" What is the nurse's best response? A. "Benign tumors don't usually cause death." B. "Benign tumors grow very rapidly." C. "Benign tumors can spread from one place to another." D. "Benign tumors invade surrounding tissue."
orrect response: "Benign tumors don't usually cause death." Explanation: Benign tumors remain at their site of development. They may grow large, but their growth rate is slower than that of malignant tumors. They usually do not cause death unless their location impairs the function of a vital organ, such as the brain. Reference: Chapter 15: Management of Patients with Oncologic Disorders - Page 326
A nurse is assessing a client with multiple myeloma. Due to this condition, what will this client be at risk for? A. chronic liver failure. B. acute heart failure. C. pathologic bone fractures. D. hypoxemia.
pathologic bone fractures. Explanation: Clients with multiple myeloma are at risk for pathologic bone fractures secondary to diffuse osteoporosis and osteolytic lesions. Also, clients are at risk for renal failure secondary to myeloma proteins by causing renal tubular obstruction. Liver failure and heart failure aren't usually sequelae of multiple myeloma. Hypoxemia isn't usually related to multiple myeloma. Reference: Chapter 34: Management of Patients With Hematologic Neoplasms - Page 997
The registered nurse (RN) and licensed practical nurse (LPN) are preparing an educational program for clients who may be at risk for the development of iron-deficiency anemia. Which clients would receive the greatest benefit from this program? Select all that apply. A young female client with bulimia nervosa An older adult client on a fixed income A client with Crohn's disease A client who lives in a nursing home A client who is a vegetarian
Correct response: A young female client with bulimia nervosa An older adult client on a fixed income A client with Crohn's disease Explanation: Those who consume a healthy diet absorb less than 10% of the iron in food. Clients whose nutrition is compromised by unhealthy dieting or who cannot afford to eat a healthy diet, lack knowledge about nutrition, or have malabsorption disorders are at great risk for iron-deficiency anemia. A young female client with bulimia nervosa has an unhealthy diet. An older adult client on a fixed income may not have the funds to eat a healthy diet. A client with Crohn's disease has a malabsorption syndrome. A client who resides in a nursing home has prepared meals as well as available supplements if required. A client who is a vegetarian is still able to receive ample iron supplementation in the vegetables being eaten. Reference: Chapter 33: Management of Patients With Nonmalignant Hematologic Disorders - Page 930
A nurse cares for an adult client with chronic lymphocytic leukemia (CLL). Which statements regarding the disease will the nurse include in the teaching? Select all that apply. A. "This type of leukemia primarily impacts older adults." B ''This type of leukemia does not appear to have familial predisposition." C.. "This type of leukemia is rarely seen in certain ethnicities." D. "This type of leukemia primarily impacts pediatric adults." E. "This type of leukemia is rarely aggressive."
Correct response: A. "This type of leukemia primarily impacts older adults." B. "This type of leukemia is rarely seen in certain ethnicities." Explanation: Chronic lymphocytic leukemia (CLL) is a common malignancy of older adults and primarily impacts older adults and has a strong familial predisposition. This type of leukemia rarely impacts Native Americans and infrequently individuals of Asian descent. While many clients will have a normal life expectancy, others will have a very short life expectancy due to the aggressive nature of the disease. Reference: Chapter 34: Management of Patients With Hematologic Neoplasms - Page 976
A client with Hodgkin disease had a bone marrow biopsy yesterday and reports aching at the biopsy site, rated a 5 (on a 1-10 scale). After assessing the biopsy site, which nursing intervention is most appropriate? Notify the physician Administer aspirin (ASA) 325 mg po, as ordered Administer acetaminophen 500 mg po, as ordered Reposition the client to a high Fowler position and continue to monitor the pain
Correct response: Administer acetaminophen 500 mg po, as ordered Explanation: After a marrow sample is obtained, pressure is applied to the site for several minutes. The site is then covered with a sterile dressing. Most clients have no discomfort after a bone marrow biopsy, but the site of a biopsy may ache for 1 or 2 days. Warm tub baths and a mild analgesic agent (e.g., acetaminophen) may be useful. Aspirin-containing analgesic agents should be avoided it the immediate post-procedure period because they can aggravate or potentiate bleeding. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 32: Assessment of Hematologic Function and Treatment Modalities, Bone Marrow Aspiration and Biopsy, p. 570. Chapter 32: Assessment of Hematologic Function and Treatment Modalities - Page 570
A client receiving a unit of packed red blood cells (PRBCs) has been prescribed morphine 1 mg intravenously now for pain. What is the bestmethod for the nurse to administer the morphine? A. Add the morphine to the blood to be slowly administered. B. Inject the morphine into a distal port on the blood tubing. C. Administer the morphine into the closest tubing port to the client for fast delivery. D. Disconnect the blood tubing, flush with normal saline, and administer morphine.
Correct response: D. Disconnect the blood tubing, flush with normal saline, and administer morphine. Explanation: Never add medications to blood or blood products. The transfusion must be temporarily stopped in order to administer the morphine. Reference: Chapter 32: Assessment of Hematologic Function and Treatment Modalities - Page 917
A client with sickle cell anemia has a A. low hematocrit. B. high hematocrit. C. normal hematocrit. normal blood smear.
Correct response: low hematocrit. Explanation: A client with sickle cell anemia has a low hematocrit and sickled cells on the smear. A client with sickle cell trait usually has a normal hemoglobin level, a normal hematocrit, and a normal blood smear. Reference: Chapter 33: Management of Patients With Nonmalignant Hematologic Disorders - Page 937
The nurse and the client are discussing some strategies for ingesting iron to combat the client's iron-deficiency anemia. Which is among the nurse's strategies? Drink liquid iron preparations with a straw. Take iron with an antacid to avoid stomach upset. Avoid vitamin C as it prevents absorption. Taking iron pills with milk aids in absorption.
Drink liquid iron preparations with a straw. Explanation: Dilute liquid preparations of iron with another liquid such as juice and drink with a straw to avoid staining the teeth. Avoid taking iron simultaneously with an antacid, which interferes with iron absorption. Drink orange juice or take other forms of vitamin C with iron to promote its absorption. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed. Philadelphia: Lippincott Williams & Wilkins, 2018, Chapter 33: Management of Patients with Nonmalignant Hematologic Disorders, p. 929. Chapter 33: Management of Patients With Nonmalignant Hematologic Disorders - Page 929
The nurse is teaching a healthy lifestyle class to a group of adolescents. The nurse recommends Eating four servings of vegetables and fruits per each day Decreasing caloric intake to maintain a body mass index lower than 24 Exercising at least 60 minutes per day doing moderate to vigorous activties at least 5 days per week Increasing proteins to more than 5 1/2 ounces per day for the male students to build muscle mass
Exercising at least 60 minutes per day doing moderate to vigorous activties at least 5 days per week Explanation: The American Cancer Society recommendations are for adolescents to engage in at least 60 minutes of moderate to vigorous physical activity at least 5 days per week. The MyPyramid recommendations include 4 1/2 cups of fruits and vegetables every day. People who have a body mass index less than 24 are at increased risk for problems associated with poor nutritional status. Ingesting more protein will not necessarily build more muscle mass and is not recommended for normal healthy individuals. Reference: Chapter 15: Management of Patients with Oncologic Disorders - Page 329
A client with severe anemia reports symptoms of tachycardia, palpitations, exertional dyspnea, cool extremities, and dizziness with ambulation. Laboratory test results reveal low hemoglobin and hematocrit levels. Based on the assessment data, which nursing diagnoses is most appropriate for this client? Ineffective tissue perfusion related to inadequate hemoglobin and hematocrit Imbalanced nutrition, less than body requirements, related to inadequate intake of essential nutrients Risk for falls related to complaints of dizziness Fatigue related to decreased hemoglobin and hematocrit
Ineffective tissue perfusion related to inadequate hemoglobin and hematocrit Explanation: The symptoms indicate impaired tissue perfusion due to a decrease in the oxygen-carrying capacity of the blood. Cardiac status should be carefully assessed. When the hemoglobin level is low, the heart attempts to compensate by pumping faster and harder in an effort to deliver more blood to hypoxic tissue. This increased cardiac workload can result in such symptoms as tachycardia, palpitations, dyspnea, dizziness, orthopnea, and exertional dyspnea. Heart failure may eventually develop, as evidenced by an enlarged heart (cardiomegaly) and liver (hepatomegaly) and by peripheral edema. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 33: Management of Patients With Nonmalignant Hematologic Disorders, p. 928. Chapter 33: Management of Patients With Nonmalignant Hematologic Disorders - Page 928
The nurse is performing an assessment for a client with anemia admitted to the hospital to have blood transfusions administered. Why would the nurse need to include a nutritional assessment for this patient? It is part of the required assessment information. It is important for the nurse to determine what type of foods the patient will eat. It may indicate deficiencies in essential nutrients. It will determine what type of anemia the patient has.
It may indicate deficiencies in essential nutrients. Explanation: A nutritional assessment is important, because it may indicate deficiencies in essential nutrients such as iron, vitamin B12, and folate. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 33: Management of Patients With Nonmalignant Hematologic Disorders, Maintaining Adequate Nutrition, p. 929. Chapter 33: Management of Patients With Nonmalignant H
The nurse reviewing laboratory results of a client recovering from abdominal surgery notices an elevated number of reticulocytes. What is the nurse's firstaction? Perform an abdominal assessment. Notify the healthcare provider. Document the findings as expected results. Hold the prescribed blood transfusion.
Perform an abdominal assessment. Explanation: The bone marrow can release immature forms of erythrocytes, called reticulocytes, into the circulation in response to bleeding. The nurse should assess this client's abdomen, because the client is recovering from abdominal surgery. The nurse should assess and gather more data before notifying the healthcare provider. A blood transfusion would not be held if internal bleeding is expected. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 32: Assessment of Hematologic Function and Treatment Modalities, Erythropoiesis, p. 906. Chapter 32: Assessment of Hematologic Function and Treatment Modalities - Page 906
The client is diagnosed with polycythemia vera. The nurse prepares the client for which procedure? Apheresis Phlebotomy Blood transfusion Platelet infusion
Phlebotomy Explanation: Polycythemia vera is a condition in which the blood contains a large amount of red blood cells, increasing the viscosity of the blood. Phlebotomy is a preferred treatment to rid the circulation of excess red blood cells. Apheresis is a process in which platelets and leukocytes are removed from the blood. Blood and platelet infusions can exacerbate this condition. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 32: Assessment of Hematologic Function and Treatment Modalities, Therapeutic Phlebotomy, p. 914. Chapter 32: Assessment of Hematologic Function and Treatment Modalities - Page 914
The family of a dying client being cared for at home is requesting information on how best to prepare food. Which suggestion by the nurse may stimulate appetite? Eating alone so the client can eat at his own pace and not be hurried Providing several choices on the plate so that the client has what may appeal to him Offering high caloric foods to build fat and muscle Preparing cool or cold foods that may be better tolerated
Preparing cool or cold foods that may be better tolerated Explanation: Preparing cool or cold foods may be tolerated better by the client and thus stimulate appetite. Hot foods may have an aroma that may cause nausea. Clients may enjoy a mealtime companion making the eating experience more pleasurable. Offering small portions is appropriate because large, multiple portions/choices may shut down the appetite. Although weight loss may be significant, clients should have the ability to pick and choose foods that interest them. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 16: End-of-Life Care, Artificial Nutrition and Hydration, p. 406. Chapter 16: End-of-Life Care - Page 406
