MS TEST 1

31. Which patient should the nurse assign as the roommate for a patient who has aplastic anemia? A patient with chronic heart failure A patient who has viral pneumonia A patient who has right leg cellulitis A patient with multiple abdominal drains

ANS: A Patients with aplastic anemia are at risk for infection because of the low white blood cell production associated with this type of anemia, so the nurse should avoid assigning a roommate with any possible infectious process.

3. The nurse plans a presentation for community members about how to decrease the risk for antibiotic-resistant infections. Which information will the nurse include in the teaching plan? (Select all that apply.) Antibiotics may sometimes be prescribed to prevent infection. Continue taking antibiotics until all of the prescription is gone. Unused antibiotics that are more than a year old should be discarded. Antibiotics are effective in treating influenza associated with high fevers. Hand washing is effective in preventing many viral and bacterial infections.

ANS: A, B, E All prescribed doses of antibiotics should be taken. In some situations, such as before surgery, antibiotics are prescribed to prevent infection. There should not be any leftover antibiotics because all prescribed doses should be taken. However, if there are leftover antibiotics, they should be discarded at once because the number left will not be enough to treat a future infection. Hand washing is considered the single most effective action in decreasing infection transmission. Antibiotics are ineffective in treating viral infections such as influenza.

8. Which nursing intervention is important when providing care for a patient with sickle cell crisis? Limiting the patient's intake of oral and IV fluids Evaluating the effectiveness of opioid analgesics Encouraging the patient to ambulate as much as tolerated Teaching the patient about high-protein, high-calorie foods

ANS: B Pain is the most common clinical manifestation of a crisis and usually requires large doses of continuous opioids for control. Fluid intake should be increased to reduce blood viscosity and improve perfusion. Rest is usually ordered to decrease metabolic requirements. Patients are instructed about the need for dietary folic acid, but high-protein, high-calorie diets are not emphasized.

8. Which patient would benefit from education about HIV preexposure prophylaxis (PrEP)? A 23-yr-old woman living with HIV infection. A 52-yr-old recently single woman just diagnosed with chlamydia. A 33-yr-old hospice worker who received a needle stick injury 3 hours ago. A 60-yr-old male in a monogamous relationship with an HIV-uninfected partner.

ANS: B Preexposure prophylaxis (PrEP) is used to prevent HIV infection. Persons who would be good candidates for PrEP include individuals with a recent diagnosis of an STI and those with more than one partner. Individuals who are not on PrEP but who have a recent high-risk exposure (such as a needle stick) would be better candidates for postexposure prophylaxis (PEP). A person in a monogamous relationship with an HIV-uninfected partner is considered low-risk for HIV infection.

6. Which patient statement to the nurse indicates a need for additional instruction about taking oral ferrous sulfate? "I could take a stool softener if I feel constipated." "I can take the iron with orange juice before eating." "I should notify my health care provider if my stools turn black." "I will increase my fluid and fiber intake while I am taking iron."

ANS: C It is normal for the stools to appear black when a patient is taking iron, and the patient should not call the health care provider about this. The other patient statements are correct.

9. The nurse palpates enlarged cervical lymph nodes on a patient diagnosed with acute human immunodeficiency virus (HIV) infection. Which action would be appropriate for the nurse to take? Instruct the patient to apply ice to the neck. Tell the patient a secondary infection is present. Explain to the patient that this is an expected finding. Request that an antibiotic be prescribed for the patient.

ANS: C Persistent generalized lymphadenopathy is common in the early stages of HIV infection. No antibiotic is needed because the enlarged nodes are probably not caused by bacteria. Lymphadenopathy is common with acute HIV infection and is therefore not likely to represent an additional infection. Ice will not decrease the swelling in persistent generalized lymphadenopathy

6. Which exposure by the nurse is most likely to require postexposure prophylaxis when the patient's human immunodeficiency virus (HIV) status is unknown? Bite to the arm that does not result in open skin Splash into the eyes while emptying a bedpan containing stool Needle stick with a needle and syringe used for a venipuncture Contamination of open skin lesions with patient vaginal secretions

ANS: C Puncture wounds are the most common means for workplace transmission of blood-borne diseases, and a needle with a hollow bore that had been contaminated with the patient's blood would be a high-risk situation. The other situations described would be much less likely to result in transmission of the virus.

12. Which nursing action will be most useful in assisting a young adult to adhere to a newly prescribed antiretroviral therapy (ART) regimen? Give the patient detailed information about possible medication side effects. Remind the patient of the importance of taking the medications as scheduled. Help the patient develop a schedule to decide when the drugs should be taken. Encourage the patient to join a support group for adults who are HIV positive.

ANS: C The best approach to improve adherence is to learn about important activities in the patient's life and adjust the ART around those activities. The other actions are also useful, but they will not improve adherence as much as individualizing the ART to the patient's schedule.

42. Which finding about a patient with polycythemia vera is most important for the nurse to report to the health care provider? Hematocrit 55% Presence of plethora Calf swelling and pain Platelet count 450,000/L

ANS: C The calf swelling and pain suggest that the patient may have developed a deep vein thrombosis, which will require diagnosis and treatment to avoid complications such as pulmonary embolus. The other findings will also be reported to the health care provider but are expected in a patient with this diagnosis.

19. Which patient who has arrived at the human immunodeficiency virus (HIV) clinic should the nurse assess first? Patient whose rapid HIV-antibody test is positive. Patient whose latest CD4+ count has dropped to 250/μL. Patient who has had 10 liquid stools in the last 24 hours. Patient who has nausea from prescribed antiretroviral drugs.

ANS: C The nurse should assess the patient for dehydration and hypovolemia. The other patients also will require assessment and possible interventions, but do not require immediate action to prevent complications such as hypovolemia and shock.

7. A patient who is human immunodeficiency virus (HIV)-infected has a CD4+ cell count of 400/μL. Which factor is most important for the nurse to determine before the initiation of antiretroviral therapy (ART) for this patient? CD4+ cell count How the patient obtained HIV Patient's tolerance for potential medication side effects Patient's ability to follow a complex medication regimen

ANS: D Drug resistance develops quickly unless the patient takes ART medications on a strict, regular schedule. In addition, drug resistance endangers both the patient and community. The other information is also important to consider, but patients who are unable to manage and follow a complex drug treatment regimen should not be considered for ART.

13. The health care provider orders a liver and spleen scan for a patient who has been in a motor vehicle crash. Which action should the nurse take to prepare the patient for this procedure? Check for any iodine allergy. Insert a large-bore IV catheter. Administer prescribed sedatives. Assist the patient to a flat position.

ANS: D During a liver and spleen scan, a radioactive isotope is injected IV, and images from the radioactive emission are used to evaluate the structure of the spleen and liver. An indwelling IV catheter and sedation are not needed. The patient is placed in a flat position before the scan.

1. A patient who is receiving an IV antibiotic develops wheezes and dyspnea. In which order should the nurse implement these prescribed actions? (Put a comma and a space between each answer choice [A, B, C, D, E]). a. Discontinue the antibiotic. b. Give diphenhydramine IV. c. Inject epinephrine IM or IV. d. Prepare an infusion of dopamine. e. Apply 100% oxygen using a nonrebreather mask.

ANS:A, E, C, B, D

24. Which action will the nurse include in the plan of care for a patient admitted with multiple myeloma? Monitor fluid intake and output. Administer calcium supplements. Assess lymph nodes for enlargement. Limit weight bearing and ambulation.

ANS: A A high fluid intake and urine output helps prevent the complications of kidney stones caused by hypercalcemia and renal failure caused by deposition of Bence-Jones protein in the renal tubules. Weight bearing and ambulation are encouraged to help bone retain calcium. Lymph nodes are not enlarged with multiple myeloma. Calcium supplements will further increase the patient's calcium level and are not used.

25. Which nursing intervention is appropriate for a patient with non-Hodgkin's lymphoma whose platelet count drops to 18,000/μL during chemotherapy? Test all stools for occult blood. Encourage fluids to 3000 mL/day. Provide oral hygiene every 2 hours. Check the temperature every 4 hours.

ANS: A Because the patient is at risk for spontaneous bleeding, the nurse should check stools for occult blood. A low platelet count does not require an increased fluid intake. Oral hygiene is important, but it is not necessary to provide oral care every 2 hours. The low platelet count does not increase risk for infection, so frequent temperature monitoring is not indicated

1. The nurse provides discharge instructions to a patient who has an immune deficiency involving the T lymphocytes. Which health screening should the nurse include in the teaching plan for this patient? Screening for cancers Screening for allergies Screening for antibody deficiencies Screening for autoimmune disorders

ANS: A Cell-mediated immunity is responsible for the recognition and destruction of cancer cells. Allergic reactions, autoimmune disorders, and antibody deficiencies are mediated primarily by B lymphocytes and humoral immunity.

33. A patient with immune thrombocytopenic purpura (ITP) has an order for a platelet transfusion. Which information indicates that the nurse should consult with the health care provider before obtaining and administering platelets?a. Platelet count is 42,000/L. Blood pressure is 94/56 mm Hg. Petechiae are present on the chest. Blood is oozing from the venipuncture site.

ANS: A Platelet transfusions are not usually indicated until the platelet count is below 10,000 to 20,000/L unless the patient is actively bleeding. Therefore, the nurse should clarify the order with the health care provider before giving the transfusion. The other data all indicate that bleeding caused by ITP may be occurring and that the platelet transfusion is appropriate.

16. To evaluate the effectiveness of antiretroviral therapy (ART), which laboratory test result will the nurse review? Viral load testing Enzyme immunoassay Rapid HIV antibody testing Immunofluorescence assay

ANS: A The effectiveness of ART is measured by the decrease in the amount of virus detectable in the blood. The other tests are used to detect HIV antibodies, which remain positive even with effective ART.

11. The complete blood count (CBC) indicates that a patient is thrombocytopenic. Which action should the nurse include in the plan of care? Avoid intramuscular injections. Encourage increased oral fluids. Check temperature every 4 hours. Increase intake of iron-rich foods.

ANS: A Thrombocytopenia is a decreased number of platelets, which places the patient at high risk for bleeding. Neutropenic patients are at high risk for infection and sepsis and should be monitored frequently for signs of infection. Encouraging fluid intake and iron-rich food intake is not indicated in a patient with thrombocytopenia.

1. The nurse is caring for a patient living with asymptomatic chronic HIV infection (HIV). Which prophylactic measures will the nurse include in the plan of care? (Select all that apply.) Hepatitis B vaccine Pneumococcal vaccine Influenza virus vaccine Trimethoprim-sulfamethoxazole Varicella zoster immune globulin

ANS: A, B, C Asymptomatic chronic HIV infection is a stage between acute HIV infection and a diagnosis of symptomatic chronic HIV infection. Although called asymptomatic, symptoms (e.g., fatigue, headache, low-grade fever, night sweats) often occur. Prevention of other infections is an important intervention in patients who are living with HIV, and these vaccines are recommended as soon as the HIV infection is diagnosed. Antibiotics and immune globulin are used to prevent and treat infections that occur later in the course of the disease when the CD4+ counts have dropped or when infection has occurred.

32. Which patient requires the most rapid assessment and care by the emergency department nurse? The patient with hemochromatosis who reports abdominal pain. The patient with neutropenia who has a temperature of 101.8° F. The patient with thrombocytopenia who has oozing gums after a tooth extraction. The patient with sickle cell anemia who has had nausea and diarrhea for 24 hours.

ANS: B A neutropenic patient with a fever is assumed to have an infection and is at risk for rapidly developing sepsis. Rapid assessment, cultures, and initiation of antibiotic therapy are needed. The other patients also require rapid assessment and care but not as urgently as the neutropenic patient.

21. The registered nurse (RN) is caring for a patient who is living with HIV and admitted with tuberculosis. Which task can the RN delegate to unlicensed assistive personnel (UAP)? Teach the patient how to dispose of tissues with respiratory secretions. Stock the patient's room with the necessary personal protective equipment. Interview the patient to obtain the names of family members and close contacts. Tell the patient's family members the reason for the use of airborne precautions.

ANS: B A patient diagnosed with tuberculosis would be placed on airborne precautions. Because all health care workers are taught about the various types of infection precautions used in the hospital, the UAP can safely stock the room with personal protective equipment. Obtaining contact information and patient teaching are higher-level skills that require RN education and scope of practice.

5. A patient who collects honey to earn supplemental income has developed a hypersensitivity to bee stings. Which statement by the patient would indicate a need for additional teaching? "I need to find a different way to earn extra money." "I will take oral antihistamines before going to work." "I can get a prescription for epinephrine and learn to self-inject it." d. "I should wear a Medic-Alert bracelet indicating my allergy to bee stings."

ANS: B Because the patient is at risk for bee stings and the severity of allergic reactions tends to increase with added exposure to allergen, taking oral antihistamines will not adequately control the patient's hypersensitivity reaction. The other patient statements indicate a good understanding of management of the problem.

7. Which potential complication should the nurse identify as a high risk for a patient admitted to the hospital with idiopathic aplastic anemia? Seizures Infection Neurogenic shock Pulmonary edema

ANS: B Because the patient with aplastic anemia has pancytopenia, the patient is at risk for infection and bleeding. There is no increased risk for seizures, neurogenic shock, or pulmonary edema.

18. A routine complete blood count for an active older man indicates possible myelodysplastic syndrome. What should the nurse plan to explain to the patient? Blood transfusion Bone marrow biopsy Filgrastim administration Erythropoietin administration

ANS: B Bone marrow biopsy is needed to make the diagnosis and determine the specific type of myelodysplastic syndrome. The other treatments may be necessary later if there is progression of the myelodysplastic syndrome, but the initial action for this asymptomatic patient will be a bone marrow biopsy.

11. The nurse observes scleral jaundice in a patient being admitted with hemolytic anemia. Which laboratory result the nurse should check? Schilling test Bilirubin level Stool occult blood Gastric acid analysis

ANS: B Jaundice is caused by the elevation of bilirubin level associated with red blood cell hemolysis. Other tests would not be helpful in monitoring hemolytic anemia.

22. A clinic patient reports experiencing an allergic reaction to an unknown allergen several weeks ago. Which action is appropriate for the registered nurse (RN) to delegate to a licensed practical/vocational nurse (LPN/VN)? Perform a focused physical assessment. Administer a cutaneous scratch skin test. Obtain the health history from the patient. Review diagnostic study results with the patient.

ANS: B LPN/VNs are educated and licensed to administer medications under the supervision of an RN. RN-level education and the scope of practice include assessment of health history, focused physical assessment, and teaching about study results.

7. The nurse is reviewing laboratory results and notes a patient's activated partial thromboplastin time (aPTT) level is 28 seconds. The nurse should notify the health care provider in anticipation of adjusting which medication? Aspirin Heparin Warfarin Erythropoietin

ANS: B The aPTT level is increased (prolonged) in heparin administration. aPTT is used to monitor whether heparin is at a therapeutic level (needs to be greater than the normal range of 25 to 35 sec). Prothrombin time (PT) and international normalized ratio (INR) are most commonly used to test for therapeutic levels of warfarin (Coumadin). Aspirin affects platelet function. Erythropoietin is used to stimulate red blood cell production.

17. A young adult who has von Willebrand disease is admitted to the hospital for minor knee surgery. Which laboratory value should the nurse monitor? Platelet count Bleeding time Thrombin timed. Prothrombin time

ANS: B The bleeding time is affected by von Willebrand disease. Platelet count, prothrombin time, and thrombin time are normal in von Willebrand disease.

19. Which action will the admitting nurse include in the care plan for a patient who has neutropenia? Avoid intramuscular injections. Check temperature every 4 hours. Place a "No Visitors" sign on the door. Omit fruits and vegetables from the diet.

ANS: B The earliest sign of infection in a neutropenic patient is an elevation in temperature. While unpeeled fresh fruits and vegetables should be avoided, fruits and vegetables that are peeled or cooked are acceptable. Injections may be required for administration of medications such as filgrastim (Neupogen). The number of visitors may be limited and visitors with communicable diseases should be avoided, but a "no visitors" policy is not needed.

38. Several patients call the outpatient clinic and ask to make an appointment as soon as possible. Which patient should the nurse schedule to be seen first? A 44-yr-old with sickle cell anemia who says his eyes always look yellow A 23-yr-old with no previous health problems who has a nontender axillary lump A 50-yr-old with early-stage chronic lymphocytic leukemia who reports chronic fatigue A 19-yr-old with hemophilia who wants to learn to self-administer factor VII replacement

ANS: B The patient's age and presence of a nontender axillary lump suggest possible lymphoma, which needs rapid diagnosis and treatment. The other patients have questions about treatment or symptoms that are consistent with their diagnosis but do not need to be seen urgently.

8. The nurse taking a health history learns that the patient, who has worked in rubber tire manufacturing, has allergic rhinitis and multiple food allergies. Which action by the nurse is correct? Recommend that the patient use latex gloves in preventing blood-borne pathogen contact. Document the patient's history and teach about clinical manifestations of a type I latex allergy. Encourage the patient to carry an epinephrine kit in case a type IV allergic reactionto latex develops. d. Tell the patient to use oil-based hand creams to decrease contact with natural proteins in latex gloves.

ANS: B The patient's allergy history and occupation indicate a risk of developing a latex allergy. Teach the patient about symptoms that may occur. Epinephrine is not an appropriate treatment for contact dermatitis that is caused by a type IV allergic reaction to latex. Using latex gloves increases the chance of developing latex sensitivity. Oil-based creams will increase the exposure to latex from latex gloves.

29. A postoperative patient receiving a transfusion of packed red blood cells develops chills, fever, headache, and anxiety 35 minutes after the transfusion is started. After stopping the transfusion, what action should the nurse take? Send a urine specimen to the laboratory. Administer PRN acetaminophen (Tylenol). Draw blood for a new type and crossmatch. Give the prescribed PRN diphenhydramine.

ANS: B The patient's clinical manifestations are consistent with a febrile, nonhemolytic transfusion reaction. The transfusion should be stopped, and antipyretics administered for the fever as ordered. A urine specimen is needed if an acute hemolytic reaction is suspected. Diphenhydramine is used for allergic reactions. This type of reaction does not indicate incorrect crossmatching.

23. The health care provider asks the nurse to evaluate whether a patient's angioedema has responded to prescribed therapies. Which assessment should the nurse perform? Obtain the patient's blood pressure and heart rate. Question the patient about any clear nasal discharge. Observe for swelling of the patient's lips and tongue. Assess the patient's extremities for wheal and flare lesions.

ANS: C Angioedema is characterized by swelling of the eyelids, lips, and tongue. Wheal and flare lesions, clear nasal drainage, and hypotension and tachycardia are characteristic of other allergic reactions.

24. A nurse has obtained donor tissue typing information about a patient who is waiting for a kidney transplant. Which results should be reported to the transplant surgeon? Patient is Rh positive and donor is Rh negative. Six antigen matches are present in HLA typing. Results of patient-donor crossmatching are positive. Panel of reactive antibodies (PRA) percentage is low.

ANS: C Positive crossmatching is an absolute contraindication to kidney transplantation because a hyperacute rejection will occur after the transplant. The other information shows that the tissue match between the patient and potential donor is acceptable.

20. A patient is anxious and reports difficulty breathing after being stung by a wasp. What is the nurse's priority action? Provide high-flow oxygen. Administer antihistamines. Assess the patient's airway. Remove the stinger from the site.

ANS: C The initial action with any patient with difficulty breathing is to assess and maintain the airway. The patient's symptoms of anxiety and difficulty breathing may have other causes than anaphylaxis, so additional assessment is warranted. The other actions are part of the emergency management protocol for anaphylaxis, but the priority is airway assessment and maintenance.

12. The health care provider's progress note for a patient states that the complete blood count (CBC) shows a "shift to the left." Which assessment finding should the nurse expect? Cool extremities Pallor and weakness Elevated temperature Low oxygen saturation

ANS: C The term "shift to the left" indicates that the number of immature polymorphonuclear neutrophils (bands) is elevated and that finding is a sign of infection. There is no indication that the patient is at risk for hypoxemia, pallor or weakness, or cool extremities.

18. The charge nurse is assigning semiprivate rooms for new admissions. Which patient could safely be assigned as a roommate for a patient who has acute rejection of an organ transplant? a. A patient who has viral pneumonia A patient with second-degree burns A patient with an anaphylactic reaction A patient with graft-versus-host disease

ANS: C There is no increased exposure to infection from a patient who had an anaphylactic reaction. Treatment for a patient with acute rejection includes administration of additional immunosuppressants and the patient should not be exposed to increased risk for infection as would occur from patients with viral pneumonia, graft-versus-host disease, and burns.

3. A nurse reviews the laboratory data for an older adult. The nurse would be most concerned about which finding? Hematocrit of 35% Hemoglobin of 11.8 g/dL Platelet count of 400,000/μL White blood cell count of 2800/μL

ANS: D Because the total white blood cell (WBC) count is not usually affected by aging, the low WBC count in this patient would indicate that the patient's immune function may be compromised, and the underlying cause of the problem needs to be investigated. The platelet count is normal. The slight decrease in hemoglobin and hematocrit are not unusual for an older patient.

20. Which laboratory test will the nurse use to determine whether filgrastim (Neupogen) is effective for a patient with acute lymphocytic leukemia who is receiving chemotherapy? Platelet count Reticulocyte count Total lymphocyte count Absolute neutrophil count

ANS: D Filgrastim increases the neutrophil count and function in neutropenic patients. Although total lymphocyte, platelet, and reticulocyte counts are also important to monitor in this patient, the absolute neutrophil count is used to evaluate the effects of filgrastim.

15. The nurse reviews the laboratory test results of a patient admitted with abdominal pain. Which information will be most important for the nurse to communicate to the health care provider? Monocytes 4% Hemoglobin 13.6 g/dL Platelet count 168,000/μL White blood cell count 15,500/μL

ANS: D The elevation in white blood cells indicates that the patient has an inflammatory or infectious process ongoing, which may be the cause of the patient's pain, and that further diagnostic testing is needed. The monocytes are at a normal level. The hemoglobin and platelet counts are normal.

13. A patient with human immunodeficiency virus (HIV) infection has developed Cryptosporidium parvum infection. Which outcome would be appropriate for the nurse to include in the plan of care? The patient will be free from injury. The patient will receive immunizations. The patient will have adequate oxygenation. The patient will maintain intact perineal skin.

ANS: D The major manifestation of C. pravum infection is loose, watery stools, which would increase the risk for perineal skin breakdown. The other outcomes would be appropriate for other complications (e.g., pneumonia, dementia, influenza) associated with HIV infection.

1. The nurse is advising a patient who was exposed 4 days ago to human immunodeficiency virus (HIV) through unprotected sexual intercourse. The patient's antigen-antibody test has just been reported as negative for HIV. What information should the nurse give to this patient? "You will need to be retested in 2 weeks." "You do not need to fear infecting others." "We won't know for about 10 years if you have HIV infection." "With no symptoms and this negative test, you do not have HIV."

ANS: A HIV screening tests detect HIV-specific antibodies or antigens. However, there may be a delay between infection and the time a screening test is able to detect HIV. The typical "window period" for antigen-antibody combination assays is approximately 2 weeks. It is not known based on this information whether the patient is infected with HIV or can infect others. It would be best practice to have him return for repeat testing in approximately 2 weeks.

14. A patient with pancytopenia of unknown origin is scheduled for diagnostic tests. The nurse will ensure a consent form was signed before which test? Bone marrow biopsy Abdominal ultrasound Complete blood count (CBC) Activated partial thromboplastin time (aPTT)

ANS: A A bone marrow biopsy is a minor surgical procedure that requires the patient or guardian to sign a surgical consent form. The other procedures do not require a signed consent.

9. The nurse examines the lymph nodes of a patient during a physical assessment. Which finding would be of most concern to the nurse? A 2-cm nontender supraclavicular node A 1-cm mobile and nontender axillary node An inability to palpate any superficial lymph nodes Firm inguinal nodes in a patient with an infected foot

ANS: A Enlarged and nontender nodes are suggestive of malignancies such as lymphoma. Firm nodes are an expected finding in a known area of infection. The superficial lymph nodes are usually not palpable in adults, but if they are palpable, they are normally 0.5 to 1 cm and nontender.

18. Eight years after seroconversion, a patient with human immunodeficiency virus infection has a CD4+ cell count of 800/μL and an undetectable viral load. What should be included in the plan of care at this time? Encourage adequate nutrition, exercise, and sleep. Teach about the side effects of antiretroviral agents. Explain opportunistic infections and antibiotic prophylaxis. Monitor symptoms of acquired immunodeficiency syndrome (AIDS).

ANS: A The CD4+ level for this patient is in the normal range, indicating that the patient is the stage of asymptomatic chronic infection when the body is able to produce enough CD4+ cells to maintain a normal CD4+ count. Maintaining healthy lifestyle behaviors is an important goal in this stage. AIDS and increased incidence of opportunistic infections typically develop when the CD4+ count is much lower than normal. Although the initiation of ART is highly individual, it would not be likely that a patient with a normal CD4+ level would receive ART.

10. Which information about a patient population would be most useful to help the nurse plan for human immunodeficiency virus (HIV) testing needs? Age Lifestyle Symptoms Sexual orientation

ANS: A The current Centers for Disease Control and Prevention policy is to offer routine testing for HIV to all individuals age 13 to 64 years. Although lifestyle, symptoms, and sexual orientation may suggest increased risk for HIV infection, the goal is to test all individuals in this age range.

20. An older adult who takes medications for coronary artery disease and hypertension is newly diagnosed with HIV infection and is starting antiretroviral therapy. Which information will the nurse include in patient teaching? Many drugs interact with antiretroviral medications. HIV infections progress more rapidly in older adults. Less frequent CD4+ level monitoring is needed in older adults. Hospice care is available for patients with terminal HIV infection.

ANS: A The nurse will teach the patient about potential interactions between antiretrovirals and the medications that the patient is using for chronic health problems. Treatment and monitoring of HIV infection is not affected by age. A patient beginning early ART is not a candidate for hospice. Progression of HIV is not affected by age although it may be affected by chronic disease.

4. An older adult patient who is having an annual checkup tells the nurse, "I feel fine, and I don't want to pay for all these unnecessary cancer screening tests!" Which information should the nurse plan to teach this patient? Consequences of aging on cell-mediated immunity Decrease in antibody production associated with aging Incidence of cancer-associated infections in older adults Impact of poor nutrition on immune function in older adults

ANS: A The primary impact of aging on immune function is on T cells, which are important for immune surveillance and tumor immunity. Antibody function is not affected as much by aging. Poor nutrition can also contribute to decreased immunity, but there is no evidence that it is a contributing factor for this patient. Although some types of cancer are associated with specific infections, this patient does not have an active infection.

17. A patient is admitted to the hospital with acute rejection of a kidney transplant. Which intervention will the nurse expect for this patient? Testing for human leukocyte antigen (HLA) match Administration of immunosuppressant medications Insertion of an arteriovenous graft for hemodialysis Placement of the patient on the transplant waiting list

ANS: B Acute rejection is treated with the administration of additional immunosuppressant drugs such as corticosteroids. Because acute rejection is potentially reversible, there is no sign that the patient will need another transplant or hemodialysis. There is no need to repeat HLA testing.

21. Immediately after the nurse administers an intradermal injection of an allergen on the forearm, the patient reports itching at the site, weakness, and dizziness. What action should the nurse take first? Apply antiinflammatory cream. Place a tourniquet above the site. Administer subcutaneous epinephrine. Reschedule the patient's other allergen tests.

ANS: B Application of a tourniquet will decrease systemic circulation of the allergen and should be the first reaction. The other actions may occur, but the tourniquet application slows the allergen progress into the patient's system, allowing treatment of the anaphylactic response. A local antiinflammatory cream may be applied to the site of a cutaneous test for persistent itching. Epinephrine will be needed if the allergic reaction progresses to anaphylaxis. Other testing may be delayed and rescheduled after development of anaphylaxis.

46. When a patient with splenomegaly is scheduled for splenectomy, which action will the nurse include in the preoperative plan of care? Recommend ibuprofen for left upper quadrant pain. Schedule immunization with the pneumococcal vaccine. Avoid the use of acetaminophen (Tylenol) for 2 weeks prior to surgery. Discourage deep breathing and coughing to reduce risk for splenic rupture.

ANS: B Asplenic patients are at high risk for infection with pneumococcal infections and immunization reduces this risk. There is no need to avoid acetaminophen use before surgery, but nonsteroidal antiinflammatory drugs (NSAIDs) may increase bleeding risk and should be avoided. The enlarged spleen may decrease respiratory depth, and the patient should be encouraged to take deep breaths.

2. Which example should the nurse use to explain an infant's "passive immunity" to a new mother? Vaccinations Breastfeeding c. Stem cells in peripheral blood d. Exposure to communicable diseases

ANS: B Colostrum in breast milk provides passive immunity through antibodies from the mother. These antibodies protect the infant for a few months. However, memory cells are not retained, so the protection is not permanent. Active immunity is acquired by being immunized with vaccinations or having an infection. Stem cells are unspecialized cells used to repopulate a person's bone marrow after high-dose chemotherapy.

15. The nurse teaches a patient about drug therapy after a kidney transplant. Which statement by the patient would indicate a need for further instructions? "I need to be monitored closely for development of cancer." "After a couple of years, I will be able to stop taking the cyclosporine." "If I develop acute rejection episode, I will need additional types of drugs." "The drugs are combined to inhibit different ways the kidney can be rejected."

ANS: B Cyclosporine, a calcineurin inhibitor, will need to be continued for life. The other patient statements are accurate and indicate that no further teaching is necessary about those topics.

27. Which assessment finding should the nurse caring for a patient with thrombocytopenia communicate immediately to the health care provider? Bruises on the patient's back. The patient is difficult to arouse. Purpura on the patient's oral mucosa. The patient's platelet count is 52,000/μL.

ANS: B Difficulty in arousing the patient may indicate a cerebral hemorrhage, which is life threatening and requires immediate action. The other information should be documented and reported but would not be unusual in a patient with thrombocytopenia.

14. Which intervention will be included in the nursing care plan for a patient with immune thrombocytopenic purpura? Assign the patient to a private room. Avoid intramuscular (IM) injections. Use rinses rather than a soft toothbrush for oral care. Restrict activity to passive and active range of motion.

ANS: B IM or subcutaneous injections should be avoided because of the risk for bleeding. A soft toothbrush can be used for oral care. There is no need to restrict activity or place the patient in a private room.

34. Which problem reported by a patient with hemophilia is most important for the nurse to communicate to the health care provider? Leg bruises Tarry stools Skin abrasions d. Bleeding gums

ANS: B Melena is a sign of gastrointestinal bleeding and requires collaborative actions such as checking hemoglobin and hematocrit and administration of coagulation factors. The other problems indicate a need for patient teaching about how to avoid injury but are not indicators of possible serious blood loss.

19. A patient in the health care provider's office for allergen testing using the cutaneous scratch method develops itching and swelling at the skin site. Which action should the nurse plan to take first? Monitor the patient's edema. Administer a dose of epinephrine. Obtain a prescription for oral antihistamines. Assess the patient's use of new skin products.

ANS: B Rapid administration of epinephrine when excessive itching or swelling at the skin site is observed can prevent the progression to anaphylaxis. The initial symptoms of anaphylaxis are itching and edema at the site of the exposure. The nurse should not wait and assess for development of more edema. Hypotension, tachycardia, dilated pupils, and wheezes occur later. Exposure to skin products does not address the immediate concern of a possible anaphylactic reaction.

3. A patient is being evaluated for possible atopic dermatitis. The nurse should expect elevation of which laboratory value? a. IgA b. IgE c. Basophils d. Neutrophils

ANS: B Serum IgE is elevated in an allergic response (type 1 hypersensitivity disorders). The eosinophil level will be elevated rather than neutrophil or basophil counts. IgA is in body secretions and would not be tested when evaluating a patient who has symptoms of atopic dermatitis.

12. Which patient should the nurse assess first? Patient with urticaria after receiving an IV antibiotic Patient who is sneezing after subcutaneous immunotherapy Patient who has graft-versus-host disease and severe diarrhea Patient with multiple chemical sensitivities with muscle stiffness

ANS: B Sneezing after subcutaneous immunotherapy may indicate impending anaphylaxis and assessment and emergency measures should be initiated. The other patients also have findings that need assessment and intervention by the nurse, but do not have evidence of life-threatening complications.

11. Which statement by a patient would alert the nurse to a risk for decreased immune function? "I had a chest x-ray 6 months ago." "I had my spleen removed after a car accident." "I take one baby aspirin every day to prevent stroke." d. "I usually eat eggs or meat for at least two meals a day."

ANS: B Splenectomy increases the risk for septicemia from bacterial infections. The patient's protein intake is good and should improve immune function. Daily aspirin use does not affect immune function. A chest x-ray does not have enough radiation to suppress immune function.

6. A patient's complete blood count (CBC) shows a hemoglobin of 19 g/dL and a hematocrit of 54%. Which question should the nurse ask to determine possible causes of this finding? "Have you had a recent weight loss?" "Do you have any history of lung disease?" "Have you noticed any dark or bloody stools?" "What is your dietary intake of meat and protein?"

ANS: B The hemoglobin and hematocrit results indicate polycythemia, which can be associated with chronic obstructive pulmonary disease. The other questions would be appropriate for patients who are anemic.

16. The nurse is caring for a patient with type A hemophilia being admitted to the hospital with severe pain and swelling in the right knee. Which action should the nurse take? Apply heat to the knee. Immobilize the knee joint. Assist the patient with light weight bearing. Perform passive range of motion to the knee.

ANS: B The initial action should be total rest of the knee to minimize bleeding. Ice packs are used to decrease bleeding. Range of motion (ROM) and weight-bearing exercise are contraindicated initially, but after the bleeding stops, ROM and physical therapy are started.

14. A patient seeks care in the emergency department after sharing needles for heroin injection with a friend who has hepatitis B. To provide immediate protection from infection, what medication will the nurse expect to administer? Corticosteroids Gamma globulin Hepatitis B vaccine Fresh frozen plasma

ANS: B The patient should first receive antibodies for hepatitis B from injection of gamma globulin. The hepatitis B vaccination series should be started to provide active immunity. Fresh frozen plasma and corticosteroids will not be effective in preventing hepatitis B in the patient.

21. A patient who has acute myelogenous leukemia (AML) asks the nurse whether the planned chemotherapy will be worth undergoing. Which response by the nurse is appropriate? "If you do not want to have chemotherapy, other treatment options include stem cell transplantation." "The side effects of chemotherapy are difficult, but AML often goes into remission with chemotherapy." "The decision about treatment is one that you and the doctor need to make rather than asking what I would do." "You don't need to make a decision about treatment right now because leukemias in adults tend to progress slowly."

ANS: B This response uses therapeutic communication by addressing the patient's question and giving accurate information. The other responses either give inaccurate information or fail to address the patient's question, which will discourage the patient from asking the nurse for information.

28. The nurse is planning to administer a transfusion of packed red blood cells (PRBCs) to a patient with blood loss from gastrointestinal hemorrhage. Which action can the nurse delegate to unlicensed assistive personnel (UAP)? Verify the patient identification (ID) according to hospital policy. Obtain the patient's temperature and blood pressure before the transfusion. Double-check the product numbers on the PRBCs with the patient ID band. Monitor the patient for shortness of breath or chest pain during the transfusion

ANS: B UAP education includes measurement of vital signs. UAP would report the vital signs to the registered nurse (RN). The other actions require more education and a larger scope of practice and should be done by licensed nursing staff members.

2. According to the Center for Disease Control and Prevention (CDC) guidelines, which personal protective equipment will the nurse put on before assessing a patient who is on contact precautions for Clostridium difficile diarrhea? (Select all that apply.) Mask Gown Gloves Shoe covers Eye protection

ANS: B, C Because the nurse will have substantial contact with the patient and bedding when doing an assessment, gloves and gowns are needed. Eye protection and masks are needed for patients in contact precautions only when spraying or splashing is anticipated. Shoe covers are not recommended in the CDC guidelines.

14. A patient treated for human immunodeficiency virus (HIV) infection for 6 years has developed fat redistribution to the trunk with wasting of the arms, legs, and face. What recommendation will the nurse give to the patient? Review foods that are higher in protein. Teach about the benefits of daily exercise. Discuss a change in antiretroviral therapy. Talk about treatment with antifungal agents.

ANS: C A frequent first intervention for metabolic disorders is a change in antiretroviral therapy (ART). Treatment with antifungal agents would not be appropriate because there is no indication of fungal infection. Changes in diet or exercise have not proven helpful for this problem.

25. A patient who is receiving immunotherapy has just received an allergen injection. Which assessment finding is most important to communicate to the health care provider? The patient's IgG level is increased. The injection site is red and swollen. There is a 2-cm wheal at the site of the injection. The patient's symptoms did not improve in 2 months.

ANS: C A local reaction larger than quarter size may indicate that a decrease in the allergen dose is needed. An increase in IgG shows that the therapy is effective. Redness and swelling at the site are not unusual. Because immunotherapy usually takes 1 to 2 years to achieve an effect, an improvement in the patient's symptoms is not expected after a few months.

37. Which action for a patient with neutropenia is appropriate for the registered nurse (RN) to delegate to a licensed practical/vocational nurse (LPN/VN)? Assessing the patient for signs and symptoms of infection Teaching the patient the purpose of neutropenic precautions Administering subcutaneous filgrastim (Neupogen) injection Developing a discharge teaching plan for the patient and family

ANS: C Administration of subcutaneous medications is included in LPN/VN education and scope of practice. Patient teaching, assessment, and developing the plan of care require RN level education and scope of practice.

3. A patient informed of a positive rapid screening test result for human immunodeficiency virus (HIV) is anxious and does not appear to hear what the nurse is saying. What action by the nurse is most important at this time? Inform the patient about the available treatments. Teach the patient how to manage a possible drug regimen. Remind the patient to return for retesting to verify the results. Ask the patient to identify those persons who had intimate contact.

ANS: C After an initial positive antibody test result, the next step is retesting to confirm the results. A patient who is anxious is not likely to be able to take in new information or be willing to disclose information about the HIV status of other individuals.

39. After receiving change-of-shift report for several patients with neutropenia, which patient should the nurse assess first? A 23-yr-old who reports severe fatigue A 56-yr-old with frequent explosive diarrhea A 33-yr-old with a fever of 100.8° F (38.2° C) A 66-yr-old who has white pharyngeal lesions

ANS: C Any fever in a neutropenic patient indicates infection and can quickly lead to sepsis and septic shock. Rapid assessment and (if prescribed) initiation of antibiotic therapy within 1 hour are needed. The other patients also need to be assessed but do not have symptoms of potentially life-threatening problems.

4. Which patient statement to the nurse indicates that the patient understands self-care for pernicious anemia? "I need to start eating more red meat and liver." "I will stop having a glass of wine with dinner." "I could choose nasal spray rather than injections of vitamin B12." "I will need to take a proton pump inhibitor such as omeprazole (Prilosec)."

ANS: C Because pernicious anemia prevents the absorption of vitamin B12, this patient requires injections or intranasal administration of cobalamin. Alcohol use does not cause cobalamin deficiency. Proton pump inhibitors decrease the absorption of vitamin B12. Eating more foods rich in vitamin B12 is not helpful because the lack of intrinsic factor prevents absorption of the vitamin.

7. The nurse reviewing a clinic patient's medical record notes that the patient missed the previous appointment for weekly immunotherapy. Which action by the nurse is appropriate? Schedule an additional dose the following week. Administer the scheduled dosage of the allergen. Consult with the health care provider about giving a lower allergen dose. Reevaluate the patient's sensitivity to the allergen with a repeat skin test.

ANS: C Because there is an increased risk for adverse reactions after a patient misses a scheduled dose of allergen, the nurse should check with the health care provider before administration of the injection. A skin test is used to identify the allergen and would not be used at this time. An additional dose for the week may increase the risk for a reaction.

15. Which laboratory result will the nurse expect to show a decreased value if a patient develops heparin-induced thrombocytopenia (HIT)? Prothrombin time Erythrocyte count Fibrinogen degradation products Activated partial thromboplastin time

ANS: D Platelet aggregation in HIT causes neutralization of heparin, so the activated partial thromboplastin time will be shorter, and more heparin will be needed to maintain therapeutic levels. The other data will not be affected by HIT.

5. The nurse assesses a patient with pernicious anemia. Which finding would the nurse expect? Yellow-tinged sclerae Shiny, smooth tongue Tender, bleeding gums Numbness of extremities

ANS: C Extremity numbness is associated with cobalamin (vitamin B12) deficiency or pernicious anemia. Loss of the papillae of the tongue occurs with chronic iron deficiency. Yellow-tinged sclera is associated with hemolytic anemia and the resulting jaundice. Gum bleeding and tenderness occur with thrombocytopenia or neutropenia.

16. An older adult patient has a prescription for cyclosporine following a kidney transplant. Which information in the patient's health history has implications for planning patient teaching about the safe use of cyclosporine? The patient restricts salt to 2 grams per day. The patient eats green leafy vegetables daily. The patient drinks grapefruit juice every day. The patient drinks 3 to 4 quarts of fluid each day.

ANS: C Grapefruit juice can increase the toxicity of cyclosporine. The patient should be taught to avoid grapefruit juice. Normal fluid and sodium intake or eating green leafy vegetables will not affect cyclosporine levels or renal function.

4. A patient who is diagnosed with acquired immunodeficiency syndrome (AIDS) tells the nurse, "I feel obsessed with morbid thoughts about dying." Which response by the nurse is appropriate? "Thinking about dying will not improve the course of AIDS." "Do you think that taking an antidepressant might be helpful?" "Can you tell me more about the thoughts that you are having?" "It is important to focus on the good things about your life now."

ANS: C More assessment of the patient's psychosocial status is needed before taking any other action. The statements, "Thinking about dying will not improve the course of AIDS" and "It is important to focus on the good things in life" or suggesting an antidepressant discourage the patient from sharing any further information with the nurse and decrease the nurse's ability to develop a trusting relationship with the patient.

5. Which is an appropriate nursing intervention for a hospitalized patient with severe hemolytic anemia? Provide a diet high in vitamin K. Teach the patient how to avoid injury. Encourage alternating rest and activity. Place the patient on protective isolation.

ANS: C Nursing care for patients with anemia should alternate periods of rest and activity to avoid undue fatigue. There is no indication that the patient has a bleeding disorder, so a diet high in vitamin K or teaching about how to avoid injury is not needed. Protective isolation might be used for a patient with aplastic anemia, but it is not indicated for hemolytic anemia.

8. The nurse notes pallor of the skin and nail beds in a newly admitted patient. The nurse should ensure that which laboratory test has been ordered? Platelet count Neutrophil count Hemoglobin level White blood cell count

ANS: C Pallor of the skin or nail beds is indicative of anemia, which would be indicated by a low Hgb level. Platelet counts indicate a person's clotting ability. A neutrophil is a type of white blood cell that helps to fight infection.

11. A patient who uses injectable illegal drugs asks the nurse how to prevent acquired immunodeficiency syndrome (AIDS). Which response by the nurse is most accurate? "Clean drug injection equipment before each use." "Ask those who share equipment to be tested for HIV." "Consider participating in a needle-exchange program." "Avoid sexual intercourse when using injectable drugs."

ANS: C Participation in needle-exchange programs has been shown to decrease and control the rate of HIV infection. Cleaning drug equipment before use also reduces risk, but it might not be consistently practiced. HIV antibodies do not appear for several weeks to months after exposure, so testing drug users would not be very effective in reducing risk for HIV exposure. HIV can be transmitted through both intercourse and injection.

22. The nurse designs a program to decrease the incidence of human immunodeficiency virus (HIV) infection in the adolescent and young adult populations. Which information should the nurse assign as the highest priority? Methods to prevent perinatal HIV transmission. Ways to sterilize needles used by injectable drug users. Prevention of HIV transmission between sexual partners. Means to prevent transmission through blood transfusions.

ANS: C Sexual transmission is the most common way that HIV is transmitted. The nurse should also provide teaching about perinatal transmission, needle sterilization, and blood transfusion, but the rate of HIV infection associated with these situations is lower.

36. A patient with possible disseminated intravascular coagulation arrives in the emergency department with a blood pressure of 82/40, temperature of 102° F (38.9° C), and severe back pain. Which prescribed action will the nurse implement first? Administer morphine sulfate 4 mg IV. Give acetaminophen (Tylenol) 650 mg. Infuse normal saline 500 mL over 30 minutes. Schedule complete blood count and coagulation studies.

ANS: C The patient's blood pressure indicates hypovolemia caused by blood loss and should be addressed immediately to improve perfusion to vital organs. The other actions are also appropriate and should be rapidly implemented, but improving perfusion is the priority for this patient.

35. A patient with septicemia develops prolonged bleeding from venipuncture sites and blood in the stools. Which action is most important for the nurse to take? Avoid other venipunctures. Apply dressings to the sites. Notify the health care provider. Give prescribed proton-pump inhibitors.

ANS: C The patient's new onset of bleeding and diagnosis of sepsis suggest that disseminated intravascular coagulation (DIC) may have developed, which will require collaborative actions such as diagnostic testing, blood product administration, and heparin administration. The other actions are also appropriate, but the most important action should be to notify the health care provider so that DIC treatment can be initiated rapidly.

4. A patient with pancytopenia will have a bone marrow aspiration from the left posterior iliac crest. Which action would be important for the nurse to take after the procedure? Elevate the head of the bed to 45 degrees. Use a -in sterile gauze to pack the wound. Have the patient lie on the left side for 1 hour. Apply a sterile 2-in gauze dressing to the site.

ANS: C To decrease the risk for bleeding, the patient should lie on the left side for 30 to 60 minutes. After a bone marrow biopsy, the wound is small and will not be packed with gauze. A pressure dressing is used to cover the aspiration site. There is no indication to elevate the patient's head.

2. The nurse assesses a patient who has numerous petechiae on both arms. Which question should the nurse ask the patient? "Are you taking any oral contraceptives?" "Have you been prescribed antiseizure drugs?" "Do you take medication containing salicylates?" "How long have you taken antihypertensive drugs?"

ANS: C Salicylates interfere with platelet function and can lead to petechiae and ecchymoses. Antiseizure drugs may cause anemia but not clotting disorders or bleeding. Oral contraceptives increase a person's clotting risk. Antihypertensives do not usually cause problems with decreased clotting.

2. A patient who has a positive test for human immunodeficiency virus (HIV) antibodies is admitted to the hospital with Pneumocystis jiroveci pneumonia (PCP) and a CD4+ count of less than 200 cells/L. Based on diagnostic criteria established by the Centers for Disease Control and Prevention (CDC), which statement by the nurse is correct? "The patient meets the criteria for a diagnosis of acute HIV infection." "The patient will be diagnosed with asymptomatic chronic HIV infection." c. "The patient will likely develop symptomatic HIV infection within 1 year." d. "The patient has developed acquired immunodeficiency syndrome (AIDS)."

ANS: D Development of PCP meets the diagnostic criteria for AIDS. The other responses indicate earlier stages of HIV infection than is indicated by the PCP infection.

9. Which statement by a patient indicates good understanding of the nurse's teaching about preventing sickle cell crisis? "Home oxygen therapy is frequently used to decrease sickling." "There are no effective medications that can help prevent sickling." "Routine continuous dosage opioids are prescribed to prevent a crisis." "Risk for a crisis is decreased by having an annual influenza vaccination."

ANS: D Because infection is the most common cause of a sickle cell crisis, influenza, Haemophilus influenzae, pneumococcal pneumonia, and hepatitis immunizations should be administered. Although continuous dose opioids and oxygen may be administered during a crisis, patients do not receive these therapies to prevent crisis. Hydroxyurea (Hydrea) is a medication used to decrease the number of sickle cell crises.

15. The nurse prepares to administer the following medications to a hospitalized patient with human immunodeficiency (HIV). Which medication is most important to administer at the scheduled time? Nystatin tablet Oral acyclovir (Zovirax) Aerosolized pentamidine (NebuPent) Oral tenofovir AF/emtricitabine/bictegravir (Biktarvy)

ANS: D It is important that antiretrovirals be taken at the prescribed time every day to avoid developing drug-resistant HIV. The other medications should also be given as close as possible to the correct time, but they are not as essential to receive at the same time every day.

44. A patient who has non-Hodgkin's lymphoma is receiving combination treatment with rituximab (Rituxan) and chemotherapy. Which patient assessment finding requires the most rapid action by the nurse? Anorexia Vomiting Oral ulcers Lip swelling

ANS: D Lip swelling in angioedema may indicate a hypersensitivity reaction to the rituximab. The nurse should stop the infusion and further assess for anaphylaxis. The other findings may occur with chemotherapy but are not immediately life threatening.

13. What action is expected by the nurse caring for a patient who has an acute exacerbation of polycythemia vera? Place the patient on bed rest. Administer iron supplements. Avoid use of aspirin products. Monitor fluid intake and output.

ANS: D Monitoring hydration status is important during an acute exacerbation because the patient is at risk for fluid overload or underhydration. Aspirin therapy is used to decrease risk for thrombosis. The patient should be encouraged to ambulate to prevent deep vein thrombosis. Iron is contraindicated in patients with polycythemia vera.

10. The nurse should assess the patient undergoing plasmapheresis for which clinical manifestation? Shortness of breath High blood pressure Transfusion reaction Extremity numbness

ANS: D Numbness and tingling may occur as the result of the hypocalcemia caused by the citrate used to prevent coagulation. The other clinical manifestations are not associated with plasmapheresis.

43. Following successful treatment of Hodgkin's lymphoma for a 55-yr-old woman, which topic will the nurse include in patient teaching? Potential impact of chemotherapy treatment on fertility Application of soothing lotions to treat residual pruritus Use of maintenance chemotherapy to maintain remission Need for follow-up appointments to screen for malignancy

ANS: D The chemotherapy used in treating Hodgkin's lymphoma results in a high incidence of secondary malignancies; follow-up screening is needed. Chemotherapy will not impact the fertility of a 55-yr-old woman. Maintenance chemotherapy is not used for Hodgkin's lymphoma. Pruritus is a clinical manifestation of lymphoma but should not be a concern after treatment.

30. A patient in the emergency department reports back pain and difficulty breathing 15 minutes after a transfusion of packed red blood cells is started. What should the nurse's first action be? Administer oxygen therapy at a high flowrate. Obtain a urine specimen to send to the laboratory. Notify the health care provider about the symptoms. Disconnect the transfusion and infuse normal saline.

ANS: D The patient's symptoms indicate a possible acute hemolytic reaction caused by the transfusion. The first action should be to disconnect the transfusion and infuse normal saline. The other actions also are needed but are not the highest priority.

2. Which menu choice indicates that the patient understands the nurse's recommendations about dietary choices for iron-deficiency anemia? Omelet and whole wheat toast Cantaloupe and cottage cheese c. Strawberry and banana fruit plate d. Cornmeal muffin and orange juice

ANS: A Eggs and whole grain breads are high in iron. The other choices are appropriate for other nutritional deficiencies but are not the best choice for a patient with iron-deficiency anemia.

40. Which action will the nurse include in the plan of care for a patient who has thalassemia major? Administer chelation therapy as needed. Teach the patient to use iron supplements. Avoid the use of intramuscular injections. Notify health care provider of hemoglobin 11 g/dL.

ANS: A The frequent transfusions used to treat thalassemia major lead to iron toxicity in patients unless iron chelation therapy is consistently used. Iron supplementation is avoided in patients with thalassemia. There is no need to avoid intramuscular injections. The goal for patients with thalassemia major is to maintain a hemoglobin of 10 g/dL or greater.

13. Ten days after receiving a bone marrow transplant, a patient develops a skin rash. What should the nurse suspect is the cause of the rash? The donor T cells are attacking the patient's skin cells. The patient needs treatment to prevent hyperacute rejection. The patient's antibodies are rejecting the donor bone marrow. The patient is experiencing a delayed hypersensitivity reaction.

ANS: A The patient's history and symptoms indicate that the patient is experiencing graft-versus-host disease, in which the donated T cells attack the patient's tissues. The history and symptoms are not consistent with rejection or delayed hypersensitivity.

5. A pregnant woman with asymptomatic chronic human immunodeficiency virus (HIV) infection is seen at the clinic. The patient states, "I am very nervous about making my baby sick." Which information will the nurse include when teaching the patient? The antiretroviral medications used to treat HIV infection are teratogenic. Most infants born to HIV-positive mothers are not infected with the virus. Because it is an early stage of HIV infection, the infant will not contract HIV. Her newborn will be born with HIV unless she uses antiretroviral therapy (ART).

ANS: B Only 25% of infants born to HIV-positive mothers develop HIV infection, even when the mother does not use ART during pregnancy. The percentage drops to 2% when ART is used. Perinatal transmission can occur at any stage of HIV infection (although it is less likely to occur when the viral load is lower). ART can safely be used in pregnancy, although some ART drugs should be avoided.

10. Which instruction will the nurse plan to include in discharge teaching for a patient admitted with a sickle cell crisis? Limit fluids to 2 to 3 quarts per day. Avoid exposure to crowds when possible. Take a daily multivitamin supplement with iron. Drink no more than two caffeinated beverages daily.

ANS: B Exposure to crowds increases the patient's risk for infection, the most common cause of sickle cell crisis. There is no restriction on caffeine use. Iron supplementation is generally not recommended. A high-fluid intake is recommended.

45. Which information obtained by the nurse assessing a patient admitted with multiple myeloma is most important to report to the health care provider? Patient reports severe back pain. Serum calcium level is 15 mg/dL. Patient reports no stool for 5 days. Urine sample has Bence-Jones protein.

ANS: B Hypercalcemia may lead to complications such as dysrhythmias or seizures and should be addressed quickly. The other patient findings will also be discussed with the health care provider but are not life threatening.

3. A patient who is receiving methotrexate for severe rheumatoid arthritis develops a megaloblastic anemia. Which nutrient supplement should the nurse plan to explain to the patient? Iron Folic acid Cobalamin (vitamin B12) Ascorbic acid (vitamin C)

ANS: B Methotrexate use can lead to folic acid deficiency. Supplementation with oral folic acid supplements is the usual treatment. The other nutrients would not correct folic acid deficiency, although they would be used to treat other types of anemia.

22. A patient who has a history of a transfusion-related acute lung injury (TRALI) is to receive a transfusion of packed red blood cells (PRBCs). Which action by the nurse will decrease the risk for TRALI for this patient? Infuse PRBCs slowly over 4 hours. Transfuse leukocyte-reduced PRBCs. Administer the prescribed diuretic before the transfusion. Give the PRN dose of antihistamine before the transfusion.

ANS: B TRALI is caused by a reaction between the donor and the patient leukocytes that causes pulmonary inflammation and capillary leaking. The other actions may help prevent respiratory problems caused by circulatory overload or by allergic reactions, but they will not prevent TRALI.

26. A patient receiving outpatient chemotherapy for myelogenous leukemia develops an absolute neutrophil count of 850/μL. Which collaborative action should the outpatient clinic nurse anticipate?? Discuss the need for hospital admission to treat the neutropenia. Teach the patient to administer filgrastim (Neupogen) injections. Plan to discontinue the chemotherapy until the neutropenia resolves. Order a high-efficiency particulate air (HEPA) filter for the patient's home.

ANS: B The patient may be taught to self-administer filgrastim injections. Although chemotherapy may be stopped with severe neutropenia (neutrophil count <500/μL), administration of filgrastim usually allows the chemotherapy to continue. Patients with neutropenia are at higher risk for infection when exposed to other patients in the hospital. HEPA filters are expensive and are used in the hospital, where the number of pathogens is much higher than in the patient's home environment.

16. Which information shown in the table below about a patient who has just arrived in the emergency department is most urgent for the nurse to communicate to the health care provider? Assessment • BP 110/68 • Pulse 98 beats/min • Brisk capillary refill • Multiple ecchymoses on arms Complete Blood Count • Hgb 10.6 g/dL • Hct 30% • WBC 5100/μL • Platelets 19,500/μL Patient History • Occasional aspirin use • Abdominal pain x 1 week • Large, dark stool this morning Heart rate Platelet count Abdominal pain White blood cell count

ANS: B The platelet count is severely decreased and places the patient at risk for spontaneous bleeding. The other information is also pertinent but not as indicative of the need for rapid treatment as the platelet count.

41. Which information is most important for the nurse to monitor when evaluating the effectiveness of deferoxamine (Desferal) for a patient with hemochromatosis? Skin color Hematocrit Liver function Serum iron level

ANS: D Because iron chelating agents are used to lower serum iron levels, the most useful information will be the patient's iron level. The other parameters will also be monitored but are not the most important to monitor when determining the effectiveness of deferoxamine.

17. The nurse is caring for a patient who is living with human immunodeficiency virus (HIV) and taking antiretroviral therapy (ART). Which information is most important for the nurse to address when planning care? The patient reports feeling "constantly tired." The patient reports having no side effects from the medications. The patient is unable to explain the effects of atorvastatin (Lipitor). The patient reports missing doses of tenofovir AF/emtricitabine (Descovy).

ANS: D Because missing doses of ART can lead to drug resistance, this patient statement indicates the need for interventions such as teaching or changes in the drug scheduling. Fatigue is a common side effect of ART. The nurse should discuss medication actions and side effects with the patient, but this is not as important as addressing the skipped doses of Descovy.

1. A patient is being discharged after an emergency splenectomy following a motor vehicle crash. Which instructions should the nurse include in the discharge teaching? Check often for swollen lymph nodes. Watch for excess bleeding or bruising. Take iron supplements to prevent anemia. Wash hands and avoid persons who are ill.

ANS: D Splenectomy increases the risk for infection, especially with gram-positive bacteria. The risks for lymphedema, bleeding, and anemia are not increased after a person has a splenectomy.

1. A patient is to receive an infusion of 250 mL of platelets over 2 hours through tubing that is labeled: 1 mL equals 10 drops. How many drops per minute will the nurse infuse?

ANS: 21 To infuse 250 mL over 2 hours, the calculated drip rate is 20.8 drops/min or 21 drops/min.

12. A patient who has been receiving IV heparin infusion and oral warfarin (Coumadin) for a deep vein thrombosis (DVT) is diagnosed with heparin-induced thrombocytopenia (HIT) when the platelet level drops to 110,000/μL. Which action will the nurse include in the plan of care? Prepare for platelet transfusion. Discontinue the heparin infusion. Administer prescribed warfarin (Coumadin). Give low-molecular-weight heparin (LMWH).

ANS: B All heparin is discontinued when HIT is diagnosed. The patient should be instructed to never receive heparin or LMWH. Warfarin is usually not given until the platelet count has returned to 150,000/μL. The platelet count does not drop low enough in HIT for a platelet transfusion, and platelet transfusions increase the risk for thrombosis.

23. A patient who has acute myelogenous leukemia (AML) is considering treatment with a hematopoietic stem cell transplant (HSCT). What is the best approach for the nurse to assist the patient with this treatment decision? Discuss the need for insurance to cover post-HSCT care. Inquire whether there are questions or concerns about HSCT. Emphasize the positive outcomes of a bone marrow transplant. Explain that a cure is not possible with any treatment except HSCT.

ANS: B Offering the patient an opportunity to ask questions or discuss concerns about HSCT will encourage the patient to voice concerns about this treatment and will allow the nurse to assess whether the patient needs more information about the procedure. Treatment of AML using chemotherapy is another option for the patient. It is not appropriate for the nurse to ask the patient to consider insurance needs in making this decision.

47. The nurse has obtained the health history, physical assessment data, and laboratory results shown in the accompanying figure for a patient admitted with aplastic anemia. Which information is most important to communicate to the health care provider? History • Fatigue, which has increased over last month • Frequent constipation Physical Assessment • Conjunctiva pale pink, moist• Multiple bruises• Clear lung sounds Laboratory Results • Hct 33%• WBC 1500/μL• Platelets 70,000/μL Bruising Neutropenia Increasing fatigue Thrombocytopenia

ANS: B The low white blood cell count indicates that the patient is at high risk for infection and needs immediate actions to diagnose and treat the cause of the leukopenia. The other information may require further assessment or treatment but does not place the patient at immediate risk for complications.

6. Which information about intradermal skin testing should the nurse teach to a patient with possible allergies? "Do not eat anything for about 6 hours before the testing." "Take an oral antihistamine about an hour before the testing." "Plan to wait in the clinic for 20 to 30 minutes after the testing." "Reaction to the testing will take about 48 to 72 hours to occur."

ANS: C Allergic reactions usually occur within minutes after injection of an allergen, and the patient will be monitored for at least 20 minutes for anaphylactic reactions after the testing. Medications that might modify the response, such as antihistamines, should be avoided before allergy testing. There is no reason to be NPO for skin testing. Results with intradermal testing occur within minutes.

10. A patient who had a total hip replacement had an intraoperative hemorrhage 14 hours ago. Which laboratory test result would the nurse expect? Hematocrit of 46% Hemoglobin of 13.8 g/dL Elevated reticulocyte count Decreased white blood cell count

ANS: C Hemorrhage causes the release of reticulocytes (immature red blood cells) from the bone marrow into circulation. The hematocrit and hemoglobin levels are normal. Bleeding does not affect the white blood cell count.

9. What instructions about plasmapheresis should the nurse include in the teaching plan for a patient diagnosed with systemic lupus erythematosus (SLE)? Plasmapheresis counteracts recovery of IgG production. Plasmapheresis removes eosinophils and basophils from the blood. Plasmapheresis decreases the damage to organs from T lymphocytes. Plasmapheresis prevents inflammatory mediators from injuring tissues.

ANS: D Plasmapheresis is used in SLE to remove antibodies, antibody-antigen complexes, and inflammatory mediators, such as complement, from the blood. T lymphocytes, foreign antibodies, eosinophils, and basophils do not directly contribute to the tissue damage in SLE. Immunosuppressive therapy is used to prevent recovery of IgG production.

1. An adult male with chronic anemia is experiencing increased fatigue and occasional palpitations at rest. Which laboratory data would the nurse identify as consistent with these symptoms? RBC count of 4,500,000/L Hematocrit (Hct) value of 38% Normal red blood cell (RBC) indices Hemoglobin (Hgb) of 8.6 g/dL (86 g/L)

ANS: D The patient's symptoms indicate moderate anemia, which is consistent with a Hgb of 6 to 10 g/dL. The other values are all within the range of normal.