test 5 test bank

18. The patient is admitted with upper GI bleeding following an episode of forceful retching following excessive alcohol intake. The nurse suspects a Mallory-Weiss tear and is aware that: a. a Mallory-Weiss tear is a longitudinal tear in the gastroesophageal mucosa. b. this type of bleeding is treated by giving chewable aspirin. c. the bleeding, although impressive, is self-limiting with little actual blood loss. d. is not usually associated with alcohol intake or retching.

ANS: A A Mallory-Weiss tear is an arterial hemorrhage from an acute longitudinal tear in the gastroesophageal mucosa and accounts for 10% to 15% of upper GI bleeding episodes. It is associated with long-term nonsteroidal antiinflammatory drug or aspirin ingestion and with excessive alcohol intake. The upper GI bleeding usually occurs after episodes of forceful retching. Bleeding usually resolves spontaneously; however, lacerations of the esophagogastric junction may cause massive GI bleeding, requiring surgical repair.

19. The nurse is caring for a patient who is passing bright red blood rectally. The nurse should expect to insert a nasogastric tube to: a. rule out massive upper GI bleeding. b. detect the presence of melena in the stomach. c. visually determine the presence of occult bleeding. d. obtain samples for guaiac to confirm current bleeding.

ANS: A Bright red or maroon blood (hematochezia) is usually a sign of a lower GI source of bleeding but can be seen when upper GI bleeding is massive (more than 1000 mL). Melena is shiny, black, foul-smelling stool; it is not present in the stomach. Occult bleeding means that blood is not visible and is detected only by testing the stool with a chemical reagent (guaiac).

9. The liver detoxifies the blood by: a. converting fat-soluble compounds to water-soluble compounds. b. converting water-soluble compounds to fat-soluble compounds. c. excreting fat-soluble compounds in feces. d. metabolizing inactive toxic substances to active forms.

ANS: A Drugs, hormones, and other toxic substances are metabolized by the liver into inactive forms for excretion. This process is usually accomplished by conversion of the fat-soluble compounds to water-soluble compounds. They can then be excreted via the bile or the urine.

20. The patient is admitted with generalized fatigue and a low hemoglobin and hematocrit (anemia). The patient denies vomiting and states that his last bowel movement earlier that day was normal in color and consistency. However, because GI blood loss can be a cause of anemia, the nurse should expect to: a. obtain a stool sample for guaiac testing. b. chart that the patient reports the presence of melena in his stool. c. inspect the patients next stool for the presence of coffee-ground contents. d. obtain guaiac positive stools only if bleeding is current.

ANS: A GI blood loss is often occult or detected only by testing the stool with a chemical reagent (guaiac). Stool and nasogastric drainage can test guaiac positive for up to 10 days after a bleeding episode. Melena is shiny, black, foul-smelling stool and results from the degradation of blood by stomach acids or intestinal bacteria. Vomiting or drainage from a nasogastric tube that yields blood or coffee-groundlike material is associated with upper GI bleeding. However, blood or coffee-groundlike contents may not be present if bleeding has ceased or if it arises beyond a closed pylorus.

24. The patient is admitted with complaints of chronic fatigue and shortness of breath. The nurse notices that the patient is tachycardic and has multiple bruises and petechiae on his body and arms. The patient also complains of frequent nosebleeds. The nurse should evaluate the patients ____________ a. complete blood count, including platelet count b. hemoglobin and hematocrit c. electrolyte values. d. blood culture results

ANS: A In addition to the general symptoms of anemia, unique disorders have their own classic clinical features. The patient with aplastic anemia may have bruising, nosebleeds, petechiae, and a decreased ability to fight infections. These effects result from thrombocytopenia and decreased WBC counts, which occur when the bone marrow fails to produce blood cells. The CBC with differential, which includes a platelet count, would allow for evaluation of all aspects of aplastic anemia. Hemoglobin and hematocrit help to assess for blood loss, but assessment of cause (e.g., low platelets) is more important. Electrolyte values and blood culture results are not relevant to this scenario.

36. The patient is admitted with pancreatitis and has severe ascites. In caring for this patient, the nurse should: a. monitor the patients blood pressure and evaluate for signs of dehydration. b. restrict intravenous and oral fluid intake because of fluid shifts. c. avoid the use of colloid IV solutions in managing the patients fluid status. d. only use crystalloid fluids to prevent IV lines from clotting.

ANS: A In patients with severe acute pancreatitis, some fluid collects in the retroperitoneal space and peritoneal cavity. Patients sequester up to one third of their plasma volume. Initially, most patients develop some degree of dehydration and, in severe cases, hypovolemic shock. Fluid replacement is a high priority in the treatment of acute pancreatitis. The IV solutions ordered for fluid resuscitation are usually colloids or lactated Ringers solution; however, fresh frozen plasma and albumin may also be used. IV fluid administration with crystalloids at 500 mL/hr is at times required to maintain hemodynamic status. Often, vigorous IV fluid replacement at 250 to 300mL/hr continues for the first 48 hours or a volume adequate to maintain a urine output of greater than or equal to 0.5 mL/kg body weight per hour. Fluid replacement helps to maintain perfusion to the pancreas and kidneys, reducing the potential for complications.

16. Infection by Helicobacter pylori bacteria is a major cause of: a. duodenal ulcers. b. Cushings ulcers. c. Curlings ulcers. d. stress ulcers.

ANS: A Infection with Helicobacter pylori bacteria is a major cause of duodenal ulcers. A stress ulcer is an acute form of peptic ulcer that often accompanies severe illness, systemic trauma, or neurological injury. Stress ulcers that develop as a result of burn injury are often called Curlings ulcers. Stress ulcers associated with severe head trauma or brain surgery are called Cushings ulcers.

27. The patient has yellow skin and low hemoglobin and hematocrit levels. The nurse should look for: a. an elevated bilirubin level. b. a low reticulocyte count. c. sickled cells. d. low white blood cell and platelet counts.

ANS: A Laboratory findings in anemia include a decreased RBC count and decreased hemoglobin and hematocrit values. The reticulocyte count is usually increased, indicating a compensatory increased RBC production with release of immature cells. This patients jaundice is indicative of hemolytic anemia. Patients with hemolytic anemia also have an increased bilirubin level. In sickle cell disease, a stained blood smear reveals sickled cells. In aplastic anemia, the reticulocyte, platelet, RBC, and WBC counts are decreased because the marrow fails to produce any cells.

45. The patients platelet count is 35,000/microliter. The provider orders the administration of 10 units of single-donor platelets. After transfusion, the nurse can expect the patients platelet count to be: a. between 85,000/microliter and 135,000/microliter. b. Between 50,000/microliter and 75,000/microliter. c. greater than 150,000/microliter. d. between 150,000/microliter and 185,000/microliter.

ANS: A Medical treatment of thrombocytopenia includes infusions of platelets. Patients who require multiple platelet transfusions should be evaluated for single-donor platelet products, which permit administration of 6 to 10 units of platelets with exposure to the antigens of only one person. For every unit of single-donor platelets, the platelet count should increase by 5000 to 10,000/microliter.

11. The process in which antibody and complement proteins attach to the target cell and enhance the phagocytes ability to engulf the target cell is known as: a. opsonization. b. phagocytosis. c. the lymphoreticular system. d. the portal circulation.

ANS: A Neutrophils are attracted to and migrate to areas of inflammation or bacterial invasion, where they ingest and kill invading microorganisms by phagocytosis. Once phagocytes have been attracted to an area by the release of mediators, a process called opsonization occurs, in which antibody and complement proteins attach to the target cell and enhance the phagocytes ability to engulf the target cell. When infectious organisms escape the local phagocytic responses, they may be engulfed and destroyed in a similar fashion by the tissue macrophages within the lymphoreticular organs. The portal circulation of the spleen and liver filters the majority of blood, where infectious organisms can be removed before infecting the tissues.

30. The patient is admitted for chemotherapy, but the nurse notices laboratory values indicating that the patient is immunosuppressed. The nurse should: a. place the patient in a single room with a HEPA filtration system. b. tell staff that hand washing is not recommended when working with this patient. c. start as many intravenous lines as possible to provide potential antibiotics. d. avoid the use of antimicrobial soaps when bathing and providing perineal care.

ANS: A Nursing interventions focus on protecting the patient from infection. Research studies support the use of high-efficiency particulate air (HEPA) filtration and laminar airflow in single-patient rooms for prevention of infection with airborne microorganisms. Nurses should diligently ensure adequate hygiene measures that include general bathing with antimicrobial soaps, oral care, and perineal care. Hand washing is paramount for staff, patients, and visitors. Nursing staff members play an important role in limiting breaks in skin integrity and ensuring sterile technique when procedures are unavoidable.

14. The ratio of helper T4 cell to suppressor T cells is normally 2:1. A lower than normal ratio may indicate acquired immunodeficiency syndrome (AIDS). This is because T4 cells: a. enhance humoral immune response. b. suppress the humoral response. c. suppress the cell-mediated response. d. are a feature of an autoimmune disease.

ANS: A Once contact is made with a specific antigen, the T lymphocyte differentiates into helper/inducer T cells, suppressor T cells, and cytotoxic killer cells. Although these T cells are microscopically identical, they can be distinguished by proteins present on the cell surface called cluster of differentiation (CD). Helper T cells (also known as T4 cells because they carry a CD4 marker) enhance the humoral immune response by stimulating B cells to differentiate and produce antibodies. Suppressor T cells downgrade and suppress the humoral and cell-mediated responses. The ratio of helper to suppressor T cells is normally 2:1, and an alteration in this ratio may cause disease. For example, a depressed ratio (a decrease of helper T cells in relation to suppressor T cells) is found in acquired immunodeficiency syndrome (AIDS), whereas a higher ratio (a decrease in suppressor T cells in relation to helper T cells) is a feature of an autoimmune disease.

39. Pain control is a nursing priority in patients with acute pancreatitis because pain: a. increases pancreatic secretions. b. is caused by decreased distention of the pancreatic capsule. c. decreases the patients metabolism. d. is caused by dilation of the biliary system.

ANS: A Pain control is a nursing priority in patients with acute pancreatitis not only because the disorder produces extreme patient discomfort but also because pain increases the patients metabolism and thus increases pancreatic secretions. The pain of pancreatitis is caused by edema and distention of the pancreatic capsule, obstruction of the biliary system, and peritoneal inflammation from pancreatic enzymes. Pain is often severe and unrelenting and is related to the degree of pancreatic inflammation.

37. The nurse is caring for a patient with severe pancreatitis and who is orally intubated and on mechanical ventilation. The patients calcium level this morning was 5.5 mg/dL. The nurse notifies the provider and: a. places the patient on seizure precautions. b. expects that the provider will come and remove the endotracheal tube. c. withhold any further calcium treatments. d. place an oral airway at the bedside.

ANS: A Patients with severe hypocalcemia (serum calcium level less than 6 mg/dL) should be placed on seizure precaution status, and respiratory support equipment should be available (e.g., oral airway, suction). In this case, the patient is already intubated so an oral airway is not needed. This value is critically low and replacement of calcium is expected.

28. The nurse is caring for a patient who is being treated for peptic ulcer disease. Suddenly, the patient yells that her abdomen is killing her. The nurse notes that the patients abdomen is rigid. The nurse should: a. call the provider immediately. b. give the patient pain medication. c. remove the NG tube. d. give the patient an antacid.

ANS: A Perforation of the gastric mucosa is the major GI complication of peptic ulcer disease. The most common signs of this complication are an abrupt onset of abdominal pain, followed rapidly by signs of peritonitis. Emergent surgery is indicated for treatment. Pain medication is not the treatment of choice in this situation. These patients almost always have nasogastric tubes placed for gastric decompression. Antacids and histamine blockers may or may not be indicated, depending on the cause of the upper GI bleeding. Mortality rates for patients with perforations range from 10% to 40%, depending on the age and condition of the patient at the time of surgery; therefore, it is essential that the provider be called immediately.

43. The nurse is caring for a critically ill patient with end stage liver disease. The nurse knows that the patient is at risk for hyperdynamic circulation and varices. Which of the following assessments would indicate a hyperdynamic status? a. cardiac output of 8 L/min. b. normal sinus rhythm on the cardiac monitor. c. blood pressure of 180/90 mm Hg. d. Stools that are guaiac positive.

ANS: A Portal hypertension causes two main clinical problems for the patient: hyperdynamic circulation and development of esophageal or gastric varices. Liver cell destruction causes shunting of blood and increased cardiac output. Vasodilation is also present (so vasodilators are not needed), which causes decreased perfusion to all body organs, even though the cardiac output is very high. This phenomenon is known as high-output failure or hyperdynamic circulation. Clinical signs and symptoms are those of heart failure and include jugular vein distention, pulmonary crackles, and decreased perfusion to all organs. Blood pressure decreases and dysrhythmias are common. Guaiac-positive stools may be an indication of gastrointestinal bleeding.

4. The nurse is caring for a patient who is receiving several cardiac medications designed to stimulate the sympathetic nervous system, vitamin B12, and an H2 blocker. The nurse should do which of the following? a. Assess for signs of peptic ulcer. b. Be watchful for increased saliva production. c. Evaluate for a decrease in potassium level. d. Give the patient medications to prevent anemia.

ANS: A Secretion of mucus by Brunners glands is inhibited by sympathetic stimulation, which leaves the duodenum unprotected from gastric juice. This inhibition is thought to be one of the reasons why this area of the GI tract is the site for more than 50% of peptic ulcers. Sympathetic stimulation produces a scant output of thick saliva. Vitamin B12 is critical for the formation of red blood cells (RBCs), and a deficiency in this vitamin causes anemia. However, the patient is receiving vitamin B12. The stomach also secretes fluid that is rich in sodium, potassium, and other electrolytes. Loss of these fluids via vomiting or gastric suction places the patient at risk for fluid and electrolyte imbalances and acid-base disturbances. However, nothing indicates that the patient is vomiting or has GI suction.

3. The nurse is caring for a patient who has a peptic ulcer. To treat the ulcer and prevent more ulcers from forming, the nurse should be prepared to administer: a. H2-histamine receptor blockers. b. gastrin. c. vagal stimulation. d. vitamin B12.

ANS: A Stimulants of hydrochloric acid secretion include vagal stimulation, gastrin, and the chemical properties of chyme. Histamine, which stimulates the release of gastrin, also stimulates the secretion of hydrochloric acid. Current drug therapies for ulcer disease use H2-histamine receptor blockers that block the effects of histamine and therefore hydrochloric acid stimulation. Vitamin B12 is critical for the formation of red blood cells (RBCs), and a deficiency in this vitamin causes anemia but has no effect on ulcer formation. Gastrin is a hormone that stimulates acid. The vagus nerve helps digestion; however, vagal stimulation is not a treatment for peptic ulcer disease.

5. The nurse examines the patients complete blood count with differential analysis and notices that the patients neutrophils are elevated, but the lymphocytes are lower than normal. The drop in lymphocyte count in the differential is most likely due to: a. the increase in neutrophil count. b. a new viral infection. c. a decreased number of bands. d. the lack of immature neutrophils.

ANS: A The differential count measures the percentage of each type of white blood cell (WBC) present in the venous blood sample, the total adding up to 100%. If the percentage of one type of WBC goes up (neutrophil count), the percentage of the remaining WBCs must go down as a result of the mathematical function of the differential. An elevation in the neutrophil count usually indicates a bacterial infection. Bands are immature neutrophils. The phrase a shift to the left refers to an increased number of bands, or band neutrophils, compared with mature neutrophils on a complete blood count (CBC) report. This finding generally indicates an acute bacterial infectious process (not viral) that draws on the WBC reserves in the bone marrow and causes less mature forms to be released.

32. The patient is admitted with neutropenia. The nurse should continually assess the patient for: a. signs of systemic infection. b. a drop in temperature from its normal set point. c. the absence of chills. d. bradycardia.

ANS: A There are no specific signs or symptoms of a low neutrophil count. Every body system is examined for physical findings of infection. Typical signs may not be evident. Pain such as sore throat or urethral discomfort may be indicative of an infected site. Areas of heavy bacterial colonization (e.g., oral mucosa, perineal area, and venipuncture and catheter sites) have the highest risk of infection; however, the most common clinical infections are sepsis and pneumonia. Additional signs or symptoms of systemic infection include a rise in temperature from its normal set point, chills, and accompanying tachycardia.

26. The patient is being treated for an H. pylori infection with proton pump inhibitor, metronidazole, and tetracycline but is not responding. The nurse expects that: a. bismuth will be added to the current triple therapy. b. a 6-day course of levofloxacin may be used. c. a second-line therapy is not usually effective. d. the proton pump inhibitor will be changed to a higher dose.

ANS: A Triple-agent therapy with a proton pump inhibitor and two antibiotics for 14 days is the recommended treatment for eradication of H. pylori. In case first-line therapy fails, a bismuth-based quadruple therapy has been proven to be effective in 76% of patients. This second-line therapy consists of a PPI, bismuth, metronidazole, and a tetracycline. A 10-day course of levofloxacin may also be administered as a second-line therapy for H. pylori infections.

5. After gastric bypass surgery, the patient is getting vitamin B12 via injection. The patient asks why he cant get the vitamin by mouth. The nurse explains that: a. the patient may not have enough intrinsic factor for normal absorption. b. the patient would have to drink water, and the small intestine cant handle water. c. the vitamin is absorbed in the upper part of the small bowel and would travel too fast. d. all vitamins are absorbed in the terminal ileum and it would take too long for B12.

ANS: A Vitamin B12 is absorbed in the terminal ileum in the presence of intrinsic factor produced in the stomach. Gastric bypass may lead to reduced levels of intrinsic factor. The small intestine also handles water, electrolyte, and vitamin absorption. Vitamins, with the exception of B12, and iron are absorbed in the upper part of the small bowel.

1. Numbers of white blood cells (WBCs) are increased in circumstances of: (Select all that apply.) a. inflammation. b. allergy. c. invasion by pathogenic organisms. d. malnutrition. e. immune diseases.

ANS: A, B, C WBCs play a key role in the defense against infectious organisms and foreign antigens. Numbers of WBCs are increased in circumstances of inflammation, tissue injury, allergy, or invasion with pathogenic organisms. Numbers of WBCs are diminished in conditions of malnutrition, advancing age, and immune diseases.

10. Accepted treatments for disseminated intravascular coagulation (DIC) may require: (Select all that apply.) a. platelet infusions. b. administration of fresh frozen plasma. c. cryoprecipitate. d. packed RBCs. e. heparin.

ANS: A, B, C, D Administration of platelets is the highest priority for transfusion because they provide the clotting factors needed to establish an initial platelet plug from any bleeding site. Fresh frozen plasma is administered for fibrinogen replacement. It contains all clotting factors and antithrombin III; however, factor VIII is often inactivated by the freezing process, thus necessitating administration of concentrated factor VIII in the form of cryoprecipitate. Transfusions of packed RBCs are given to replace cells lost in hemorrhage. Although heparins antithrombin activity prevents further clotting, it may increase the risk of bleeding and may cause further problems. Its use is controversial when it is administered to patients with DIC.

8. The nurse is caring for an elderly patient who is being admitted for anemia of unknown cause. The patient has been on multiple medications at home for various ailments. In assessing the patients medication list, the nurse notes medications that may alter hemostasis, including: (Select all that apply.) a. aminoglycosides. b. antiplatelet agents. c. cephalosporins. d. vasoconstrictors. e. sulfonamides.

ANS: A, B, C, E Medications that may alter hemostasis include aminoglycosides, anticoagulants, antiplatelet agents, cephalosporins, histamine blockers, nitrates, sulfonamides, sympathomimetics, and vasodilators.

6. When dealing with hematological malignancies, therapies that have significant management roles include: (Select all that apply.) a. chemotherapy. b. biotherapy. c. bone marrow transplantation. d. surgery. e. radiation.

ANS: A, B, C, E Therapy commonly includes chemotherapy and biotherapy. Bone marrow transplantation is used in selected cases. Surgery may be performed to establish a pathological diagnosis by excisional or incisional biopsy but has no other significant role in the management of hematological malignancies. Radiation may be used to treat lymphoma when the disease is limited to single nodes or node groups.

3. Inflammation is initiated by cellular injury and: (Select all that apply.) a. is necessary for tissue repair. b. inhibits the process called chemotaxis. c. is harmful when uncontrolled. d. is less efficient when complement proteins are present. e. occurs when mediators cause vasoconstriction.

ANS: A, C Inflammation is initiated by cellular injury, is necessary for tissue repair, and is harmful when uncontrolled. When cellular injury occurs, a process called chemotaxis generates both a mediator and a neutrophil response. Mediator substances (histamine, serotonin, kinins, lysosomal enzymes, prostaglandin, platelet-activating factor, clotting factors, and complement proteins) are released at the site of injury. These mediators cause vasodilation, increase blood flow, induce capillary permeability, and promote chemotaxis and phagocytosis by neutrophils. Inflammatory symptoms such as redness, heat, pain, and swelling are sequelae of these responses. Complement proteins enhance the antibody activity, phagocytosis, and inflammation.

9. In caring for the patient who has a coagulopathy, the nurse should: (Select all that apply.) a. assess fluids for occult blood. b. observe for oozing and bleeding and remove clots that form. c. limit invasive procedures. d. take temperatures rectally to increase accuracy. e. weigh dressings to assess blood loss.

ANS: A, C, E Additional nursing interventions specific to the patient with a coagulopathy include the following: weigh dressings to assess blood loss, assess fluids for occult blood, observe for oozing and bleeding from skin and mucous membranes, and leave clots undisturbed. Precautions such as limiting invasive procedures, including indwelling urinary catheters or rectal temperature measurement, are also important.

10. The process by which the body actively produces cells and mediators that result in the destruction of the antigen is called: a. passive immunity. b. active immunity. c. autoimmunity. d. recognition of self as nonself.

ANS: B Active immunity is a term used when the body actively produces cells and mediators that result in the destruction of the antigen. Passive immunity is that which is transferred from another person (e.g., maternal antibodies transferred to the newborn through the placenta). In autoimmunity, the body abnormally sees self as nonself and an immune response is activated against those tissues.

41. The nurse is assessing a patient being admitted for anemia. The nurse sees no overt signs of bleeding. The nurse understands that: a. all patients with bleeding disorders demonstrate active bleeding. b. many patients have bleeding that is not obvious. c. mucous membranes have a high threshold for bleeding. d. capillaries in mucous membranes lie deep in the membrane.

ANS: B Although many patients with bleeding disorders demonstrate active bleeding from body orifices, mucous membranes, and open lesions or intravenous line sites, equal numbers of patients have less obvious bleeding. The most susceptible sites for bleeding are existing openings in the epithelial surfaces. Mucous membranes have a low threshold for bleeding because the capillaries lie close to the membrane surface, and minor injury may damage and expose vessels. Substantial blood loss can occur in any coagulopathy, resulting in hypovolemic shock.

7. When examining the patients laboratory values, the nurse notices an elevation in the eosinophil count. The nurse realizes that eosinophils become elevated: a. with acute bacterial infections. b. in response to allergens and parasites. c. when the spleen is removed. d. in situations that do not require phagocytosis.

ANS: B An elevation in the neutrophil count (not eosinophil count) usually indicates a bacterial infection. Eosinophils are important in the defense against allergens and parasites and are thought to be involved in the detoxification of foreign proteins. Eosinophils are found largely in the tissues of the skin, lung, and gastrointestinal tract (not the spleen). Eosinophils respond to chemotactic mechanisms triggering them to participate in phagocytosis.

44. The nurse is caring for a patient with severe ascites due to chronic liver failure. The patient is lying supine in bed and complaining of difficulty breathing. The nurses first action should be to: a. measure abdominal girth to determine the amount of fluid accumulation. b. position the patient in a semi-Fowlers position. c. prepare the patient for emergent paracentesis. d. administer diuretics.

ANS: B Ascites is problematic because as more fluid is retained, it pushes up on the diaphragm, thereby impairing breathing. Positioning the patient in a semi-Fowlers position allows for free diaphragm movement. Frequent monitoring of abdominal girth alerts the nurse to fluid accumulation, but the most immediate and easiest action would be to place the patient in semi-Fowlers position. Paracentesis is sometimes done to relieve symptoms, but it is not usually done emergently. Diuretics must be administered cautiously because if the intravascular volume is depleted too quickly, acute renal failure may be induced.

25. The nurse is assessing a patient being admitted with complaints of fatigue and shortness of breath as well as abdominal tenderness. The nurse notes that the patient is jaundiced; the physical examination reports an enlarged liver The nurse suspects that the patient has a. aplastic anemia. b. hemolytic anemia. c. sickle cell anemia. d. anemia due to acute blood loss.

ANS: B Assessment of the patient with hemolytic anemia may reveal jaundice, abdominal pain, and enlargement of the spleen or liver. These findings result from the increased destruction of RBCs, their sequestration (abnormal distribution in the spleen and liver), and the accumulation of breakdown products. The patient with aplastic anemia may have bruising, nosebleeds, petechiae, and a decreased ability to fight infections. These effects result from thrombocytopenia and decreased WBC counts, which occur when the bone marrow fails to produce blood cells. Patients with sickle cell anemia may have joint swelling or pain, and delayed physical and sexual development. Decreased circulating volume is manifested by clinical findings reflective of low blood volume (e.g., low right atrial pressure) and the effects of gravity on the lack of volume (e.g., orthostasis).

27. The nurse is to assist the provider in performing bedside endoscopy on a patient. The prevent respiratory complications, the nurse places the patient: a. supine in Trendelenburg position. b. in a left lateral reverse Trendelenburg position. c. flat with the feet elevated. d. in a semi-fowlers position.

ANS: B Because endoscopy is performed at the patients bedside, the nurse assists with procedures and monitors for untoward effects. Maintenance of airway and breathing during endoscopic procedures is of major concern. Placement of the patient in a left lateral reverse Trendelenburg position helps to prevent respiratory complications.

7. The nurse is caring for a patient with liver disease. When assessing the patients laboratory values, the nurse should: a. disregard the level of conjugated bilirubin. b. assess the indirect serum bilirubin. c. call the provider immediately if the direct bilirubin is elevated. d. be aware that unconjugated bilirubin is harmless.

ANS: B Bilirubin enters the circulation bound to albumin and is unconjugated. This portion of the bilirubin is reflected in the indirect serum bilirubin level. Accumulation of unconjugated bilirubin is toxic to cells. In the liver, bilirubin is conjugated with glucuronic acid. Conjugated bilirubin is soluble and excreted in bile. Some conjugated bilirubin returns to the blood and is reflected in the direct serum bilirubin level.

1. Of the four major blood components, plasma: a. is made up of circulating ions. b. comprises about 55% of blood volume. c. is transported to the cells by serum proteins. d. comprises about 45% of blood volume.

ANS: B Blood has four major components: (1) a fluid component called plasma, (2) circulating solutes such as ions, (3) serum proteins, and (4) cells. Plasma comprises about 55% of blood volume and is the transportation medium for important serum proteins such as albumin, globulin, fibrinogen, prothrombin, and plasminogen. The hematopoietic cells comprise the remaining 45% of blood volume.

13. Cellular immunity is mediated by: a. B lymphocytes. b. T lymphocytes. c. immunoglobulins. d. suppressor B cells.

ANS: B Cellular immunity is mediated by the T lymphocyte. Humoral immunity is mediated by B lymphocytes and involves the formation of antibodies (immunoglobulins) in response to specific antigens that bind to their receptor sites. Suppressor T cells (not B cells) downgrade and suppress the humoral and cell-mediated responses.

46. The patient is admitted with anemia and active bleeding. The nurse suspects intravascular disseminated coagulation (DIC). Definitive diagnosis of DIC is made by evidence of: a. a decrease in fibrin degradation products. b. an increased D-dimer level. c. thrombocytopenia. d. low fibrinogen levels.

ANS: B Diagnosis of DIC is made based on recognition of pertinent risk factors, clinical symptoms, and the results of laboratory studies. Evidence of factor depletion in the form of thrombocytopenia and low fibrinogen levels is seen in the early phase; however, definitive diagnosis is made by evidence of excess fibrinolysis detectable by elevated fibrin degradation products, an increased D-dimer level, or a decreased antithrombin III level.

11. The nurse is caring for a patient with a heart rate of 140 beats/min. The provider orders parasympathetic medications to slow down the heart rate. With this type of medication, the nurse should a. evaluate the patient for symptoms of constipation. b. observe for diarrhea. c. assess mucus membranes for signs of dryness. d. expect decreased bowel sounds.

ANS: B Functions of the GI system are influenced by neural and hormonal factors. Parasympathetic cholinergic fibers, or drugs that mimic parasympathetic effects, stimulate GI secretion and motility.

22. The patient is admitted with the diagnosis of GI bleeding. The patients heart rate is 140 beats per minute, and his blood pressure is 84/44 mm Hg. These values may indicate: a. a need for hourly vital signs. b. approximately 25% loss of total blood volume. c. resolution of hypovolemic shock. d. increased blood flow to the skin, lungs, and liver.

ANS: B Hypotension is an advanced sign of shock. As a rule, a systolic pressure of less than 100 mm Hg, a postural decrease in blood pressure of greater than 10 mm Hg, or a heart rate of greater than 120 beats/min reflects a blood loss of at least 1000 mL25% of the total blood volume. Vital signs should be monitored at least every 15 minutes. As blood loss exceeds 1000 mL, the shock syndrome progresses, causing decreased blood flow to the skin, lungs, liver, and kidneys.

9. Lymphocytes are made up of B cells and T cells. B cells: a. mature in lymphoid tissue. b. mediate humoral immunity. c. migrate to the thymus gland. d. destroy virus-infected cells

ANS: B Lymphocytes are responsible for specific immune responses and participate in two types of immunity: humoral immunity, which is mediated by B lymphocytes; and cellular immunity, which is mediated by T lymphocytes. B lymphocytes, or B cells, originate in the bone marrow and are also thought to mature there. B cells perform in antibody production. T cells are produced in the bone marrow, but they migrate to the thymus for maturation; then, most of them travel and reside in lymphoid tissues throughout the body. They live longer than B cells and participate in long-term immunity. The natural killer cell is a third type of lymphocyte, thought to be a differentiated form of the T lymphocyte. It is responsible for surveillance and destruction of virus-infected and malignant cells.

29. The nurse is evaluating the patients laboratory values and notes an IgG level of 240 mg/dL. The nurse realizes that this patient is a candidate for: a. no change in therapy because the level is normal. b. an immunoglobulin infusion. c. gene replacement therapy. d. increased doses of immunosuppressive medications.

ANS: B Medical therapy is directed at reversing the cause of the immune dysfunction and preventing infectious complications. In primary immunodeficiencies, B-cell and T-cell defects are treated with specific replacement therapy or bone marrow transplantation. IgG blood levels of less than 300 mg/dL warrant immunoglobulin infusion. Gene replacement therapy may soon be a realistic curative treatment option for some disorders. In secondary immunodeficiencies, the underlying causative condition is treated. For example, malnutrition is corrected, or doses of immunosuppressive medications are adjusted. For this patient, immunosuppressive medications should be discontinued or doses lowered.

8. Although monocytes may circulate for only 36 hours, they can survive for months or even years as tissue macrophages. Monocytes found in the liver are called: a. alveolar macrophages. b. Kupffers cells. c. histiocytes. d. monokines.

ANS: B Monocytes are the largest of the leukocytes and constitute only 3% to 7% of the WBC differential. Once they migrate from the bloodstream into the tissues, monocytes mature into tissue macrophages, which are powerful phagocytes. In the lung, these tissue macrophages are known as alveolar macrophages; in the liver, they are Kupffers cells; in connective tissue, they are histiocytes. When activated by antigens, macrophages secrete substances called monokines that act as chemical communicators between the cells involved in the immune response.

42. The patient is diagnosed with hepatitis. In caring for this patient, the nurse should: a. administer antiinflammatory medications. b. provide rest, nutrition, and antiemetics if needed. c. provide antianxiety medications freely to decrease agitation. d. instruct the patient to take over-the-counter antiinflammatory medications at home.

ANS: B No definitive treatment for acute inflammation of the liver exists. Goals for medical and nursing care include providing rest and assisting the patient in obtaining optimal nutrition. Medications to help the patient rest or to decrease agitation must be closely monitored because most of these drugs require clearance by the liver, which is impaired during the acute phase. Nursing measures such as administration of antiemetics may be helpful. Small, frequent, palatable meals and supplements should be offered. Patients must be instructed not to take any over-the-counter drugs that can cause liver damage. Alcohol should be avoided.

35. The patient is admitted with acute pancreatitis and is demonstrating severe abdominal pain, vomiting, and ascites. Using the Ranson classification criteria, the nurse determines that this patient: a. has a 99% chance of survival. b. has a 15% chance of dying. c. has a 40% chance of dying. d. has no chance of survival.

ANS: B Patients with acute pancreatitis can develop mild or fulminant disease. As a consequence, research has addressed criteria for predicting the prognosis of patients with acute pancreatitis. The early classification criteria were developed by Ranson, who suggested that the number of signs present within the first 48 hours of admission directly relates to the patients chance of significant morbidity and mortality. In Ransons research, patients with fewer than three signs had a 1% mortality rate, those with three or four signs had a 15% mortality rate, those with five or six signs had a 40% mortality rate, and those with seven or more signs had a 100% mortality rate.

2. The nurse is assessing the patient and notices that his oral cavity is only slightly moist and contains a scant amount of thick saliva even though the patients fluid intake has been sufficient. The nurses realizes that the condition of the patients mouth is probably caused by: a. thoughts of food. b. sympathetic nerve stimulation. c. overstimulation of the sublingual glands. d. parasympathetic nerve stimulation.

ANS: B Saliva is the major secretion of the oropharynx and is produced by three pairs of salivary glands: submaxillary, sublingual, and parotid. Stimuli such as sight, smell, thoughts, and taste of food stimulate salivary gland secretion. Parasympathetic stimulation promotes a copious secretion of watery saliva. Conversely, sympathetic stimulation produces a scant output of thick saliva. The normal daily secretion of saliva is 1200 mL.

29. The patient is admitted for GI bleeding, but the source is not known. Before ordering endoscopy, the provider orders Sandostatin (octreotide) to be given intravenously. The purpose of this medication is to: a. increase portal pressure and improve liver function. b. decrease splanchnic blood flow and portal pressure. c. vasodilate the splanchnic arteriolar bed. d. increase blood flow in the livers collateral circulation.

ANS: B Somatostatin or octreotide is commonly ordered to slow or stop bleeding. Early administration provides for stabilization before endoscopy. These drugs decrease splanchnic blood flow and reduce portal pressure, and have minimal adverse effects. Vasopressin is used to lower (not increase) portal pressure by vasoconstriction of the splanchnic arteriolar bed. Ultimately, it decreases pressure and flow in liver collateral circulation channels to decrease bleeding. However, vasopressin is not a first-line therapy because of its adverse effects.

17. In vivo, the primary activator of the coagulation cascade occurs via the: a. intrinsic pathway. b. extrinsic pathway. c. common pathway. d. either intrinsic or extrinsic pathway.

ANS: B The classic theory of coagulation is viewed as occurring through two distinct pathways, intrinsic and extrinsic, which share a common final pathway, formation of insoluble fibrin. It is now known that the classic cascade theory of coagulation illustrates what occurs in vitro. In vivo, the primary activator of the coagulation cascade occurs via the extrinsic pathway. The intrinsic pathway serves to amplify the coagulation cascade.

1. The patient is admitted with constipation. In anticipation of treatment, the nurse prepares to: a. give medications that will suppress the autonomic nervous system. b. provide therapies that will innervate the autonomic nervous system. c. teach the patient that the submucosa is the innermost part of the gut wall. d. give medications intravenously since the submucosa has no blood vessels.

ANS: B The second layer of the gut wall, the submucosa, is composed of connective tissue, blood vessels, and nerve fibers. Beneath the mucosa, submucosa, and muscular layer are various nerve plexuses that are innervated by the autonomic nervous system. Disturbances in these neurons in a given segment of the GI tract cause a lack of motility. Therapies innervating the autonomic nervous system are thus appropriate. The muscular layer is the major layer of the wall. The serosa is the outermost layer.

23. A reduction in the number of circulating RBCs or hemoglobin, which leads to inadequate oxygenation of tissues, is known as: a. polycythemia. b. anemia. c. iron deficiency. d. an increase in hemoglobin.

ANS: B The term anemia refers to a reduction in the number of circulating RBCs or hemoglobin, which leads to inadequate oxygenation of tissues. Polycythemia, a disorder in which the number of circulating RBCs is increased, is seen less often but can affect hypoxic patients (e.g., those with chronic obstructive pulmonary disease). Iron deficiency anemia is the most common type of anemia.

43. The patient is admitted with anemia caused by blood loss and thrombocytopenia. His platelet count is 22,000/microliter. The patient is scheduled for a transfusion of RBCs and a transfusion of platelets. The nurse should: a. give the RBCs before the platelets. b. give the platelets before the RBCs. c. use local therapies to stop the bleeding. d. give the platelets and RBCs at the same time.

ANS: B When the patients blood does not clot because of thrombocytopenia, administration of RBCs before platelets will result in RBC loss from disrupted vascular structures. Platelets should be given first. Local therapies to stop bleeding are used when systemic anticoagulation is necessary for treatment of another health condition (e.g., myocardial infarction, ischemic stroke, or pulmonary embolism). Local procoagulants act by direct tissue contact and initiation of a surface clot.

5. Causes of anemia include: (Select all that apply.) a. hypoxic states. b. blood loss. c. impaired production of red blood cells. d. increased destruction of red blood cells. e. chronic obstructive pulmonary disease.

ANS: B, C, D Causes of anemia include (1) blood loss (acute or chronic), (2) impaired production of RBCs, (3) increased RBC destruction, or (4) a combination of these. Polycythemia, a disorder in which the number of circulating RBCs is increased, is seen less often but can affect hypoxic patients (e.g., those with chronic obstructive pulmonary disease).

2. Autoimmunity can result from: (Select all that apply.) a. recognition of tissue as self. b. injury to tissues. c. infection. d. malignancy. e. unknown causes.

ANS: B, C, D, E In autoimmunity, the body abnormally sees self as nonself and an immune response is activated against those tissues. Autoimmunity can result from injury to tissues, infection, or malignancy, although in many cases the cause is not known.

7. Secondary immunodeficiency involves the loss of a previously functional immune defense system that can be caused by: (Select all that apply.) a. a single gene defect. b. AIDS. c. aging. d. nutritional deficiencies. e. immunosuppressive therapies

ANS: B, C, D, E In primary immunodeficiency, the dysfunction exists in the immune system. Most primary immunodeficiencies are congenital disorders related to a single gene defect. Secondary or acquired immunodeficiency is the result of factors outside the immune system, is not related to a genetic defect, and involves the loss of a previously functional immune defense system. AIDS is the most notable secondary immunodeficiency disorder caused by an infection. Aging, dietary insufficiencies, malignancies, stressors (emotional, physical), immunosuppressive therapies, and certain diseases such as diabetes or sickle cell disease are additional examples of conditions that may be associated with acquired immunodeficiencies.

4. Exudate formation at the inflammatory site functions to: (Select all that apply.) a. opsonize bacteria. b. dilute toxins. c. deliver proteins. d. attach to the target cell. e. carry away toxins.

ANS: B, C, E Exudate formation at the inflammatory site has three functions: dilute toxins produced, deliver proteins and leukocytes to the site, and carry away toxins and debris. Once phagocytes have been attracted to an area by the release of mediators, a process called opsonization occurs, in which antibody and complement proteins attach to the target cell and enhance the phagocytes ability to engulf the target cell.

44. The patient has a platelet count of 9,000/microliter. The nurse realizes that: a. this is a normal platelet level. b. spontaneous bleeding may occur. c. the patient is at great risk for fatal hemorrhage. d. this level is considered slightly low.

ANS: C A quantitative deficiency of platelets is termed thrombocytopenia. By definition, this is a platelet count of less than 150,000/microliter. A value of 30,000/microliter is considered critically low, and spontaneous bleeding may occur. Fatal hemorrhage is a great risk when the count is less than 10,000/microliter.

21. The nurse is caring for a patient with active GI bleeding. Estimated blood loss is 1,000 mL. Which of the following assessments would the nurse expect to find with this amount of blood loss? a. all vital signs would expect to be normal with this amount of blood loss. b. oral temperature of 103. c. heart rate 125 beats per minute. d. systolic blood pressure of 120 mm Hg.

ANS: C As blood loss exceeds 1000 mL, the shock syndrome progresses, causing decreased blood flow to the skin, lungs, liver, and kidneys. Hypotension is an advanced sign of shock. As a rule, a systolic pressure of less than 100 mm Hg, a postural decrease in blood pressure of greater than 10 mm Hg, or a heart rate of greater than 120 beats/min reflects a blood loss of at least 1000 mL25% of the total blood volume.

6. The nurse is assessing the patient admitted with pancreatitis. In doing so, the nurse: a. palpates the pancreas for size and shape. b. emphasizes to the patient that pancreatic inflammation does not spread. c. assesses symptoms that could indicate involvement of the stomach. d. explains to the patient that back pain is not a sign of pancreatitis.

ANS: C Because the pancreas lies retroperitoneally, it cannot be palpated; this characteristic explains why diseases of the pancreas can cause pain that radiates to the back. In addition, a well-developed pancreatic capsule does not exist, and this may explain why inflammatory processes of the pancreas can spread freely and affect the surrounding organs (stomach and duodenum).

37. The patient is admitted with multiple myeloma. The nurse assesses the patient and is aware that the symptom most unique to this disease is: a. fever. b. night sweats. c. bone pain. d. lymph node enlargement.

ANS: C Bone pain is common in multiple myeloma, whereas lymph node enlargement is more representative of lymphoma. Fever is particularly difficult to interpret because it may be a manifestation of the disease process or may accompany an infectious complication. General signs and symptoms such as fatigue, malaise, myalgias, activity intolerance, and night sweats are nonspecific indicators of immune disease.

14. When assessing the patients bowel sounds, the nurse: a. listens to the abdomen after palpation is done. b. places the patient in a relaxed prone position. c. listens to bowel sounds before palpation. d. places a pillow over the patients knees.

ANS: C Bowel sounds are high-pitched, gurgling sounds caused by air and fluid as they move through the GI tract. Bowel sounds are auscultated before palpation. However, auscultation after palpation can be done if no bowel sounds were heard to stimulate peristalsis. Optimal positioning of the patient to relax the abdomen is performed before auscultation is begun. A supine position with the patients arms at the sides or folded at the chest is usually recommended. Placing a pillow under the patients knees also helps to relax the abdominal wall.

2. Erythrocytes (RBCs) are flexible biconcave disks without nuclei whose primary component is an oxygen-carrying molecule called: a. erythropoietin. b. a reticulocyte. c. hemoglobin. d. 2,3-DPG

ANS: C Erythrocytes (RBCs) are flexible biconcave disks without nuclei whose primary component is an oxygen-carrying molecule called hemoglobin. RBCs are generated from precursor stem cells under the influence of a growth factor called erythropoietin. Erythropoietin is secreted by the kidney in response to a perceived decrease in perfusion or tissue hypoxia. Reticulocytes are immature RBCs that may be released when there is a demand for RBCs that exceeds the number of available mature cells. The oxygen affinity for hemoglobin is modulated primarily by the concentration of 2,3-diphosphoglycerate (2,3-DPG) and depends on the blood pH and body temperature.

28. Critical to caring for the immunocompromised patient is the understanding that: a. the immunocompromised patient has normal white blood cell (WBC) physiology. b. the immunosuppression involves a single element or process. c. infection is the leading cause of death in these patients. d. immune incompetence is symptomatic even without pathogen exposure.

ANS: C Infection is the leading cause of death in the immunocompromised patient. The immunocompromised patient is one with defined quantitative or qualitative defects in WBCs or immune physiology. The defect may be congenital or acquired, and may involve a single element or multiple processes. Regardless of the cause, the physiological outcome is immune incompetence, with lack of normal inflammatory, phagocytic, antibody, or cytokine responses. Immune incompetence is often asymptomatic until pathogenic organisms invade the body and create infection.

36. The patient is diagnosed with lymphoma, but has a normal white blood cell (WBC) count. The nurse understands that this patient a. has normal WBC function since the WBC is normal. b. will have increased bruising and bleeding. c. is at risk for infection. d. is at risk for an allergic reaction.

ANS: C Malignant diseases involving WBCs are termed leukemia, lymphoma, and plasma cell neoplasm (multiple myeloma). Regardless of the specific neoplastic disorder, a deficiency of functional WBCs is a common problem. Despite normal serum cell counts, WBC activity is always impaired, and infection is the most common complication of all these disorders.

24. The patient has a hemoglobin of 8.5 g/dL and hematocrit of 27%. The nurse administers 2 units of packed red blood cells to the patient and repeats the labwork a few hours later. The new hemoglobin and hematocrit would be expected to be: a. hemoglobin 7.5 g/dL and hematocrit 25%. b. hemoglobin 9.5 g/dL and hematocrit 29%. c. hemoglobin 10.5 g/dL and hematocrit 32%. d. hemoglobin 12.5 g/dL and hematocrit 36%.

ANS: C One unit of packed RBCs can be expected to increase the Hgb value by 1 g/dL and the Hct value by 2% to 3%, but this effect is influenced by the patients intravascular volume status and whether the patient is actively bleeding.

39. The patient comes to the hospital complaining of headache, fever, and sore throat for the past 2 weeks and is concerned that he might have acquired immune deficiency syndrome (AIDS). The patients blood work shows the presence of HIV antibodies. The nurse should explain that: a. HIV symptoms will continue throughout the patients life. b. HIV is an acute disease with a short prognosis. c. AIDS is considered a chronic disease. d. very few people with HIV develop AIDS.

ANS: C Seroconversion is manifested by the presence of HIV antibodies and usually occurs 2 to 4 weeks after the initial infection. Symptoms associated with seroconversion include flu-like symptoms such as fever, sore throat, headache, malaise, nausea and usually last 1 to 2 weeks. The earlier stages of HIV infection may last as long as 10 years and may produce few or no symptoms, although viral particles are actively replacing normal cells. AIDS is the final stage of HIV infection. It is estimated that 99% of untreated HIV-infected individuals will progress to AIDS. Treatment regimens with combined antiviral drug regimens are controlling the progression to AID. AIDS is now considered, for many infected individuals, a chronic disease.

31. The nurse is caring for a patient with a Minnesota tube in place when the patient suddenly shows signs of severe pain and respiratory distress. The nurse should: a. cut the gastric balloon lumen and watch for improved symptoms. b. cut the esophageal lumen and watch for improvement. c. cut all three lumina and remove the tube. d. call the provider with an update of the patients condition.

ANS: C Spontaneous rupture of the gastric balloon, upward migration of the tube, and occlusion of the airway are other possible complications that need to be assessed. Esophageal rupture may occur and is characterized by the abrupt onset of severe pain. In the event of either of these two life-threatening emergencies, all three lumina are cut and the entire tube is removed. For this reason, scissors are kept at the patients bedside at all times. Endotracheal intubation is strongly recommended to protect the airway.

41. The patient is admitted with acute pancreatitis and is later diagnosed as having a pseudocyst. The nurse realizes that: a. surgery for pseudocysts must be done immediately. b. a cholecystectomy is usually done when pseudocysts are found. c. pseudocysts may resolve spontaneously, so surgery may be delayed. d. pseudocysts require pancreatic resection, removing the entire pancreas.

ANS: C Surgery may also be indicated for pseudocysts; however, surgery is usually delayed because some pseudocysts resolve spontaneously. Surgery may also be performed when gallstones are thought to be the cause of the acute pancreatitis. A cholecystectomy is usually performed. Pancreatic resection for acute necrotizing pancreatitis may be performed to prevent systemic complications of the disease process. In this procedure, dead or infected pancreatic tissue is surgically removed while most of the gland is preserved. The indication for surgical intervention is clinical deterioration of the patient despite the use of conventional treatments, or the presence of peritonitis.

20. A patient with a history of pulmonary embolism is being worked up for a potential coagulopathy that increases the risk for clotting. The nurse understands that the provider may order a test for a. factor VII deficiency. b. factor X deficiency. c. protein C deficiency. d. factor IX deficiency.

ANS: C The coagulation factors are plasma proteins that circulate as inactive enzymes, and most are synthesized in the liver. Vitamin K is necessary for synthesis of factors II, VII, IX, X, necessary for clotting to occur and for anticoagulation factors protein C and protein S. A deficiency of anticoagulation factors could lead to increased clot formation and problems such as stroke and pulmonary emboli.

33. The patients white blood cell (WBC) level is 4000 cells/microliter. The differential shows a neutrophil count of 65% and a band level of 5%. The absolute neutrophil count is a. 4000 cells/microliter. b. 3000 cells/microliter. c. 2800 cells/microliter. d. 2600 cells/microliter.

ANS: C The differential demonstrates the percentage of each type of WBC circulating in the bloodstream. The absolute neutrophil count is calculated by multiplying the total WBC count (without a decimal point) by the percentages (with decimal points) of polymorphonuclear leukocytes (polys; also called segs or neutrophils) and bands (immature neutrophils). WBC (segs + bands) This gives an actual number that is translated into the categories of mild, moderate, or severe neutropenia.

22. The patient is being seen for complaints of general malaise, fatigue, and shortness of breath. The patient states that he has felt this way since he had a cold 6 weeks earlier. The nurse should expect the provider to order: a. lymph node biopsy. b. differential blood count only. c. complete blood count (CBC) with differential. d. Bone marrow biopsy.

ANS: C The first screening diagnostic tests performed to detect hematological or immunological dysfunction are a Complete Blood Count (CBC) with differential and a coagulation profile. The CBC evaluates the cellular components of blood. The CBC reports the total RBC count and RBC indices, hematocrit, hemoglobin, WBC count and differential, platelet count, and cell morphologies. The most invasive microscopic examinations of the bone marrow or lymph nodes are reserved for circumstances when laboratory tests are inconclusive or when an abnormality in cellular maturation is suspected (e.g., aplastic anemia, leukemia, or lymphoma). A differential laboratory test is not done without the CBC first. A bone marrow biopsy is not warranted; it would only be done if preliminary studies indicated a hematological problem.

23. The patient is being admitted with GI bleeding. Blood work includes serial hemoglobin and hematocrit levels. The nurse understands that: a. the hematocrit is a direct reflection of quick blood loss. b. as extravascular fluid enters the vascular space the hematocrit increases. c. the hematocrit value does not change substantially during the first few hours. d. the administration of intravenous fluids has no effect on hematocrit levels.

ANS: C The hematocrit (Hct) value does not change substantially during the first few hours after an acute bleeding episode. During this time, the severity of the bleeding must not be underestimated. Only when extravascular fluid enters the vascular space to restore volume does the Hct value decrease. This effect is further complicated by fluids and blood products that are administered during the resuscitation period.

8. The liver plays a major role in homeostasis by: a. synthesizing factor I but not factor II. b. synthesizing clotting factors without the need for vitamin K. c. removing active clotting factors from the circulation. d. synthesizing factor II but not factor I.

ANS: C The liver synthesizes fibrinogen (factor I); prothrombin (factor II); and factors VII, IX, and X. Vitamin K is essential for the synthesis of other clotting factors. The liver also removes active clotting factors from the circulation and therefore prevents clotting in the macrovasculature and microvasculature.

33. The patient is admitted with severe abdominal pain due to pancreatitis. The patient asks the nurse, What causes this? Why does it hurt so much? The nurse should answer: a. Pancreatitis is extremely rare and no one knows why it causes pain. b. Pancreatitis is caused by diabetes; you should be checked. c. Injury to certain cells in the pancreas causes it to digest (eat) itself, causing pain. d. The pain is localized to the pancreas. Fortunately, it will not affect anything else.

ANS: C The most common theory regarding the development of pancreatitis is that an injury or disruption of pancreatic acinar cells allows leakage of the pancreatic enzymes into pancreatic tissue. The leaked enzymes (trypsin, chymotrypsin, and elastase) become activated in the tissue and start the process of autodigestion. Pancreatitis is one of the most common pancreatic diseases; it is not caused by diabetes. The activated enzymes break down tissue and cell membranes, causing edema, vascular damage, hemorrhage, necrosis, and fibrosis. These now toxic enzymes and inflammatory mediators are released into the bloodstream and cause injury to vessel and organ systems, such as the hepatic and renal systems.

13. The nurse is assessing a patient who is admitted with abdominal pain. To detect abdominal masses, the nurse: a. observes for skin pigmentation and discolorations. b. looks for pulsations originating from the vena cava. c. has the patient take a deep breath. d. watches for signs of pain and distention.

ANS: C The nurse looks for any obvious abdominal masses, which are best seen on deep inspiration. Pulsations, if they are seen, usually originate from the aorta. The nurse observes for pigmentation of skin (jaundice), lesions, discolorations, old or new scars, and vascular and hair patterns that may indicate general nutrition and hydration status, not masses. Abdominal distention, particularly in the presence of pain, should always be investigated because it usually indicates trapped air or fluid within the abdominal cavity.

6. The nurse is caring for a patient receiving chemotherapeutic agents, and notices that the patients neutrophils count is low. The nurse realizes that: a. the patient has a bacterial infection. b. a shift to the left is occurring. c. chemotherapeutic agents alter the ability to fight infection. d. neutrophils have a long life span and multiply slowly.

ANS: C The survival time of neutrophils is short. When serious infection is present, neutrophils may live only hours as the neutrophils phagocytize infectious organisms. Because of this short life span, drugs that affect rapidly multiplying cells (e.g., chemotherapeutic agents) quickly decrease the neutrophil count and alter the patients ability to fight infection. An elevation in the neutrophil count usually indicates a bacterial infection. Bands are immature neutrophils. The phrase a shift to the left refers to an increased number of bands, or band neutrophils, compared with mature neutrophils on a complete blood count (CBC) report.

4. The nurse is caring for a patient who has undergone a splenectomy, and notices that the patients platelet count has increased. The nurse realizes that the increase is due to: a. platelet response to infection. b. stimulation secondary to erythropoietin. c. the patients inability to store platelets. d. the platelets 120-day life cycle.

ANS: C Two thirds of the platelets circulate in the blood. The spleen stores the remaining third and may become enlarged if excess or rapid platelet removal occurs. In patients who have had a splenectomy, 100% of the platelets remain in circulation. Platelets are the first responders in the clotting response (not infection), and they form a platelet plug that temporarily repairs an injured vessel. RBCs (not platelets) are generated from precursor stem cells under the influence of a growth factor called erythropoietin. Platelets have a life span of 8 to 12 days, but they may be used more rapidly if there are many vascular injuries or clotting stimuli. Maturation of RBCs takes 4 to 5 days, and their life span is about 120 days.

18. Common to both the intrinsic and the extrinsic pathway is: a. factor XII b. factor VII. c. factor X. d. subendothelial collagen.

ANS: C When blood is exposed to subendothelial collagen or is injured, factor XII is activated, which initiates coagulation via the intrinsic pathway. In the extrinsic pathway, tissue injury precipitates release of a substance known as tissue factor, which activates factor VII. Factor VII is key in initiating blood coagulation, and the two pathways intersect at the activation of factor X. Both coagulation pathways illustrate a final common pathway of clot formation, retraction, and fibrinolysis.

16. With minor vessel injury, primary hemostasis is achieved: a. after several minutes. b. with fibrin to solidify the platelet plug. c. usually within seconds. d. as a permanent solution.

ANS: C With minor vessel injury, primary hemostasis is temporarily achieved with platelet plugs, usually within seconds. During secondary hemostasis, the platelet plug is solidified with fibrin, an end product of the coagulation pathway, and requires several minutes to reach completion.

17. The nurse is caring for a patient with the diagnosis of sepsis. The patient is on a ventilator in the critical care unit, and is receiving a proton pump inhibitors (PPI) to reduce the risk for a stress ulcer. In this scenario, a stress ulcer is likely secondary to: a. infection with Helicobacter pylori bacteria. b. decreased acetylcholine production. c. a decreased number of parietal cells. d. ischemia associated with sepsis.

ANS: D A stress ulcer is an acute form of peptic ulcer that often accompanies severe illness, systemic trauma, or neurological injury. Ischemia is the prior etiology associated with stress ulcer formation. Ischemic ulcers develop within hours of an event such as hemorrhage, multisystem trauma, severe burns, heart failure, or sepsis. The shock, anoxia, and sympathetic responses decrease mucosal blood flow leading to ischemia. The secretion of acid is important in the pathogenesis of ulcer disease. Acetylcholine (a neurotransmitter), gastrin (a hormone), and secretin (a hormone) stimulate the chief cells, which stimulate acid secretion. Parietal cell mass in people with peptic ulcer disease is 1.5 to 2 times greater than in persons without disease. Infection with Helicobacter pylori bacteria is a major cause of duodenal ulcers.

40. The nurse is caring for a patient with acute pancreatitis. To provide adequate pain control, the nurse: a. should suggest that the patient receive epidural analgesia. b. provides oral pain medication on an as needed (PRN) basis. c. removes any nasogastric tubes. d. administers pain medication on a routine schedule.

ANS: D Analgesic administration is a nursing priority. Adequate pain control requires the use of IV opiates, often in the form of a patient-controlled analgesia (PCA) pump. In the case in which a PCA pump is not ordered, pain medications are administered on a routine schedule, rather than as needed, to prevent uncontrollable abdominal pain. Insertion of a nasogastric tube connected to low intermittent suction may help ease pain.

15. When assessing bowel sounds, the nurse: a. uses the bell part of the stethoscope. b. listens at least 15 minutes. c. expects bowel sounds to be regular in rhythm. d. listens for 5 minutes before noting absent bowel sounds.

ANS: D Bowel sounds are best heard with the diaphragm of the stethoscope and are systematically assessed in all four quadrants of the abdomen. The frequency and character of the sounds are noted. The frequency of bowel sounds has been estimated at 5 to 35 per minute, and the sounds are usually irregular. The amount of time for bowel sounds to be auscultated ranges from 30 seconds to up to 7 minutes. It is recommended that bowel sounds be assessed a minimum of 5 minutes before an assessment of absence of bowel sounds can be made.

15. The mechanism responsible for the rejection of transplanted tissue and the destruction of single malignant cells is known as immunosurveillance. The nurse understands that this is a function of: a. helper T lymphocytes. b. suppressor T lymphocytes. c. T4 lymphocytes. d. killer T lymphocytes.

ANS: D Cytotoxic or killer T cells (CD8 marker) participate directly in the destruction of antigens by binding to and altering the intracellular environment, which ultimately destroys the cell. Killer cells also release cytotoxic substances into the antigen cell that cause cell lysis. Killer T cells additionally provide the body with immunosurveillance capabilities that monitor for abnormal cells or tissue. This mechanism is responsible for the rejection of transplanted tissue and the destruction of single malignant cells. Helper T cells (also known as T4 cells because they carry a CD4 marker) enhance the humoral immune response by stimulating B cells to differentiate and produce antibodies. Suppressor T cells downgrade and suppress the humoral and cell-mediated responses.

30. The nurse is caring for a patient who has a Sengstaken-Blakemore tube in place. In caring for this patient, the nurse must: a. maintain as little traction as possible. b. apply external traction using side rail of the bed. c. deflate the gastric balloon before the esophageal balloon. d. deflate the esophageal balloon before the gastric balloon.

ANS: D It is crucial that the esophageal balloon be deflated before the gastric balloon is deflated, or else the entire tube will be displaced upward and occlude the airway. Correct positioning and traction are maintained by using an external traction source or a nasal cuff around the tube at the mouth or nose. External traction can be attached to a helmet or to the foot of the bed (not the side rail). Proper amounts of traction are essential because too little traction lets the balloon fall away from the gastric wall, resulting in insufficient pressure being placed on the bleeding vessels. Too much traction causes discomfort, gastric ulceration, or vomiting.

25. The patient is ordered to have large volume gastric lavage. The nurse will most likely need to: a. insert a small-bore nasogastric tube. b. use 2 to 4 liters of room temperature normal saline. c. remove the nasogastric tube before lavage is started. d. insert a large-bore nasogastric tube.

ANS: D Large-volume gastric lavage before endoscopy for acute upper gastrointestinal bleeding is safe and provides better visualization of the gastric fundus. A large-bore nasogastric tube is inserted and is connected to suction. If lavage is ordered, 1 to 2 liters of room temperature normal saline is instilled via nasogastric tube and is then gently removed by intermittent suction or gravity until the secretions are clear. After lavage, the nasogastric tube may be left in or removed.

38. Cases of primary immunodeficiency are usually related to: a. aging. b. nutritional deficiencies. c. malignancies. d. a single gene defect.

ANS: D Most primary immunodeficiencies are congenital disorders related to a single gene defect. Secondary or acquired immunodeficiency is the result of factors outside the immune system, is not related to a genetic defect, and involves the loss of a previously functional immune defense system. Aging, dietary insufficiencies, malignancies, stressors (emotional, physical), immunosuppressive therapies, and certain diseases such as diabetes or sickle cell disease are examples of conditions that may be associated with acquired immunodeficiencies.

38. Trends in nutritional management of the patient with pancreatitis are changing. As a result, the nurse understands that: a. patients with pancreatitis must eat nothing in order to prevent release of secretin. b. nasogastric suction is essential in treating patients with pancreatitis. c. a nasogastric tube is no longer required to treat patients with ileus. d. immediate oral feeding in patients with mild pancreatitis may help recovery.

ANS: D Nasogastric suction and nothing by mouth status were classic treatments for patients with acute pancreatitis to suppress pancreatic exocrine secretion by preventing the release of secretin from the duodenum. Normally, secretin, which stimulates pancreatic secretion production, is stimulated when acid is in the duodenum; therefore, nasogastric suction has been a primary treatment. Nausea, vomiting, and abdominal pain may also be decreased with nasogastric suctioning. A nasogastric tube is also necessary in patients with ileus, severe gastric distention, and a decreased level of consciousness to prevent complications resulting from pulmonary aspiration. Trends in nutritional management are changing. Early nutritional support may be ordered to prevent atrophy of gut lymphoid tissue, prevent bacterial overgrowth in the intestine, and increase intestinal permeability. Immediate oral feeding in patients with mild acute pancreatitis is safe and may accelerate recovery. Early enteral nutrition appears effective and safe.

31. The nurse notes that the patients neutrophil count is less than 500 cells/microliter. The nurse realizes that this patient is: a. is at low risk for infection. b. is at mild risk for infection. c. is at moderated risk for infection. d. is at severe risk for infection.

ANS: D Neutropenia is defined as an absolute neutrophil count of less than 1500 cells/microliter of blood. Neutropenia may occur as a result of inadequate production or excess destruction of neutrophils. Patients with low neutrophil counts are predisposed to infections because of the bodys reduced phagocytic ability. Neutropenia is classified based on the patients predicted risk for infection: mild (1000 to 1500 cells/microliter), moderate (500 to 1000 cells/microliter), and severe (<500 cells/microliter).

40. When caring for a patient with HIV, the nurse should: a. not focus on the mouth, as infections of the mouth are rare. b. assure the patient that infections are not a major problem at this point. c. inform the patient that the disease does not affect the respiratory system. d. monitor the patients medication regimen.

ANS: D Nursing assessment includes evaluation of the neurological status, mouth, respiratory status, abdominal symptoms, and peripheral sensation. As with all immunosuppressed patients, those with HIV infection must be protected from infection. These patients provide additional clinical challenges because of their multisystemic, clinical complications. For unclear reasons, persons with HIV infection have a higher propensity for adverse drug reactions than other patient groups and require careful monitoring of all medication regimens.

35. Nursing care of patients with neutropenia is the same as for all immunocompromised patients. Desired patient outcomes related to medical and nursing interventions include absence of infection, negative cultures, and an absolute neutrophil count of : a. less than 500 cells/microliter. b. 500 to 1000 cells/microliter. c. 1000 to 1500 cells/microliter. d. 1500 cells/microliter or higher.

ANS: D Nursing care of patients with neutropenia is the same as for all immunocompromised patients. Desired patient outcomes related to medical and nursing interventions include absence of infection, negative cultures, and an absolute neutrophil count of 1500 cells/microliter or higher.

12. In assessing the patient complaining of abdominal pain, it is important for the nurse to understand that: a. pain receptors in the abdomen are more likely to be localized. b. pain of a peptic ulcer is easily distinguished from that of heart attack. c. visceral pain often leads to tachycardia and hypertension. d. increasing intensity of pain is always significant.

ANS: D Pain assessment is challenging. Pain receptors in the abdomen are less likely to be localized and are mediated by common sensory structures projected to the skin. Therefore, distinguishing the pain of a peptic ulcer or cholecystitis from that of a myocardial infarction is often difficult. Abdominal pain often is caused by engorged mucosa, pressure in the mucosa, distention, or spasm. Visceral pain is likely to cause pallor, perspiration, bradycardia, nausea and vomiting, weakness, and hypotension. Increasing intensity of pain, especially after surgery or other intervention, is always significant and usually signifies complicating factors, such as inflammation, gastric distention, hemorrhage into tissue or the peritoneal space, or peritonitis.

26. The patient is complaining of severe joint pain as well as fatigue and shortness of breath. The nurse notices that the patients joints are swollen and his legs are edematous. The nurse realizes that these are symptoms of: a. anemia reflective of low volume. b. aplastic anemia. c. hemolytic anemia. d. sickle cell anemia.

ANS: D Patients with sickle cell anemia may have joint swelling or pain, and delayed physical and sexual development. In crisis, the sickle cell patient often has decreased urine output, peripheral edema, and signs of uremia because renal tissue perfusion is impaired as a result of sluggish blood flow. Decreased circulating volume is manifested by clinical findings reflective of low blood volume (e.g., low right atrial pressure) and the effects of gravity on the lack of volume (e.g., orthostasis). The patient with aplastic anemia may have bruising, nosebleeds, petechiae, and a decreased ability to fight infections. These effects result from thrombocytopenia and decreased WBC counts, which occur when the bone marrow fails to produce blood cells. Assessment of the patient with hemolytic anemia may reveal jaundice, abdominal pain, and enlargement of the spleen or liver. These findings result from the increased destruction of RBCs, their sequestration (abnormal distribution in the spleen and liver), and the accumulation of breakdown products.

3. Erythrocytes (RBCs) are generated from precursor stem cells under the influence of a growth factor called: a. reticulocytes. b. hemoglobin. c. 2,3-DPG. d. erythropoietin.

ANS: D RBCs are generated from precursor stem cells under the influence of a growth factor called erythropoietin. Erythropoietin is secreted by the kidney in response to a perceived decrease in perfusion or tissue hypoxia. Reticulocytes are immature RBCs that may be released when there is a demand for RBCs that exceeds the number of available mature cells. The RBC transports hemoglobin, whose function is the transport of oxygen and carbon dioxide. Hemoglobin binds with oxygen in the lungs and transports it to the tissues. The oxygen affinity for hemoglobin is modulated primarily by the concentration of 2,3-diphosphoglycerate (2,3-DPG) and depends on the blood pH and body temperature.

12. Two types of specific immune responses exist: humoral immunity and cell-mediated immunity. These responses: a. are mutually exclusive. b. are non-specific immune responses. c. are producers of antigens. d. work together to provide immunity.

ANS: D Specificity refers to the finding that an immune response stimulates cells to develop immunity for a specific antigen. Two types of specific immune responses exist: humoral immunity and cell-mediated immunity. They are not mutually exclusive but act together to provide immunity. They do not produce antigens; they produce antibodies.

32. The nurse is caring for a patient who has had a portacaval shunt placed surgically. The nurse is aware that this procedure: a. improves survival in patients with varices. b. decreases the risk of encephalopathy. c. decreases the incidence of ascites. d. decreases rebleeding.

ANS: D Surgical shunts decrease rebleeding but do not improve survival. The procedure is associated with a higher risk of encephalopathy and makes liver transplantation, if needed, more difficult. A temporary increase in ascites occurs after all these procedures, and careful assessments and interventions are required in the care of this patient population.

19. The nurse is caring for a patient with cirrhosis of the liver. The nurse notes fresh blood starting to ooze from the patients rectum and intravenous site. The nurse contacts the provider expecting an order for: a. an infusion of protein S factor. b. blood work to evaluate protein C level. c. a laboratory test to determine factor X level. d. vitamin K injections.

ANS: D The coagulation factors are plasma proteins that circulate as inactive enzymes, and most are synthesized in the liver. Vitamin K is necessary for synthesis of factors II, VII, IX, X, and protein C and protein S (anticoagulation factors). Thus, liver disease and vitamin K deficiency are commonly associated with impaired hemostasis.

34. The patient is admitted with acute pancreatitis. The nurse should: a. assess pain level because pancreatic pain is unique in character. b. examine laboratory values for low amylase levels. c. expect lipase levels to decrease within 24 hours. d. evaluate C-reactive protein as a gauge of severity.

ANS: D The diagnosis of acute pancreatitis is based on clinical findings, the presence of associated disorders, and laboratory testing. Pain associated with acute pancreatitis is similar to that associated with peptic ulcer disease, gallbladder disease, intestinal obstruction, and acute myocardial infarction. This similarity exists because pain receptors in the abdomen are poorly differentiated as they exit the skin surface. Serum lipase and amylase tests are the most specific indicators of acute pancreatitis because as the pancreatic cells and ducts are destroyed, these enzymes are released. An elevated serum amylase level is a characteristic diagnostic feature. Amylase levels usually rise within 12 hours after the onset of symptoms and return to normal within 3 to 5 days. Serum lipase levels increase within 4 to 8 hours of clinical symptom onset and then decrease within 8 to 14 days. C-reactive protein increases within 48 hours and is a marker of severity.

34. The patient has a total white blood cell (WBC) count of 600 cells/microliter. The differential shows a normal neutrophil level of 70% with 5% bands. This patient: a. is at low risk for infection. b. is at mild risk for infection. c. is at moderated risk for infection. d. is at severe risk for infection.

ANS: D The differential demonstrates the percentage of each type of WBC circulating in the bloodstream. The absolute neutrophil count is calculated by multiplying the total WBC count (without a decimal point) by the percentages (with decimal points) of polymorphonuclear leukocytes (polys; also called segs or neutrophils) and bands (immature neutrophils). WBC (segs + bands) 600 (0.70 + 0.05) 600 0.75 = 450 cells/microliter This gives an actual number that is translated into the categories of mild, moderate, or severe neutropenia. Neutropenia is classified based on the patients predicted risk for infection: mild (1000 to 1500 cells/microliter), moderate (500 to 1000 cells/microliter), and severe (<500 cells/microliter).

10. The patient is being admitted to the hospital. At home, the patient take an over-the-counter supplement of Vitamin D and is concerned because the doctor did not order that vitamin D to be given in the hospital. The nurse explains that a. the body does not store vitamins so the doctor will have to be called. b. the kidneys will produce enough vitamin D and that supplements are not needed. c. over-the-counter supplements are never given in the hospital. d. vitamins D is stored in the liver with a 10-month supply to prevent deficiency.

ANS: D The liver plays a central role in the storage, synthesis, and transport of various vitamins and minerals. It functions as a storage depot principally for vitamins A, D, and B12, where up to 3-, 10-, and 12-month supplies, respectively, of these nutrients are stored to prevent deficiency states. The kidneys do not produce vitamin D. Over-the-counter supplements are ordered depending on the patients status.

42. The nurse is caring for a patient diagnosed with anemia. This mornings hematocrit level is 24%. Platelet level is 200,000/microliter. The nurse can expect to: a. continue monitoring the patient, as this hematocrit is normal. b. administer platelets to help control bleeding. c. give fresh frozen plasma to decrease prothrombin time. d. provide RBC transfusion because this level is below the normal threshold.

ANS: D Transfusion thresholds are established based on laboratory values and patient-specific variables. In general, a threshold for RBC transfusion is considered a hematocrit of 28% to 31%, based on the patients cardiovascular tolerance. If angina or orthostasis is present, a higher threshold may be maintained. The threshold for transfusing platelets is usually between 20,000 and 50,000/microliter. Cryoprecipitate is usually infused if the fibrinogen level is less than 100 mg/dL. Fresh frozen plasma is used to correct a prolonged prothrombin time and partial thromboplastin time or a specific factor deficiency.

21. 21. The nurse understands that when clots breakdown in a patient with a hematological disorder, that which value will increase? a. hemoglobin. b. white blood cell count. c. vitamin K. d. fibrin split products.

ANS: D When plasmin digests fibrinogen, fragments known as fibrin split products, or fibrin degradation products, are produced and function as potent anticoagulants. Fibrin split products are not normally present in the circulation but are seen in some hematological disorders as well as with thrombolytic therapy. Vitamin K is necessary for synthesis of factors II, VII, IX, X that are needed for clotting to occur. Hemoglobin may decrease if the patient is bleeding, and WBCs are not relevant to this scenario.