med surg exam 6
Which action will the admitting nurse include in the care plan for a patient who has neutropenia?
. b. Check temperature every 4 hours
Which action will the nurse include in the plan of care for a 72-year-old woman admitted with multiple myeloma? a. Monitor fluid intake and output. b. Administer calcium supplements. c. Assess lymph nodes for enlargement. d. Limit weight bearing and ambulation
a. Monitor fluid intake and output.
A child is getting induction therapy for Burkitt lymphoma. The nurse finds the child lethargic and complaining of side and back pain. The childs morning laboratory results indicate a serum calcium level of 7.2 mg/dL. What actions by the nurse are the most appropriate at this time? (Select all that apply.) a. Administer a dose of pain medication. b. Assess Chvostek and Trousseau signs. c. Call the rapid response team. d. Encourage an increased oral intake. e. Prepare to administer allopurinol (Aloprim). This child is manifesting signs of tumor lysis syndrome. The child is at risk due to the rapid destruction of cancer cells (induction therapy) and from the child's type of cancer (Burkitt lymphoma). Lethargy, flank pain, and hypocalcemia are common findings in this condition. The nurse should administer pain medication, assess for physical manifestations of hypocalcemia (Chvostek and Trousseau signs), and prepare to administer allopurinol.
a. Administer a dose of pain medication. b. Assess Chvostek and Trousseau signs. e. Prepare to administer allopurinol (Aloprim).
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? a. Neutropenia b. Increasing fatigue c. Thrombocytopenia d. Frequent constipation
a. Neutropenia
Which information obtained by the nurse assessing a patient admitted with multiple myeloma is most important to report to the health care provider? a. Serum calcium level is 15 mg/dL. b. Patient reports no stool for 5 days. c. Urine sample has Bence-Jones protein. d. Patient is complaining of severe back pain.
a. Serum calcium level is 15 mg/dL.
A routine complete blood count indicates that an active 80-year-old man may have myelodysplastic syndrome. The nurse will plan to teach the patient about a. blood transfusion b. bone marrow biopsy. c. filgrastim (Neupogen) administration. d. erythropoietin (Epogen) administration
b. bone marrow biopsy.
It is important for the nurse providing care for a patient with sickle cell crisis to a. limit the patients intake of oral and IV fluids. b. evaluate the effectiveness of opioid analgesics. c. encourage the patient to ambulate as much as tolerated. d. teach the patient about high-protein, high-calorie foods
b. evaluate the effectiveness of opioid analgesics.
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? a. "If you do not want to have chemotherapy, other treatment options include stem cell transplantation." b. "The side effects of chemotherapy are difficult, but AML frequently goes into remission with chemotherapy." c. "The decision about treatment is one that you and the doctor need to make rather than asking what I would do." d. "You don't need to make a decision about treatment right now because leukemias in adults tend to progress slowly."
b. "The side effects of chemotherapy are difficult, but AML frequently goes into remission with chemotherapy."
After receiving change-of-shift report for several patients with neutropenia, which patient should the nurse assess first? a. 56-year-old with frequent explosive diarrhea b. 33-year-old with a fever of 100.8° F (38.2° C) c. 66-year-old who has white pharyngeal lesions d. 23-year old who is complaining of severe fatigue
b. 33-year-old with a fever of 100.8° F (38.2° C)
A boy with leukemia screams whenever he needs to be turned or moved. The most probable cause of this pain is: A. Edema. b. Bone involvement. c. Petechial hemorrhages. d. Changes within the muscles. The invasion of the bone marrow with leukemic cells gradually causes a weakening of the bone and a tendency toward fractures. As leukemic cells invade the periosteum, increasing pressure causes severe pain.
b. Bone involvement.
Which action will the admitting nurse include in the care plan for a 30-year old woman who is neutropenic? a. Avoid any injections. b. Check temperature every 4 hours. c. Omit fruits or vegetables from the diet. d. Place a "No Visitors" sign on the door.
b. Check temperature every 4 hours.
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? a. Avoid venipunctures. b. Notify the patient's physician. c. Apply sterile dressings to the sites. d. Give prescribed proton-pump inhibitors.
b. Notify the patient's physician. *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
Which collaborative problem will the nurse include in a care plan for a patient admitted to the hospital with idiopathic aplastic anemia? a. Potential complication: seizures b. Potential complication: infection c. Potential complication: neurogenic shock d. Potential complication: pulmonary edema
b. Potential complication: infection
A 30-year-old man with acute myelogenous leukemia develops an absolute neutrophil count of 850/µL while receiving outpatient chemotherapy. Which action by the outpatient clinic nurse is most appropriate? a. Discuss the need for hospital admission to treat neutropenia. b. Teach the patient to administer filgrastim (Neupogen) injections. c. Plan to discontinue the chemotherapy until the neutropenia resolves. d. Order a high-efficiency particulate air (HEPA) filter for the patient's home.
b. Teach the patient to administer filgrastim (Neupogen) injections.
An appropriate nursing intervention for a hospitalized patient with severe hemolytic anemia is to a. provide a diet high in vitamin K. b. alternate periods of rest and activity. c. teach the patient how to avoid injury. d. place the patient on protective isolation
b. alternate periods of rest and activity.
The nurse notes scleral jaundice in a patient being admitted with hemolytic anemia. The nurse will plan to check the laboratory results for the a. Schilling test. b. bilirubin level. c. stool occult blood test. d. gastric analysis testing.
b. bilirubin level.
A routine complete blood count indicates that an active 80-year-old man may have myelodysplastic syndrome. The nurse will plan to teach the patient about a. blood transfusion b. bone marrow biopsy. c. filgrastim (Neupogen) administration. d. erythropoietin (Epogen) administration.
b. bone marrow biopsy.
A neonate born with ambiguous genitalia is diagnosed with congenital adrenogenital hyperplasia. Therapeutic management includes administration of: a. Vitamin D. b.Cortisone. c.Stool softeners. d.Calcium carbonate
b.Cortisone. The most common biochemical defect with congenital adrenal hyperplasia is partial or complete 21- hydroxylase deficiency. With complete deficiency, insufficient amounts of aldosterone and cortisol are produced, so circulatory collapse occurs without immediate replacement.
The nurse is planning postoperative care for a patient who is being admitted to the surgical unit form the recovery room after transsphenoidal resection of a pituitary tumor. Which nursing action should be included? a.Palpate extremities for edema. b.Measure urine volume every hour. c.Check hematocrit every 2 hours for 8 hours. d.Monitor continuous pulse oximetry for 24 hours.
b.Measure urine volume every hour.
The nurse is assessing a 41-year-old African American male patient diagnosed with a pituitary tumor causing panhypopituitarism. Assessment findings consistent with panhypopituitarism include a.high blood pressure. b.decreased facial hair. c.elevated blood glucose. d.tachycardia and cardiac palpitations.
b.decreased facial hair.
A 56-year-old patient who is disoriented and reports a headache and muscle cramps is hospitalized with possible syndrome of inappropriate antidiuretic hormone (SIADH). The nurse would expect the initial laboratory results to include a(n) a.elevated hematocrit. b.decreased serum sodium. c.low urine specific gravity. d.increased serum chloride.
b.decreased serum sodium.
It is important for the nurse providing care for a patient with sickle cell crisis to a. limit the patients intake of oral and IV fluids. b.evaluate the effectiveness of opioid analgesics. c.encourage the patient to ambulate as much as tolerated. d.teach the patient about high-protein, high-calorie foods.
b.evaluate the effectiveness of opioid analgesics. Pain is the most common clinical manifestation of a crisis and usually requires large doses of continuous opioids for control
The nurse determines that demeclocycline (Declomycin) is effective for a patient with syndrome of inappropriate antidiuretic hormone (SIADH) based on finding that the patients a.weight has increased. b.urinary output is increased. c.peripheral edema is decreased. d.urine specific gravity is increased.
b.urinary output is increased.
Which instruction will the nurse plan to include in discharge teaching for the patient admitted with a sickle cell crisis? a. Take a daily multivitamin with iron. b. Limit fluids to 2 to 3 quarts per day. c. Avoid exposure to crowds when possible. d. Drink only two caffeinated beverages daily
c. Avoid exposure to crowds when possible.
Which action will the nurse include in the plan of care for a patient who has thalassemia major? a. Teach the patient to use iron supplements. b. Avoid the use of intramuscular injections. c. Administer iron chelation therapy as needed. d. Notify health care provider of hemoglobin 11g/dL.
c. Administer iron chelation therapy as needed.
Which action will the nurse include in the plan of care for a patient who has thalassemia major? a. Teach the patient to use iron supplements. b. Avoid the use of intramuscular injections. c. Administer iron chelation therapy as needed. d. Notify health care provider of hemoglobin 11g/dL.
c. Administer iron chelation therapy as needed. *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.
Which action for a patient with neutropenia is appropriate for the registered nurse (RN) to delegate to a licensed practical/vocational nurse (LPN/LVN)? a. Assessing the patient for signs and symptoms of infection b. Teaching the patient the purpose of neutropenic precautions c. Administering subcutaneous filgrastim (Neupogen) injection d. Developing a discharge teaching plan for the patient and famil
c. Administering subcutaneous filgrastim (Neupogen) injection
Which action for a patient with neutropenia is appropriate for the registered nurse (RN) to delegate to a licensed practical/vocational nurse (LPN/LVN)? a. Assessing the patient for signs and symptoms of infection b. Teaching the patient the purpose of neutropenic precautions c. Administering subcutaneous filgrastim (Neupogen) injection d. Developing a discharge teaching plan for the patient and family
c. Administering subcutaneous filgrastim (Neupogen) injection
Which instruction will the nurse plan to include in discharge teaching for the patient admitted with a sickle cell crisis? a. Take a daily multivitamin with iron. b. Limit fluids to 2 to 3 quarts per day. c. Avoid exposure to crowds when possible. d. Drink only two caffeinated beverages daily.
c. Avoid exposure to crowds when possible.
A patient with possible disseminated intravascular coagulation arrives in the emergency department with a blood pressure of 82/40, temperature 102° F (38.9° C), and severe back pain. Which physician order will the nurse implement first? a. Administer morphine sulfate 4 mg IV. b. Give acetaminophen (Tylenol) 650 mg. c. Infuse normal saline 500 mL over 30 minutes. d. Schedule complete blood count and coagulation studies.
c. Infuse normal saline 500 mL over 30 minutes.
Which intervention will the nurse include in the plan of care for a patient with syndrome of inappropriate antidiuretic hormone (SIADH)? a. Encourage fluids to 2 to 3 L/day. b. Monitor for increasing peripheral edema. c. Offer the patient hard candies to suck on. d. Keep head of bed elevated to 30 degrees.
c. Offer the patient hard candies to suck on. Sucking on hard candies decreases thirst for a patient on fluid restriction. Patients with SIADH are on fluid restrictions of 800 to 1000 mL/day. Peripheral edema is not seen with SIADH. The head of the bed is elevated no more than 10 degrees to increase left atrial filling pressure and decrease antidiuretic hormone (ADH) release.
During the teaching session for a patient who has a new diagnosis of acute leukemia the patient is restless and is looking away, never making eye contact. After teaching about the complications associated with chemotherapy, the patient asks the nurse to repeat all of the information. Based on this assessment, which nursing diagnosis is most appropriate for the patient? a. Risk for ineffective adherence to treatment related to denial of need for chemotherapy b.Acute confusion related to infiltration of leukemia cells into the central nervous system c.Risk for ineffective health maintenance related to anxiety about new leukemia diagnosis d.Deficient knowledge: chemotherapy related to a lack of interest in learning about treatment
c. Risk for ineffective health maintenance related to anxiety about new leukemia diagnosis
When a patient with splenomegaly is scheduled for splenectomy, which action will the nurse include in the preoperative plan of care? a. Discourage deep breathing to reduce risk for splenic rupture. b. Teach the patient to use ibuprofen (Advil) for left upper quadrant pain. c. Schedule immunization with the pneumococcal vaccine (Pneumovax). d. Avoid the use of acetaminophen (Tylenol) for 2 weeks prior to surgery. Preop Hgb levels must be at 10g/dl and 30% HCT prior to surgery- anything less needs to be reported to the health care provider.
c. Schedule immunization with the pneumococcal vaccine (Pneumovax). Preop Hgb levels must be at 10g/dl and 30% HCT prior to surgery- anything less needs to be reported to the health care provider.
A 54-year-old woman with acute myelogenous leukemia (AML) is considering treatment with a hematopoietic stem cell transplant (HSCT). The best approach for the nurse to assist the patient with a treatment decision is to a. emphasize the positive outcomes of a bone marrow transplant. b. discuss the need for adequate insurance to cover post-HSCT care. c. ask the patient whether there are any questions or concerns about HSCT. d. explain that a cure is not possible with any other treatment except HSC
c. ask the patient whether there are any questions or concerns about HSCT.
A 54-year-old woman with acute myelogenous leukemia (AML) is considering treatment with a hematopoietic stem cell transplant (HSCT). The best approach for the nurse to assist the patient with a treatment decision is to a. emphasize the positive outcomes of a bone marrow transplant. b. discuss the need for adequate insurance to cover post-HSCT care. c. ask the patient whether there are any questions or concerns about HSCT. d. explain that a cure is not possible with any other treatment except HSCT.
c. ask the patient whether there are any questions or concerns about HSCT.
A 52-year-old patient has a new diagnosis of pernicious anemia. The nurse determines that the patient understands the teaching about the disorder when the patient states, I a. need to start eating more red meat and liver. b. will stop having a glass of wine with dinner. c. could choose nasal spray rather than injections of vitamin B 12 d. will need to take a proton pump inhibitor like omeprazole (Prilosec)
c. could choose nasal spray rather than injections of vitamin B 12
A 52-year-old patient has a new diagnosis of pernicious anemia. The nurse determines that the patient understands the teaching about the disorder when the patient states, "I a. need to start eating more red meat and liver." b. will stop having a glass of wine with dinner." c. could choose nasal spray rather than injections of vitamin B12." d. will need to take a proton pump inhibitor like omeprazole (Prilosec)."
c. could choose nasal spray rather than injections of vitamin B12."
A 42-year-old female patient is scheduled for transsphenoidal hypophysectomy to treat a pituitary adenoma. During preoperative teaching, the nurse instructs the patient about the need to a.cough and deep breathe every 2 hours postoperatively. b.remain on bed rest for the first 48 hours after the surgery. c.avoid brushing teeth for at least 10 days after the surgery. d.be positioned flat with sandbags at the head postoperatively.
c.avoid brushing teeth for at least 10 days after the surgery.
An expected nursing diagnosis for a 30-year-old patient admitted to the hospital with symptoms of diabetes insipidus is a.excess fluid volume related to intake greater than output. b.impaired gas exchange related to fluid retention in lungs. c.sleep pattern disturbance related to frequent waking to void. d.risk for impaired skin integrity related to generalized edema
c.sleep pattern disturbance related to frequent waking to void. Nocturia occurs as a result of the polyuria caused by diabetes insipidus
A patient who has been receiving a heparin infusion and warfarin (Coumadin) for a deep vein thrombosis (DVT) is diagnosed with heparin-induced thrombocytopenia (HIT) when her platelet level drops to 110,000/L. Which action will the nurse include in the plan of care? a. Use low-molecular-weight heparin (LMWH) only. b. Administer the warfarin (Coumadin) at the scheduled time. c. Teach the patient about the purpose of platelet transfusions. d. Discontinue heparin and flush intermittent IV lines using normal salin
d. Discontinue heparin and flush intermittent IV lines using normal salin
Which statement by a patient indicates good understanding of the nurses teaching about prevention of sickle cell crisis? a. Home oxygen therapy is frequently used to decrease sickling. b. There are no effective medications that can help prevent sickling. c. Routine continuous dosage narcotics are prescribed to prevent a crisis. d. Risk for a crisis is decreased by having an annual influenza vaccination
d. Risk for a crisis is decreased by having an annual influenza vaccination
Which statement by a patient indicates a good understanding of the nurse's teaching about prevention of sickle cell crisis? a. "Home oxygen therapy is frequently used to decrease sickling." b. "There are no effective medications that can help prevent sickling." c. "Routine continuous dosage narcotics are prescribed to prevent a crisis." d. "Risk for a crisis is decreased by having an annual influenza vaccination."
d. "Risk for a crisis is decreased by having an annual influenza vaccination."
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? a. Platelet count b. Reticulocyte count c. Total lymphocyte count d. Absolute neutrophil count
d. Absolute neutrophil count
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? d. Absolute neutrophil count
d. Absolute neutrophil count
Which laboratory result will the nurse expect to show a decreased value if a patient develops heparin-induced thrombocytopenia (HIT)? a. Prothrombin time b. Erythrocyte count c. Fibrinogen degradation products d. Activated partial thromboplastin time saline.
d. Activated partial thromboplastin time
A patient who has been receiving a heparin infusion and warfarin (Coumadin) for a deep vein thrombosis (DVT) is diagnosed with heparin-induced thrombocytopenia (HIT) when her platelet level drops to 110,000/µL. Which action will the nurse include in the plan of care? a. Use low-molecular-weight heparin (LMWH) only. b. Administer the warfarin (Coumadin) at the scheduled time. c. Teach the patient about the purpose of platelet transfusions. d. Discontinue heparin and flush intermittent IV lines using normal saline.
d. Discontinue heparin and flush intermittent IV lines using normal saline.
A child will start treatment for precocious puberty. This involves injections of synthetic: a.Thyrotropin. b.Gonadotropins. c.Somatotropic hormone. d.Luteinizing hormone releasing hormone
d. Luteinizing hormone releasing hormone
Which patient information is most important for the nurse to monitor when evaluating the effectiveness of deferoxamine (Desferal) for a patient with hemochromatosis? a. Skin color b. Hematocrit c. Liver function d. Serum iron level
d. Serum iron level
An 18-year-old male patient with a small stature is scheduled for a growth hormone stimulation test. In preparation for the test, the nurse will obtain a. ice in a basin. b.glargine insulin. c.a cardiac monitor. d.50% dextrose solution.
d.50% dextrose solution.
The nurse is caring for a child with suspected diabetes insipidus. Which clinical manifestation would she or he expect to observe? a.Oliguria b.Glycosuria c.Nausea and vomiting d.Polyuria and polydipsia Excessive urination accompanied by insatiable thirst is the primary clinical manifestation of diabetes. These symptoms may be so severe that the child does little other than drink and urinate.
d.Polyuria and polydipsia Excessive urination accompanied by insatiable thirst is the primary clinical manifestation of diabetes. These symptoms may be so severe that the child does little other than drink and urinate.
Which statement by a patient indicates a good understanding of the nurses teaching about prevention of sickle cell crisis? a. Home oxygen therapy is frequently used to decrease sickling. b.There are no effective medications that can help prevent sickling. c.Routine continuous dosage narcotics are prescribed to prevent a crisis. d.Risk for a crisis is decreased by having an annual influenza vaccination.
d.Risk for a crisis is decreased by having an annual influenza vaccination. Because infection is the most common cause of a sickle cell crisis, influenza, Haemophilus influenzae,pneumococcal pneumonia, and hepatitis immunizations should be administered.
Leukemia expected S&S
fever, pallor, fatigue, anorexia, hemorrhage (usually petechiae), and bone & joint pain. Frequently, vague abdominal pain is caused by inflammation from normal flora within the GI. Hepatosplenomegaly from infiltration of liver, spleen and lymph glands
Because myelodysplastic syndrome (MDS) arises from the pluripotent hematopoietic stem cells in the bone marrow, expected laboratory results include A. an excess of T cells. B. an excess of platelets. C. an increase in lymphocytes. D. a deficiency of all cellular blood components.
D. a deficiency of all cellular blood components.
Adult Leukemia,-AML SATA difference from other leukemias
Gingival hyperplasia, hyperplasia of the bone marrow. Sternal tenderness. Hepatosplenomegaly
Which action will the nurse include in the plan of care for a 72-year-old woman admitted with multiple myeloma? a. Monitor fluid intake and output. b. Administer calcium supplements. c. Assess lymph nodes for enlargement. d. Limit weight bearing and ambulation.
a. Monitor fluid intake and output.
The nurse is caring for a patient admitted with diabetes insipidus (DI). Which information is most important to report to the health care provider?
a. The patient is confused and lethargic.
An appropriate nursing intervention for a patient with non-Hodgkin's lymphoma whose platelet count drops to 18,000/µL during chemotherapy is to a. check all stools for occult blood. b. encourage fluids to 3000 mL/day. c. provide oral hygiene every 2 hours. d. check the temperature every 4 hours.
a. check all stools for occult blood.
An appropriate nursing intervention for a patient with non-Hodgkins lymphoma whose platelet count drops to 18,000/L during chemotherapy is to a. check all stools for occult blood. b. encourage fluids to 3000 mL/day. c. provide oral hygiene every 2 hours. d. check the temperature every 4 hours
a. check all stools for occult blood.
A child with growth hormone (GH) deficiency is receiving GH therapy. The best time for the GH to be administered is: a.At bedtime. b.After meals. c.Before meals. d.On arising in the morning.
a.At bedtime. SubQ Injections are best given at bedtime to more closely approximate the physiologic release of GH
Nursing care of a child diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH) should include (Select all that apply) a.Weigh daily. b.Encourage fluids. c.Turn frequently. d.Maintain nothing by mouth. e.Restrict fluids.
a.Weigh daily. e.Restrict fluids. Increased secretion of ADH causes the kidney to reabsorb water, which increases fluid volume and decreases serum osmolarity with a progressive reduction in sodium concentration. The immediate management of the child is to restrict fluids.
A 45-year-old male patient with suspected acromegaly is seen at the clinic. To assist in making the diagnosis, which question should the nurse ask? a. Have you had a recent head injury? b. Do you have to wear larger shoes now? c. Is there a family history of acromegaly? d. Are you experiencing tremors or anxiety
b. Do you have to wear larger shoes now?
A 68-year-old woman with acute myelogenous leukemia (AML) asks the nurse whether the planned chemotherapy will be worth undergoing. Which response by the nurse is appropriate? a. "If you do not want to have chemotherapy, other treatment options include stem cell transplantation." b. "The side effects of chemotherapy are difficult, but AML frequently goes into remission with chemotherapy." c. "The decision about treatment is one that you and the doctor need to make rather than asking what I would do." d. "You don't need to make a decision about treatment right now because leukemias in adults tend to progress quite slowly."
b. "The side effects of chemotherapy are difficult, but AML frequently goes into remission with chemotherapy."
A patient is admitted with diabetes insipidus. Which action will be appropriate for the registered nurse (RN) to delegate to an experienced licensed practical/vocational nurse (LPN/LVN)?
b. Administer prescribed subcutaneous DDAVP.
Which patient requires the most rapid assessment and care by the emergency department nurse? a. The patient with hemochromatosis who reports abdominal pain b. The patient with neutropenia who has a temperature of 101.8° F c. The patient with sickle cell anemia who has had nausea and diarrhea for 24 hours d. The patient with thrombocytopenia who has oozing after having a tooth extracted
b. The patient with neutropenia who has a temperature of 101.8° F
An appropriate nursing intervention for a hospitalized patient with severe hemolytic anemia is to a. provide a diet high in vitamin K. b. alternate periods of rest and activity. c. teach the patient how to avoid injury. d. place the patient on protective isolation.
b. alternate periods of rest and activity.
A patient with possible disseminated intravascular coagulation arrives in the emergency department with a blood pressure of 82/40, temperature 102 F (38.9 C), and severe back pain. Which physician order will the nurse implement first ? a. Administer morphine sulfate 4 mg IV. b. Give acetaminophen (Tylenol) 650 mg. c. Infuse normal saline 500 mL over 30 minutes. d. Schedule complete blood count and coagulation studies
c. Infuse normal saline 500 mL over 30 minutes.
Which additional information will the nurse need to consider when reviewing the laboratory results for a patient's total calcium level? a. The blood glucose is elevated. b.The phosphate level is normal. c.The serum albumin level is low. d.The magnesium level is normal.
c.The serum albumin level is low.
An 8-year-old girl is receiving a blood transfusion when the nurse notes that she has developed precordial pain, dyspnea, distended neck veins, slight cyanosis, and a dry cough. These manifestations are most suggestive of: a. Air embolism. B. Allergic reaction. C. Hemolytic reaction. d.Circulatory overload.
d. Circulatory overload.
Which finding by the nurse when assessing a patient with a large pituitary adenoma is most important to report to the health care provider? a.Changes in visual field b.Milk leaking from breasts c.Blood glucose 150 mg/dL d.Nausea and projectile vomiting
d.Nausea and projectile vomiting Nausea and projectile vomiting may indicate increased intracranial pressure, which will require rapid actions for diagnosis and treatment.
Which collaborative problem will the nurse include in a care plan for a patient admitted to the hospital with idiopathic aplastic anemia? a. Potential complication: seizures b. Potential complication: infection c. Potential complication: neurogenic shock d. Potential complication: pulmonary edema
. Potential complication: infection
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?
20.8 drops/minute or 21 drops/minute.
By definition, neutropenia occurs when the white blood cell (WBC) count drops below? A. 4000/μL B. 3000/μL C. 2000/μL D. 1000/μL
A. 4000/μL
What is the priority nursing intervention for a child hospitalized with hemarthrosis resulting from hemophilia? A. Immobilization and elevation of the affected joint B. Administration of acetaminophen for pain relief C. Assessment of the child's response to hospitalization D. Assessment of the impact of hospitalization on the family system Immobilization and elevation of the joint will prevent further injury until bleeding is resolved. Although acetaminophen may help with pain associated with the treatment of hemarthrosis, it is not the priority nursing intervention.
A. Immobilization and elevation of the affected joint Immobilization and elevation of the joint will prevent further injury until bleeding is resolved. Although acetaminophen may help with pain associated with the treatment of hemarthrosis, it is not the priority nursing intervention.
A 19-year-old woman 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. The platelet count is 42,000/mL. b.Petechiae are present on the chest. c.Blood pressure (BP) is 94/56 mm Hg. d.Blood is oozing from the venipuncture site.
A. The platelet count is 42,000/mL. Platelet transfusions are not usually indicated until the platelet count is below 10,000 to 20,000/mL unless the patient is actively bleeding. Therefore the nurse should clarify the order with the health care provider before giving the transfusion
Priority nursing actions when caring for a hospitalized patient with new-onset temperature of 102.2° F and severe neutropenia include (select all that apply) A. administering the prescribed antibiotic STAT. B. drawing peripheral and central line blood cultures. C. ongoing monitoring of the patient's vital signs for septic shock. D. taking a full set of vital signs and notifying the physician immediately.
A. administering the prescribed antibiotic STAT. B. drawing peripheral and central line blood cultures. C. ongoing monitoring of the patient's vital signs for septic shock. D. taking a full set of vital signs and notifying the physician immediately.
The nurse has initiated a blood transfusion on a preschool child. The child begins to exhibit signs of a transfusion reaction. Place in order the interventions the nurse should implement, sequencing from the highest priority to the lowest. a. Take the vital signs. 2 B. Stop the transfusion. 1 C. Notify the practitioner. 4 D. Maintain a patent intravenous (IV) line with normal saline 3
B, A, D, C If a blood transfusion reaction of any type is suspected, stop the transfusion, take vital signs, maintain a patent IV line with normal saline and new tubing, notify the practitioner, and do not restart the transfusion until the child's condition has been medically evaluated
The nurse is planning care for a school-age child admitted to the hospital with hemophilia. Which interventions should the nurse plan to implement for this child (Select all that apply)? A Fingersticks for blood work instead of venipunctures B. Avoidance of intramuscular (IM) injections C. Acetaminophen (Tylenol) for mild pain control D Soft toothbrush for dental hygiene E. Administration of packed red blood cells
B. Avoidance of intramuscular (IM) injections C. Acetaminophen (Tylenol) for mild pain control D Soft toothbrush for dental hygiene
An adolescent is being seen in the clinic for evaluation of acromegaly. The nurse understands that which occurs with acromegaly? A. There is a lack of growth hormone (GH) being produced. B. There is excess GH after closure of the epiphyseal plates. C. There is an excess of GH before the closure of the epiphyseal plates. D There is a lack of thyroid hormone being produced.
B. There is excess GH after closure of the epiphyseal plates.
Your primary goal in the care of the patient with DIC is to A. provide emotional support. B. recognize early signs of occult or overt bleeding. C. monitor nutritional intake. D. report abnormal laboratory results
B. recognize early signs of occult or overt bleeding.
If the patient with DIC is actively bleeding, platelets are given to correct thrombocytopenia if the count is less than A. 150,000/μL. B. 100,000/μL. C. 50,000/μL. D. 30,000/μL.
C. 50,000/μL.
Disseminated intravascular coagulation (DIC) is initiated by intravascular release of which substance? A. Platelets B. Fibrin C. Thrombin D. Histamine
C. Thrombin
Which clinical manifestation should the nurse expect when a child with sickle cell anemia experiences an acute vaso-occlusive crisis? A.Circulatory collapse B Cardiomegaly, systolic murmurs C. Hepatomegaly, intrahepatic cholestasis D. Painful swelling of hands and feet, painful joints
D. Painful swelling of hands and feet, painful joints A vaso-occlusive crisis is characterized by severe pain in the area of involvement. If in the extremities, painful swelling of the hands and feet is seen; if in the abdomen, severe pain resembles that of acute surgical abdomen; and if in the head, stroke and visual disturbances occur. Circulatory collapse results from sequestration crisis
The most common type of leukemia in older adults is A. acute myelocytic leukemia. B. acute lymphocytic leukemia. C. chronic myelocytic leukemia. D. chronic lymphocytic leukemia. Should be acute, not chronic. acute is for middle aged adults
D. chronic lymphocytic leukemia.