Final exam study guide
The nurse cares for a patient who has just had a thoracentesis. Which assessment information obtained by the nurse is a priority to communicate to the health care provider? a.Oxygen saturation is 88%. b.Blood pressure is 145/90 mm Hg. c.Respiratory rate is 22 breaths/minute when lying flat. d.Pain level is 5 (on 0 to 10 scale) with a deep breath.
ANS:A Oxygen saturation would be expected to improve after a thoracentesis. A saturation of 88%indicates that a complication such as pneumothorax may be occurring. The other assessment data also indicate a need for ongoing assessment or intervention, but the low oxygen saturation is the priority
A 19yearold 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/L. b.Petechiae are present on the chest. c.Blood pressure (BP) is 94/56 mm Hg. d.Blood is oozing from the venipuncture site.
ANS:A Platelet transfusions are not usually indicated until the platelet count is below 10,000 to 20,000/L unless the patient is actively bleeding. Therefore the nurse should clarify the order with the health care provider before giving the transfusion. The other data all indicate that bleeding caused by ITP may be occurring and that the platelet transfusion is appropriate.
A patient who is lethargic and exhibits deep, rapid respirations has the following arterial bloodgas (ABG) results: pH 7.32, PaO2 88 mm Hg, PaCO2 37 mm Hg, and HCO3 16 mEq/L. How should the nurse interpret these results? a.Metabolic acidosis b.Metabolic alkalosis c.Respiratory acidosis d.Respiratory alkalosis
ANS:A The pH and HCO3 indicate that the patient has a metabolic acidosis. The ABGs are inconsistent with the other responses
Following a thyroidectomy, a patient complains of "a tingling feeling around my mouth." Which assessment should the nurse complete immediately? a.Presence of the Chvostek's sign b.Abnormal serum potassium level c.Decreased thyroid hormone level d.Bleeding on the patient's dressing
ANS:A The patient's symptoms indicate possible hypocalcemia, which can occur secondary to parathyroid injury/removal during thyroidectomy. There is no indication of a need to check the potassium level, the thyroid hormone level, or for bleeding.
Which information obtained by the nurse caring for a patient with thrombocytopenia should be immediately communicated to the health care provider? a.The platelet count is 52,000/μL .b.The patient is difficult to arouse. c.There are purpura on the oral mucosa. d.There are large bruises on the patient's back.
ANS:B Difficulty in arousing the patient may indicate a cerebral hemorrhage, which is life threatening and requires immediate action. The other information should be documented and reported but would not be unusual in a patient with thrombocytopenia.
When caring for a patient with renal failure on a low phosphate diet, the nurse will inform unlicensed assistive personnel (UAP) to remove which food from the patient's food tray? a.Grape juice b.Milk carton c.Mixed green salad d.Fried chicken breast
ANS:B Foods high in phosphate include milk and other dairy products, so these are restricted on lowphosphate diets. Green, leafy vegetables; highfat foods; and fruits/juices are not high in phosphate and are not restricted.
The health care provider prescribes an infusion of heparin (HepLock) and daily partial thromboplastin time (PTT) testing for a patient with venous thromboembolism (VTE). The nurse will plan to a.decrease the infusion when the PTT value is 65 seconds. b.avoid giving any IM medications to prevent localized bleeding. c.monitor posterior tibial and dorsalis pedis pulses with the Doppler. d.have vitamin K available in case reversal of the heparin is needed
ANS:B IM injections are avoided in patients receiving anticoagulation. A PTT of 65 seconds is withinthe therapeutic range. Vitamin K is used to reverse warfarin. Pulse quality is not affected by VTE
Which intervention will be included in the nursing care plan for a patient with immune thrombocytopenic purpura (ITP)? a.Assign the patient to a private room. b.Avoid intramuscular (IM) injections. c.Use rinses rather than a soft toothbrush for oral care. d.Restrict activity to passive and active range of motion
ANS:B IM or subcutaneous injections should be avoided because of the risk for bleeding. A soft toothbrush can be used for oral care. There is no need to restrict activity or place the patient ina private room
Which problem reported by a patient with hemophilia is most important for the nurse to communicate to the physician? a.Leg bruises b.Tarry stools c.Skin abrasions d.Bleeding gums
ANS:B Melena is a sign of gastrointestinal bleeding and requires collaborative actions such as checking hemoglobin and hematocrit and administration of coagulation factors. The other problems indicate a need for patient teaching about how to avoid injury, but are not indicators of possible serious blood loss.
The nurse has started discharge teaching for a patient who is to continue warfarin (Coumadin) following hospitalization for venous thromboembolism (VTE). The nurse determines that additional teaching is needed when the patient says which of the following? a."I should get a Medic Alert device stating that I take Coumadin." b."I should reduce the amount of green, leafy vegetables that I eat." c."I will need routine blood tests to monitor the effects of the Coumadin." d."I will check with my health care provider before I begin any new medications.
ANS:B Patients taking warfarin are taught to follow a consistent diet with regard to foods that are high in vitamin K, such as green, leafy vegetables.
A patient with a pleural effusion is scheduled for a thoracentesis. Which action should thenurse take to prepare the patient for the procedure? a.Start a peripheral IV line to administer the necessary sedative drugs. b.Position the patient sitting upright on the edge of the bed and leaning forward. c.Obtain a large collection device to hold 2 to 3 liters of pleural fluid at one time. d.Remove the water pitcher and remind the patient not to eat or drink anything for 6hours
ANS:B When the patient is sitting up, fluid accumulates in the pleural space at the lung bases and canmore easily be located and removed. The patient does not usually require sedation for theprocedure, and there are no restrictions on oral intake because the patient is not sedated orunconscious. Usually only 1000 to 1200 mL of pleural fluid is removed at one time. Rapidremoval of a large volume can result in hypotension, hypoxemia, or pulmonary edema
A patient with a venous thromboembolism (VTE) is started on enoxaparin (Lovenox) and warfarin (Coumadin). The patient asks the nurse why two medications are necessary. Which response by the nurse is most appropriate? a."Taking two blood thinners reduces the risk for another clot to form." b."Lovenox will start to dissolve the clot, and Coumadin will prevent any more clotsfrom forming." c."Lovenox will work right away, but Coumadin takes several days to have an effecton preventing clots." d."Because of the risk for a blood clot in the lungs, it is important for you to take more than one blood thinner.
ANS:C Low molecular weight heparin (LMWH) is used because of the immediate effect on coagulation and discontinued once the international normalized ratio (INR) value indicates that the warfarin has reached a therapeutic level
Which assessment finding for a patient who has been admitted with a right calf venous thromboembolism (VTE) requires immediate action by the nurse? a.Erythema of right lower leg b.Complaint of right calf pain c.New onset shortness of breath d.Temperature of 100.4° F (38° C)
ANS:C New onset dyspnea suggests a pulmonary embolus, which will require rapid actions such as oxygen administration and notification of the health care provider
Which action by a nurse who is giving fondaparinux (Arixtra) to a patient with a lower leg venous thromboembolism (VTE) indicates that more education about the drug is needed? a.The nurse avoids rubbing the injection site after giving the drug. b.The nurse injects the drug into the abdominal subcutaneous tissue. c.The nurse ejects the air bubble in the syringe before giving the drug. d.The nurse fails to assess the partial thromboplastin time (PTT) before giving the drug
ANS:C The air bubble is not ejected before giving fondaparinux to avoid loss of medication
As related to inherited disorders, which statement is descriptive of most cases of hemophilia? a.Autosomal dominant disorder causing deficiency in a factor involved in the blood-clotting reaction b.X-linked recessive inherited disorder causing deficiency of platelets and prolongedbleeding c.X-linked recessive inherited disorder in which a blood-clotting factor is deficient d.Y-linked recessive inherited disorder in which the red blood cells become moonshaped
ANS:C The inheritance pattern in 80% of all of the cases of hemophilia is X-linked recessive. Thetwo most common forms of the disorder are factor VIII deficiency (hemophilia A or classichemophilia), and factor IX deficiency (hemophilia B or Christmas disease). The disorderinvolves coagulation factors, not platelets. The disorder does not involve red cells or the Ychromosome
The nurse notes that a patient who was admitted with diabetic ketoacidosis has rapid, deep respirations. Which action should the nurse take? a.Give the prescribed PRN lorazepam (Ativan). b.Start the prescribed PRN oxygen at 2 to 4 L/min. c.Administer the prescribed normal saline bolus and insulin. d.Encourage the patient to take deep, slow breaths with guided imagery
ANS:C The rapid, deep (Kussmaul) respirations indicate a metabolic acidosis and the need for correction of the acidosis with a saline bolus to prevent hypovolemia followed by insulin administration to allow glucose to reenter the cells
Which information should the nurse teach workers at a day care center about respiratory syncytial virus (RSV)? a.RSV is transmitted through particles in the air. b.RSV can live on skin or paper for up to a few seconds after contact. c.RSV can survive on nonporous surfaces for about 60 minutes. d.Frequent hand washing can decrease the spread of the virus
ANS:D Meticulous hand washing can decrease the spread of organisms. RSV infection is not airborne. It is acquired mainly through contact with contaminated surfaces. RSV can live on skin or paper for up to 1 hour and on cribs and other nonporous surfaces for up to 6 hours.
Which laboratory result will the nurse expect to show a decreased value if a patient develops heparininduced thrombocytopenia (HIT)?a.Prothrombin time b.Erythrocyte count c.Fibrinogen degradation products d.Activated partial thromboplastin time
ANS:D Platelet aggregation in HIT causes neutralization of heparin, so that the activated partial thromboplastin time will be shorter and more heparin will be needed to maintain therapeutic levels. The other data will not be affected by HIT
A patient who was involved in a motor vehicle crash has had a tracheostomy placed to allow for continued mechanical ventilation. How should the nurse interpret the following arterial blood gas results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mEq/L? a.Metabolic acidosis b.Metabolic alkalosis c.Respiratory acidosis d.Respiratory alkalosis
Ans: D
A patient with a possible pulmonary embolism complains of chest pain and difficulty breathing. The nurse finds a heart rate of 142 beats/minute, blood pressure of 100/60 mmHg,and respirations of 42 breaths/minute. Which action should the nurse take first? a.Administer anticoagulant drug therapy. b.Notify the patient's health care provider. c.Prepare patient for a spiral computed tomography (CT). d.Elevate the head of the bed to a semi-Fowler's position
ANS:D The patient has symptoms consistent with a pulmonary embolism (PE). Elevating the head ofthe bed will improve ventilation and gas exchange. The other actions can be accomplishedafter the head is elevated (and oxygen is started). A spiral CT may be ordered by the healthcare provider to identify PE. Anticoagulants may be ordered after confirmation of thediagnosis of PE
The nurse is caring for a 10-month-old infant with respiratory syncytial virus (RSV) bronchiolitis. Which interventions should be included in the child's care (Select all that apply)? a.Administer antibiotics. b.Administer cough syrup. c.Encourage infant to drink 8 ounces of formula every 4 hours. d.Institute cluster care to encourage adequate rest. e.Place on noninvasive oxygen monitoring
ANS:C, D, E Hydration is important in children with RSV bronchiolitis to loosen secretions and prevent shock. Clustering of care promotes periods of rest. The use of noninvasive oxygen monitoring is recommended.
A patient who has been receiving a heparin infusion and warfarin (Coumadin) for a deep vein thrombosis (DVT) is diagnosed with heparininduced 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.
ANS:D All heparin is discontinued when the HIT is diagnosed. The patient should be instructed to never receive heparin or LMWH. Warfarin is usually not given until the platelet count has returned to 150,000/μL. The platelet count does not drop low enough in HIT for a platelet transfusion, and platelet transfusions increase the risk for thrombosis
The health care provider has prescribed bed rest with the feet elevated for a patient admitted to the hospital with venous thromboembolism. Which action by the nurse to elevate the patient's feet is best? a.The patient is placed in the Trendelenburg position. b.Two pillows are positioned under the affected leg. c.The bed is elevated at the knee and pillows are placed under the feet. d.One pillow is placed under the thighs and two pillows are placed under the lower legs.
ANS:D The purpose of elevating the feet is to enhance venous flow from the feet to the right atrium, which is best accomplished by placing two pillows under the feet and one under the thighs. Placing the patient in the Trendelenburg position will lower the head below heart level, which is not indicated for this patient. Placing pillows under the calf or elevating the bed at the knee may cause blood stasis at the calf level
The nurse caring for a patient with type A hemophilia being admitted to the hospital with severe pain and swelling in the right knee will a.immobilize the joint .b.apply heat to the knee. c.assist the patient with light weight bearing. d.perform passive range of motion to the knee
ANS:A The initial action should be total rest of the knee to minimize bleeding. Ice packs are used to decrease bleeding. Range of motion (ROM) and weightbearing exercise are contraindicated initially, but after the bleeding stops, ROM and physical therapy are started
A 28yearold man with von Willebrand disease is admitted to the hospital for minor knee surgery. The nurse will review the coagulation survey to check the a.platelet count. b.bleeding time. c.thrombin time. d.prothrombin time
ANS:B The bleeding time is affected by von Willebrand disease.
