Final for Med Surg II: Hematologic, eye, reproductive, male/female/

A client with vitamin B12 deficiency needs to increase dietary intake of foods that are good sources of this vitamin. The nurse recommends that the client increase intake of which foods? Select all that apply. 1. Apples 2. Spinach 3. Carrots 4. Oranges 5. Liver

2. Spinach 4. Oranges 5. Liver Rationale: Clients with nutritional anemias require dietary sources of folic acid, such as green leafy vegetables, fish, citrus fruits, yeast, dried beans, grains, nuts and liver.

A young child admitted to the hospital with a bleeding disorder is diagnosed with idiopathic thrombocytopenic purpura (ITP). The child's mother says to the nurse. "I have a friend who has a son with hemophilia. When he bleeds, they give him a "factor," which they keep in their home refrigerator. Can we just give my child this factor?" Which response by the nurse would be best? 1. "Your friend's child has a natural deficiency in clotting factors; your child does not." 2. "Factor has a lot of negative side effects, and the doctors would rather not use it on your child." 3. "The amont of factor that would be required to treat your child would be excessive." 4. "That treatment may be tried later if your child does not response to steroids."

1. "Your friend's child has a natural deficiency in clotting factors; your child does not." Rationale: Hemophilia is characteried by a deficiency in one or more clotting factors, while ITP is a platelet disorder. Because the child with ITP is not deficient in clotting factors, this treatment would not be beneficial.

A nurse is assisting a physician with a bone marrow aspiration on a client with anemia. After the procedure, the nurse should take which action? 1. Apply pressure on the site to stop bleeding 2. Massage the area to decrease pain. 3. Apply heat to the area to diminish the discomfort 4. Cover the area with a light dressing

1. Apply pressure on the site to stop bleeding Rationale: Application of direct pressure ad pressure dressing should follow the wicrawal of the aspiration needle after a bone marrow aspiration.

A client is to have a transfusion of packed red blood cells from a designated donor. The client asks if any diseases can be transmitted by this donor. The nurse should inform the client that which of the followig diseases can be transmitted by a designated donor? Select all that apply. 1. Epstein-barr virus 2. Human immunodeficiency virus (HIV) 3. Cytomegalovirus (CMV) 4. Hepatitis A 5 Malaria

1. Epstein-barr virus 2. Human immunodeficiency virus (HIV) 3. Cytomegalovirus (CMV) Rationale: Using designated donors does not decrease this risk of contracting infectious diseases, such as the Epstein-barr virus, HIV or CMV.

During assessment , the nurse notices a systolic murmur on a client with anemia. The nurse interprets that this finding correlates with which of the following? 1. Increased quantity and speed of low-viscosity blood through valves 2. Structural abnormality of heart valves from the anemia 3. High viscosity of blood circulating through the cardiac structures 4. Decreased blood flow through the vascular system

1. Increased quantity and speed of low-viscosity blood through valves Rationale: The increase in cardiac output and flow are compensatory mechanisms because of the decrease in the quantity of hemoglobin in circulating blood.

A client has a platelet count of 18,000/mm. What intervention must the nurse include in the plan of care? 1. Institute bleeding precautions 2. Institute reverse isolation 3. Schedule medications by intramuscular route when able. 4. Obtain temperatures rectally.

1. Institute bleeding precautions Rationale: A platelet count below 20,000 indicates tht the client is at risk for bleeding and necessitates the avoidanceof activities and interventions that incease this risk.

The nurse is teaching family members about precautions to take in visiting a client who has neutropenia. Which instructions should the nurse incude in the discussion? Select all that apply. 1. People who have colds or infectious diseases should not visit 2. Visitors must wash their hands before and after a visit 3. Fresh fruits and vegetables will help fortify the client's immume system. 4. Fresh flowers will help to provide a cheerful environment 5. It is helpful to keep the client's water pitcher full to prevent dehydration

1. People who have colds or infectious diseases should not visit 2. Visitors must wash their hands before and after a visit Rationale: A client with neutropenia has a compromised immune system and is predisposed to infections. Hand hygiene will reduce the risk of infection to the client.

A client has undergone a lymph node biopsy. The nurse anticipates that the report will reveal which result if the client has Hodgkin's lymphoma? 1. Reed-Sternberg cells 2. Philadelphia chromosome 3. Epstein-Barr virus 4. Herpes simplex virus

1. Reed-Sternberg cells Rationale: Histological isolation of Reed-Sternberg cells in lymph node biopsy examination is a diagnostic feature of Hodgkin's lymphoma.

A client with anemia has a nursing diagnosis of Activity Intolerance. Which intervention should the nurse implement? Select all that apply. 1. Space interventions during the day. 2. Teach client the basics of good nutrition 3. Promote active or passive range of motion activities 4. Teach client to change position slowly to prevent dizziness. 5. Encourage defined rest periods during the day.

1. Space interventions during the day. 4. Teach client to change position slowly to prevent dizziness. 5. Encourage defined rest periods during the day. Rationale: Activity intolerance in clients with anemia results from the imbalance between oxygen demand and supply. Activities should be planned to intersperse activity with periods of rest to decrease hypoxemic episodes and to decrease tissue demand for oxygen. A client with anemia may experience dizziness if there is insufficient oxygenation of red blood cells supplying the brain, which could then interfere with tolerance of activity. Providing for rest periods aids in energy conservation.

The nurse is obtaining a health history on a client admitted with a diagnosis of "rule out aplastic anemia." Considering the diagnosis, which data is most important for the nurse to elicit during the interview? 1. Recent travel outside the country 2. Exposure to chemicals and drugs 3. History of blood transfusion 4. Medication allergies.

2. Exposure to chemicals and drugs Rationale: Aplastic anemia may be congenital or acquired, but most cases do not have an identifiable etiology. It is known that aplastic anemia may follow exposure to chemicals (e.g., Benzene, DDT) or drugs (chloramphenicol, sulfonamides).

A client with iron deficiency anemia is refusing to take the prescribed oral iron medication because the medication is causing nausea. The nurse should do which of the following? select all that apply. 1. Suggest that the client use ginger when taking the medication 2. Ask the client what she thinks is causing the nausea 3. Tell the client to use stool softeners to minimize constipation 4. Offer to administer the medication by an intramuscular injection 5. Suggest that the client take the iron with orange juice.

1. Suggest that the client use ginger when taking the medication 2. Ask the client what she thinks is causing the nausea 5. Suggest that the client take the iron with orange juice. Rationale: Nausea and vomiting are common adverse effects of oral iron preparations. The nurse should first ask the client why she does not want to take the oral medication, and then suggest ways to decrease nausea and vomiting. Ginger may help minimize nausea and the client can try this remedy and evaluate its effectiveness. Iron should be taken on an empty stomach but can be taken with orange juice. The client can evaluate if this helps nausea.

A client had a mastectomy followed by chemotherapy 6 months ago. She reports that she is now "unable to concentrate at her card game" and "it seems harder and harder to finish her errands because of exhaustion." Based on this information, the nurse should suggest that the client do which of the following? 1. Take frequent naps 2. Limit activities 3. Increase fluid intake 4. Avoid contact with others

1. Take frequent naps Rationale: This client is likely experiencing fatigue and should increase her periods of rent. The fatigue may be caused by anemia from depletion of red blood cells due to the chemotherapy.

A client with stomatitis and on neutropenic precautions is ordered to have mouthwashes every 2 hours. The nurse would provide mouthwashes containing which ingredients as most helpful to this client? Select all that apply. 1. Viscous lidocaine (Xylocaine) 2. Normal sale solution 3. Hydrogen peroxide 4. Diluted baking soda 5. A liquid antacid

1. Viscous lidocaine (Xylocaine) 2. Normal sale solution 4. Diluted baking soda 5. A liquid antacid Rationale: Viscous lidocaine helps to ease the pain of stomatitis. Diluted solution with baking soda is a soothing and acceptable in a mouthwash solution. A solution containing an antacid tends to be soothing for a client with mouth pain due to stomatitis

A client with acute myelogenous leukemia (AML) is scheduled for bone marrow transplant (BMT). In teaching the client's family about BMT, which statement by the nurse is best? 1. "The client will be in the operating room with the donor so that immediate transplantation can occur." 2. "The specially prepared marrow is infused intravenously to the client." 3. "the client will be brought to the radiology department to transplant the marrow." 4. "A large-bore needle will be inserted into the client's bone marrow where the donor marrow will be infused."

2. "The specially prepared marrow is infused intravenously to the client." Rationale: Harvested bone marrow is infused into the recipient intravenously. The transplantation is usually preceded by chemotherapy and radiation therapy. During this period and up to when the client's response to the transplantation has been successful, nursing interventions should focus on prevention of infection.

A client with thrombocytopenia presents to the primary care center. During assessment, the nurse notices petechiae. The nurse interprets that which laboratory result best supports the presence of a disorder of hemostasis? 1. Decreased erythrocyte count 2. A platelet count below 150,000/uL 3. An elevated lymphocyte count 4. A hemoglobin value of 14 or more

2. A platelet count below 150,000/uL Rationale: Clients with thrombocytopenia have decreased platelet counts below 150,000/uL. The usual presenting manifestations of this condition is the appearance of petechiae, purpura, and ecchymosis.

A nurse is admitting a client with a diagnosis of aplastic anemia. Which is the best room for the nurse is assign this client? 1. A semiprivate room with a client whose diagnosis is urosepsis 2. A regular private room at the end of the hall. 3. A private isolation room equipped with a negative airflow 4. A semiprivate room with a client whose diagnosis is thrombophlebitis

2. A regular private room at the end of the hall. Rationale: Clients with aplastic anemia usually experience pancytopenia (decreased erythrocytes leukocytes, and platelets). The client with this type of hypolastic anemia should therefore have a room where reverse isolation can be instituted.

During physical examination the nurse finds a contender moveable cervical node on a client. The nurse makes which interpretation of this finding? 1. Normal, since the node is moveable. 2. Abnormal and may suggest the presence of a malignancy 3. Normal, since the node is nontender 4. Abnormal and a positive indicator of a malignancy.

2. Abnormal and may suggest the presence of a malignancy Rationale: A nontender and moveable cervical node may suggest the presence of malignancy and even lymphoma. Palpable nodes do not confirm the diagnosis of a malignancy. Biopsy and histological examination will aid in interpreting the significance of enlarged nodes.

The nurse has admitted a child newly diagnosed with anemia of unknown origin. Which nursing diagnosis is most appropriate? 1. Decreased Cardiac output related to abnormal platelet count 2. Activity Intolerance related to generalized weakness and fatigue 3. Imbalanced Nutrition: Less than Body Requirements 4. Risk for Pain related to vaso-occlusion

2. Activity Intolerance related to generalized weakness and fatigue Rationale: Clients with anemia will experience activity intolerance with even the simplest activities of daily living.

The nurse is teaching a client with hemophilia A about home management. Which strategy should the nurse include in the teaching plan? 1. Increase iron-rich foods in the diet 2. Avoid contact sports 3. Use aspirin when severe pain occurs 4. Minimize joint pain by walking and weight-bearing

2. Avoid contact sports Rationale: Clients with hemophilia should be taught to participate in non contact sports and to avoid any activities that increase the risk of tissue injury and bleeding.

The nurse is preparing a care plan for a client with polycythemia vera on ways to maintain nutrition. The nurse should include which measure in the plan? 1. Increase intake of foods hich in iron. 2. Encourage small, frequent meals rather than three big meals. 3. Increase the amount of read meats and organ meals in the diet. 4. Encourage the use of hot spices in foods to stimulate appetite.

2. Encourage small, frequent meals rather than three big meals. Rationale: Clients with polycythemia experience satiety and fullness resulting from hepatomegaly and splenomegaly. Frequent, small meals will help maintain adequate nutrition.

The nurse in the hematology clinic is reviewing laboratory findings for a 2-year old being treated for anemia. Which finding is the best indication that the treatment is successful? 1. the child is no longer cyanotic 2. The reticulocyte count is rising 3. the child is more active 4. Stools are black indicating iron intake.

2. The reticulocyte count is rising Rationale: Reticulocytes are immature RBCs. An increase in the umber of reticulocytes indicates the body is producing new RBCs.

The white blood cell (WBC) differential on a client indicates a shift to the left. The nurse akes which accurate interpretation of this report? 1. There is an increase in the number of segmented neutrophilis 2. There is an increase in the number of bands released into the circulation 3. The number of lymphocytes increased in number 4. The number of lymphocytes exceeds the total WBC count.

2. There is an increase in the number of bands released into the circulation Rationale: A shift to the left indicates an increase to immature neutrophils or bands. An increase in the number of bands indicates an increase in the production of granulocytes, which could be a compensatory mechanism in response to infection.

A client with thrombocytopenia has neurological checks ordered every hour. The nurse explains to a curious nursing assistant that the reason for frequent neurological assessment is which of the following? 1. To determine if the coagulopathy is related to a neurological disorder. 2. To monitor the signs of intracranial bleeding 3. To evaluate the effectiveness of pharmacologic interventions 4. To correlate increasing platelet counts with the neurological status.

2. To monitor the signs of intracranial bleeding Rationale: Client with thrombocytopenia are at risk for altered cerebral perfusion from bleeding. Since a neurologic assessment can assist in determining the presence of occult bleeding in the cerebrovascular system, it is a necessary nursing intervention to include in the care of these clients.

The spouse of a client with disseminated intravascular coagulopathy (DIC) approaches the nurse and expresses concern that the spouse may be getting the wrong medication after hearing the client was receiving heparin. What is the nurse's best response? 1. "I understand you concern, but the doctors know what they are doing." 2. "Let me make sure that I have not misread the physician's order." 3. "The drug is being used to stop the abnormal clotting in capillaries and arterioles." 4. "Please ask the physican why this medication is being given."

3. "The drug is being used to stop the abnormal clotting in capillaries and arterioles." Rationale: Initially in DIC, there is accelerated coagulation with resulting increase in fibrin and platelet deposits in arterioles and capillaries, resulting in thrombosis.

A pregnant woman tells the nurse that she has a family history of sickle cell anemia and is afraid her baby will be born with the disease. The nurse would provide which information during a discussion with this client? 1. Sickle cell anemia is a male disease and would be passed on through the man's family 2. Genetic testing will be needed to determine if her fetus is affected 3. Both mother and father must carry the defective gene for the child to have sickle cell anemia 4. The child only needs one parent to be a carrier in order for the child to be affected.

3. Both mother and father must carry the defective gene for the child to have sickle cell anemia Rationale: Sickle cell is inherited as an autosomal recessive disorder. Both parents must carry the defective gene.

The nurse is caring for a child with beta-thalassemia who has received many blood transfusions. The nurse assesses for which of the following as a priority at this time? 1. Neutropenia 2. Petechiae 3. Hemosiderosis 4. Hemoglobin S formation

3. Hemosiderosis Rationale: Frequent blood transfusion will lead to an overload of iron in the body. This iron is stored in tissues and organs and is called hemosiderosis.

A cliet with iron-deficiency anemia is scheduled for a complete blood count. the nurse anticipates that the report will show which characteristics of the red blood cells (RBCs) 1. Normocytic, normachromic 2. Macrocytic, normachromic 3. Microcytic, hypochromic 4. Normacytic, hyper chromic

3. Microcytic, hypochromic Rationale: The morphologic characteristics of RBCs in iron-deficiency anemia is microcytic and hypochromic.

The nurse is administering oral care to a client with disseminated intravascular coagulopathy (DIC). Which of the following is the most appropriate for this client? 1. Limit flossing to once a day 2. Use an alcohol-based mouthwash to prevent infection. 3. Use swabs to administer oral care. 4. Encourage tooth brushing at least once a shift.

3. Use swabs to administer oral care. Rationale: Clients with DIC should be protected from injury that will result to bleeding. An oral swab is least likely to cause tissue injury to the oral cavity during mouth care.

The nurse is reviewing laboratory results of a client suspected of having disseminated intravascular coagulopathy (DIC). The nurse looks to the results of which test as the more specific marker for DIC? 1. Partial thromboplastin time (PTT) 2. Prothrombin time (PT) 3. Platelet count 4. Fibrin degradation products (FDP)

4. Fibrin degradation products (FDP) In DIC, there is abnormal initiation and formation of blood clots. As clots are formed and then begin to dissolve, more end products of fibrinogen and fibrin are also formed.

A client has been admitted with active rectal bleeding. He has been typed and cross-matched for 2 units of packed red blood cells (RBCs). Within 10 minutes of admission the client faints when getting up to the bedside commode. The nurse notifies the health care provider, who orders a unit of blood immediately. The nurse should expect which type of packed RBCs will be used for immediate transfusion? 1. A negative 2. B negative 3. AB negative 4. O negative

4. O negative Rationale: A route serology study to confirm compatibility between a blood donor and recipient takes about 1 hour. In an emergency, O negative RBCs can be safely administered to most clients, which is why a person with O-negative blood is called a universal donor.

After a prostatectomy, when should the urine be light pink? A. 1 day B. 2 days C. 1 week D. 2 weeks

A. 1 day After a prostatectomy, the urine should be light pink within 24 hours

What is an anticholinergic medication used to treat Parkinson disease? A. Benztropine mesylate (Cogentin) B. Diphenhydramine hydrochloride (Benadryl) C. Orphenadrine citrate (Banflex) D. Phenindamine hydrochloride (Neo-Synephrine)

A. Benztropine mesylate (Cogentin) Rationale: Benztropine mesylate (Cognentin) is an anticholinergic medication used to control of tremor and rigidity and counteracts the action of acetylcholine with Parkinson disease. Hardly used because of their modest benefit and bad side effects such as impaired memory, confusion to name a few.

Antiretroviral medications as post exposure prophylaxis for health care workers are started within ____ hours of exposure A. 24 hours B. 72 hours C. 36 hours D. 12 hours

B. 72 hours

Which patient is at highest risk for venous thromboembolism? A. A 50 year old postoperative patient B. A 25-year old patient with central venous catheter in place to treat septicemia C. A 71-year old otherwise healthy older adult D. A pregnant 30-year old woman due in 2 weeks.

B. A 25-year old patient with central venous catheter in place to treat septicemia Rationale: Some risk factors for venous thromboembolism include but are not limited to age older than 65 years, patients undergoing surgery, central venous catheter placement, septicemia, and pregnancy. The client in this question with two risk facts is the 25 year old with a central venous catheter is place to treat septicemia. All other patients only have one risk factor.

The nurse is caring for a patient in the clinic setting who complains of vaginal discharge that is thick with a white, cottage cheese-like appearance. The patient states that she has pruritus and irritation. The symptoms seem to be more severe just before menstruation. What should the nurse expect to be included in the plan of care for this patient? A. Clindamycin (Cleocin) B. Fluconazole (Diflucan) C. Metronidazole (Flagyl) D. Tinidazole (Tindamax)

B. Fluconazole (Diflucan) Rationale: This patient presents with symptoms of a candidiasis infection which should the treated with an anti fungal agent such as Diflucan. The other three medications are anti-infectives used to treat bacterial vaginosis and trichomoniasis.

The nurse is caring for a patient after a hysterectomy. The patient presents with increased HR, decreased BP, weak pedal pulses and decreased UOP. Which complication of a hysterectomy should the nurse be concerned about? A. Bladder dysfunction B. Hemorrhage C. Pain D. Venuous thromboembolism

B. Hemorrhage Rationale: Signs of hemorrhage include signs of decreased cardiac output such as decreased BP increased HR, weak pulses and decreased UOP. Venous thromboembolism would cause leg pain, redness warmth and edema. Bladder dysfunction would be indicated by abdominal distention and decreased UOP. Hypotension and decreased pulses are not signs of pain.

Which instruction would be appropriate to include in discharge instructions after cataract surgery with a lens implant? A. Sleep on the side of the affected eye the night after surgery B. Resume normal activities on postoperative day 2 C. Avoid bending or stooping for an extended period D. Attempt to hold in sneeze if it occurs

C. Avoid bending or stooping for an extended period Discharge instructions should include: Avoid lying on the side of the affected eye the night after surgery Keep activity light (e.g., walking, reading, watching television). Resume the following activities only as directed by the ophthalmologist driving, sexual activity, unusually strenuous activity Avoid lifting, pushing, or pulling objects heavier than 15 lbs Avoid bending or stooping for an extended period Be careful when climbing and descending stairs Sneezing if necessary should not be held in because it would increase IOP. Sneezing should be done with an open mouth to decrease pressure

The nurse is teaching a patient diagnosed with peripheral arterial disease (PAD). What should be included in the teaching plan? A. Elevate the lower extremities B. Exercise is discouraged C. Keep the lower extremities in a neutral or dependent position D. PAD should not cause pain

C. Keep the lower extremities in a neutral or dependent position Rationale: For patients with PAD, blood flow to the lower extremities needs to be enhanced; therefore, the nurse encourages keeping the lower extremities in a neutral or dependent position. In contrast, for patients with venous insufficiency, blood return to the heart needs to be enhanced, so the lower extremities ae elvated. Exercise can be prescribed to aid in the development of collateral circulation. Some pain is associated with PAD

When educating the public about eye safety, the nurse would instruct that if chemical exposure or irritant to the eye occurs the eye should be flushed with water for how long? A. 5 minutes B. 10 minutes C. 15 minutes D. 20 minutes

D. 20 minutes Rationale: When an exposure occurs, the eye should be continously flushed with tap water for 20 minutes. It is important to begin the flushing process within 5 minutes for the best outcome. Additional education should include saving the bottle or container, if a chemical exposure, for the emergency response providers so the chemical involved is known to provide further emergent care.

Which woman is at highest risk for cervical cancer? A. A 25-year old woman who smokes and has multiple sexual partners B. A 40-year old woman who had her first child at age 19 years and has been exposed to HPV C. A 18-year old woman who has just had her first sexual encounter D. An obese 30-year old woman who has nutritional deficiencies and a family history of cervical cancer

D. An obese 30-year old woman who has nutritional deficiencies and a family history of cervical cancer Rationale: Risk factors for cervical cancer include but are not limited to smoking, multiple sexual partners, first child at an early age, exposure to HPV, first sexual encounter at an early age, obesity, nutritional deficiencies, and a family history of cervical cancer. All patients have risk factors, but the 40-year old woman has the most (three: obesity, nutritional deficiencies, and family history)

__________________ is a clinical syndrome that is characterized by a progressive decline in cognitive, behavioral, and motor functions as a direct result of HIV infection: A. Cryptococcal meningitis B. Neuropathy C. Progressive multifocal leukoencephalopathy D. HIV encephalopathy

D. HIV encephalopathy