Chapter 8

9. As a home health nurse, you are obtaining an admission history for a patient who has deep vein thrombosis and is taking warfarin (Coumadin) 2 mg daily. Which statement by the patient is the best indicator that additional teaching about warfarin may be needed? 1. "I have started to eat more healthy foods like green salads and fruit." 2. "The doctor said that it is important to avoid becoming constipated." 3. "Coumadin makes me feel a little nauseated unless I take it with food." 4. "I will need to have some blood testing done once or twice a week."

1. "I have started to eat more healthy foods like green salads & fruit"

24. After receiving the change-of-shift report, which pt will you assess first? 1. 20-year old with possible acute myelogenous leukemia who has just arrived to the unit 2. 38-year old with aplastic anemia who needs teaching about decreasing infection risk before discharge 3. 40-year old with lymphedema who requests help in putting on compression stockings before getting out of bed 4. 60-year old with non-Hodgkin lymphoma who is refusing the prescribed chemotherapy regimen

1. 20-year old with possible acute myelogenous leukemia who has just arrived to the unit

15. A group of patients is assigned to an RN-LPN/LVN team. The LPN/LVN should be assigned to provide patient care and administer medications to which patient? 1. 36-year-old with chronic kidney failure who will need a subcutaneous injection of epoetin alfa (Procrit) 2. 39-year-old with hemophilia B who has been admitted to receive a transfusion of PRBCs 3. 50-year-old with newly diagnosed polycythemia vera who will require phlebotomy 4. 55-year-old with a history of stem cell transplantation who has a bone marrow aspiration scheduled

1. 36-year old with chronic kidney failure who will need a SQ injection of epoetin alfa

4. These activities are included in the care plan for a 78-year-old patient admitted to the hospital with anemia caused by possible gastrointestinal bleeding. Which activity can you delegate to an experienced UAP? 1. Obtaining stool specimens for fecal blood test (Hemoccult) slides 2. Having the patient sign a colonoscopy consent form 3. Giving the prescribed polyethylene glycol electrolyte solution (GoLYTELY) 4. Checking for allergies to contrast dye or shellfish

1. Obtaining stool specimens for a fecal blood test slides

6. You are making a room assignment for a newly arrived patient whose laboratory test results indicate pancytopenia. Which patient will be the best roommate for the new patient? 1. Patient with digoxin toxicity 2. Patient with viral pneumonia 3. Patient with shingles 4. Patient with cellulitis

1. Pt with digoxin toxicity

21. A patient with acute myelogenous leukemia is receiving induction-phase chemo. Which assessment finding requires the most rapid action? 1. Serum potassium level of 7.8 2. Urine output less thank intake by 400 mL 3. Inflammation & redness of the oral mucosa 4. Ecchymoses present on anterior trunk

1. Serum potassium level of 7.8

3. A 32-year-old patient with sickle cell anemia is admitted to the hospital during a sickle cell crisis. Which action prescribed by the health care provider will you implement first? 1. Give morphine sulfate 4 to 8 mg IV every hour as needed. 2. Administer 100% oxygen using a nonrebreather mask. 3. Start a 14-gauge IV line and infuse normal saline at 200 mL/ hr. 4. Give pneumococcal (Pneumovax) and Haemophilus influenzae (ActHIB) vaccines.

2. Administer 100% oxygen using a nonrebreather mask

13. A patient in a long-term care (LTC) facility who has chronic lymphocytic leukemia has a nursing diagnosis of Activity Intolerance related to weakness and anemia. Which nursing activity will you delegate to the UAP? 1. Evaluating the patient's response to normal activities of daily living 2. Checking the patient's blood pressure and pulse rate after ambulation 3. Determining which self-care activities the patient can do independently 4. Assisting the patient in choosing a diet that will improve strength

2. Checking the pt's B/P & pulse after ambulation

22. A patient who has been receiving cyclosporine following an organ transplantation is experiencing the following symptoms. Which one is of most concern? 1. Bleeding of the gums while brushing the teeth 2. Non-tender lump in the right groin 3. Occasional nausea after taking the medication 4. Numbness & tingling of the feet

2. Non-tender lump in the right groin

17. The nurse in an outpatient clinic is assessing a 22-year old who required a splenectomy after a recent motor vehicle accident. Which information obtained will be of most immediate concern to the nurse? 1. Pt has unprotected sex 2. Oral temperature is 100 F 3. There is abdominal pain with light palpation 4. Pt admits to occasional marijuana use

2. The oral temperature is 100 F

8. After a car accident, a patient with a medical alert bracelet indicating hemophilia A is admitted to the emergency department (ED). Which action prescribed by the health care provider will you implement first? 1. Transport to the radiology department for cervical spine radiography. 2. Transfuse factor VII concentrate. 3. Type and cross-match for 4 units of packed red blood cells (PRBCs). 4. Infuse normal saline at 250 mL/hr.

2. Transfuse factor VII concentrate

7. A 67-year-old who is receiving chemotherapy for lung cancer is admitted to the hospital with thrombocytopenia. Which statement made by the patient when you are obtaining the admission history is of most concern? 1. "I've noticed that I bruise more easily since the chemotherapy started." 2. "My bowel movements are soft and dark brown." 3. "I take one aspirin every morning because of my history of angina." 4. "My appetite has decreased since the chemotherapy started."

3. "I take one aspirin every morning because of my history of angina"

11. A 22-year-old with stage I Hodgkin disease is admitted to the oncology unit for radiation therapy. During the initial assessment, the patient tells you, "Sometimes I'm afraid of dying." Which response is most appropriate at this time? 1. "Many individuals with this diagnosis have some fears." 2. "Perhaps you should ask the doctor about medication." 3. "Tell me a little bit more about your fear of dying." 4. "Most people with stage I Hodgkin disease survive."

3. "Tell me a little bit more about your fear of dying"

5. As charge nurse, you are making the daily assignments on the medical-surgical unit. Which patient is best assigned to a float nurse who has come from the postanesthesia care unit (PACU)? 1. 30-year-old patient with thalassemia major who has an order for subcutaneous infusion of deferoxamine (Desferal) 2. 43-year-old patient with multiple myeloma who requires discharge teaching 3. 52-year-old patient with chronic gastrointestinal bleeding who has returned to the unit after a colonoscopy 4. 65-year-old patient with pernicious anemia who has just been admitted to the unit

3. 52-year old pt with chronic gastrointestinal bleeding who has returned to the unit after a colonoscopy

18. A patient with graft-versus-host disease after bone marrow transplantation is being cared for on the medical unit. Which nursing activity is best to be delegated to the travel RN? 1. Administering oral cyclosporine to the pt 2. Assessing the pt for s/s of infection caused by GVHD 3. Infusing 5% dextrose in 0.45% saline at 125mL/hr 4. Educating the pt about ways to prevent & detect infection

3. Infusing 5% dextrose in 0.45% saline at 125mL/hr

19. You are the charge nurse on an oncology unit when a patient with an absolute neutrophil count of 300/μL is admitted. Which staff member should you assign to provide care for this patient, under the supervision of an experienced oncology RN? 1. LPN/LVN who has floated from the same-day surgery unit 2. RN from a staffing agency who is being oriented to the oncology unit 3. LPN/LVN with 2 years of experience on the oncology unit 4. RN who recently transferred to the oncology unit from the ED

3. LPN/LVN with 2 yrs experience on the oncology unit

2. You are providing orientation for a new RN who is preparing to administer packed red blood cells (PRBCs) to a patient who had blood loss during surgery. Which action by the new RN requires that you intervene immediately? 1. Waiting 20 minutes after obtaining the PRBCs before starting the infusion 2. Starting an IV line for the transfusion using a 22-gauge catheter 3. Priming the transfusion set using 5% dextrose in lactated Ringer's solution 4. Telling the patient that the PRBCs may cause a serious transfusion reaction

3. Priming the transfusion set using 5% dextrose in lactated Ringer's solution

14. A transfusion of PRBCs has been infusing for 5 minutes when the patient becomes flushed and tachypneic and says, "I'm having chills. Please get me a blanket." Which action should you take first? 1. Obtain a warm blanket for the patient. 2. Check the patient's oral temperature. 3. Stop the transfusion. 4. Administer oxygen.

3. Stop the transfusion

10. A patient is admitted to the intensive care unit with disseminated intravascular coagulation associated with a gram-negative infection. Which assessment information has the most immediate implications for the patient's care? 1. There is no palpable radial or pedal pulse. 2. The patient reports chest pain. 3. The patient's oxygen saturation is 87%. 4. There is mottling of the hands and feet.

3. The pt's oxygen saturation is 87%

12. You receive a change-of-shift report about the following patients. Which one will you assess first? 1. 26-year-old with thalassemia who has a hemoglobin level of 8 g/L and orders for a PRBC transfusion 2. 44-year-old who was admitted 3 days previously in a sickle cell crisis and has orders for a computed tomographic scan 3. 50-year-old with stage IV non-Hodgkin lymphoma who is crying and saying, "I'm not ready to die" 4. 69-year-old with chemotherapy-induced neutropenia who has an oral temperature of 100.1° F (37.8° C)

4. 69-year old with chemotherapy-induced neutropenia who has an oral temperature of 100.1 F

23. A patient with Hodgkin lymphoma who is receiving radiation therapy to the groin area has skin redness & tenderness to the area. Which nursing activity can be delegated to the UAP? 1. Checking the skin for signs of redness or peeling 2. Assisting the pt in choosing appropriate clothing 3. Explaining good skin care to the pt & family 4. Cleaning the skin over the area daily with mild soap

4. Cleaning the skin over the area daily with mild soap

16. You obtain the following data about a patient admitted with multiple myeloma. Which information has the most immediate implications for the patient's care? 1. The patient reports chronic bone pain. 2. The blood uric acid level is very elevated. 3. The 24-hour urine test shows Bence Jones proteins. 4. The patient reports new-onset leg numbness.

4. The pt reports new-onset leg numbness

20. You are transferring a patient with newly-diagnosed chronic myeloid leukemia to an LTC facility. Which information is most important to communicate to the LTC charge nurse before transferring the patient? 1. Philadelphia chromosome is present in the patient's blood smear. 2. Glucose level is elevated as a result of prednisone (Deltasone) therapy. 3. There has been a 20-lb weight loss over the last year. 4. The patient's chemotherapy has resulted in neutropenia.

4. The pt's chemotherapy has resulted in neutropenia

1. You are reviewing the complete blood count for a patient who has been admitted for knee arthroscopy. Which value is most important to report to the physician before surgery? 1. Hematocrit of 33% 2. Hemoglobin level of 10.9 g/ dL 3. Platelet count of 426,000/ mm3 4. White blood cell count of 16,000/ mm3

4. White blood cell count of 16,000