Exam 1 Sakai Self-Assessment Quiz
(hematology) Which patient statement to the nurse indicates a need for additional instruction about taking oral ferrous sulfate? A. "I will call my health care provider if my stools turn black." B. " I will take a stool softener if I feel constipated occasionally." C. "I should take the iron with orange juice about an hour before eating." D. "I should increase my fluid and fiber intake while I am taking iron tablets."
A. "I will call my health care provider if my stools turn black." rationale: Iron supplements are expected to cause black stools, as the GI tract excretes excess iron. This is a normal finding.
(peri-op) Which of the following precautions are taken in the surgical area to keep the patient safe? (Select all that apply.) A. 'Time out' for surgical site and procedure verification. B. Sponge count at the beginning and end of surgery. C. Restrict unnecessary personnel from entering the operating room. D. Use of goggles and face shields by surgical team. E. Keeping the room temperature above 72 degrees.
A. 'Time out' for surgical site and procedure verification. B. Sponge count at the beginning and end of surgery. C. Restrict unnecessary personnel from entering the operating room. rationale: D- incorrect: used to protect staff, not patient E- incorrect: temperature should be 68 degrees
(cancer) The nurse is caring for a patient on the Bone Marrow Transplant Unit who received an allogeneic stem cell transplant 1 week ago. The nurse assesses for Graft vs Host Disease by assessing for: (Select all that apply). A. Abdominal pain B. Blistering of the skin C. Blurred vision D. Desquamation of the palms E. Diarrhea
A. Abdominal pain B. Blistering of the skin D. Desquamation of the palms E. Diarrhea rationale- Acute GVHD (rejection) typically involves the patient's skin, gut, and liver. A (gut), B (skin), D (skin), and E (gut) are typical S/S of acute GVHD.
(peri-op) Which of the following nursing interventions are appropriate for preventing respiratory complications after abdominal surgery? (Select all that apply.) A. Ambulating the patient as soon as possible after surgery. B. Assisting the patient to use the incentive spirometer. C. Assessing vital signs every 4 hours for the first 72 hours. D. Providing a pillow to facilitate splinting while coughing and deep-breathing. E. Assessing output from abdominal drain every 8 hours.
A. Ambulating the patient as soon as possible after surgery. B. Assisting the patient to use the incentive spirometer. D. Providing a pillow to facilitate splinting while coughing and deep-breathing. rationale: While assessing VS and drains is important, it does not PREVENT respiratory complications (C and E).
(CVAD) The nurse is attempting to flush a central line catheter and meets resistance. Which of the following is the best first action to take? A. Ask the patient to change positions and cough B. Apply more pressure when attempting to flush C. Use a smaller syringe to flush the catheter D. Change the dressing, then attempt to flush again
A. Ask the patient to change positions and cough rationale: Resistance might mean that the catheter is pressed up against the blood vessel wall and by the patient changing positions and/or coughing, the catheter comes off the wall where blood can then be extracted. Never apply force into a blocked catheter, as that might cause a catheter clot to become embolic. Also never use a smaller syringe, as the resultant intraluminal pressure is inversely related (small syringe, very large pressure) leading to dislodging a clot to become embolic again. Changing the dressing has nothing to do with the inside of the catheter lumen.
(leukemia and lymphoma) An appropriate nursing intervention for a patient with non-Hodgkin's lymphoma whose platelet count drops to 18,000ul during chemotherapy is to: A. Check all stools for 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 blood Feedback: Checking for blood in all body fluids (such as Guiac testing on stools) is an important assessment to identify microscopic bleeding in the presence of low platelet counts
(cancer) A patient is receiving Adriamycin to treat his non-Hodgkin's lymphoma. The nurse is reviewing the patient's laboratory results. Which of the following results would indicate the patient could be experiencing tumor lysis syndrome? (Select all that apply) A. Elevated phosphate level B. Decreased hemoglobin level C. Decreased calcium level D. Increased potassium level E. Decreased albumin level
A. Elevated phosphate level C. Decreased calcium level D. Increased potassium level rationale- Tumor lysis syndrome results from the lysing of cancer cells where intracellular ions enter the bloodstream. This causes hyperkalemia, hyperphospatemia, and hyperuricemia (thus hypomagnesemia and hypocalcemia).
(end of life) Which of the following are the nurse's primary concerns when providing end-of-life care for a client and family? (Select all that apply). A. Maintaining client comfort B. Arranging plans for after death C. Supporting family members D. Providing personal care E. Completing a head-to-toe assessment F. Encouraging fluids
A. Maintaining client comfort B. Arranging plans for after death C. Supporting family members D. Providing personal care rationale: All of these are important concerns for the nurse caring for a dying patient and to help their family prepare and grieve. A complete physical assessment is unnecessary since the goals of care have changed, however focused attention to breathing pattern, pain, other concerning symptoms, and urine output will offer key information as the death approaches. Encouraging fluids will prolong the inevitable and patients often have a decreased thirst as their body prepares to die.
(cancer) You are caring for a patient who has just been told that her stage IV colon cancer has recurred and metastasized to the liver and is causing liver impairment. The oncologist offers the patient the option of surgery to treat this complication from the disease. What type of surgery does the oncologist offer? A. Palliative B. Salvage C. Reconstructive D. Prophylactic
A. Palliative Feedback: This is a from of palliative treatment since the disease has relapsed after stage 4 diagnosis (worst) with confirmed metastasis to the liver and terminal at this point. Cure is no longer a feasible option. Palliation is designed to offer comfort and relieve end of life symptoms (reduce liver failure).
(peri-op) Which of the following patients has the greatest risk for developing a VTE post-operatively? A. Patient 1. 36-year old female, history of smoking and oral contraceptive use B. Patient 2. 58-year obese male, history of alcoholism C. Patient 3. 54-year old female, history of cocaine abuse and smoking D. Patient 4. 76-year old male with unilateral leg edema and a previous history of abdominal surgery
A. Patient 1. 36-year old female, history of smoking and oral contraceptive use rationale: smoking and oral contraceptive use doubles the risk of acquiring a DVT. Incorrect: B. Alcoholism is not a risk factor (obesity is a risk factor). C. Cocaine abuse is not a risk factor (smoking is a risk factor). D. Older adult is a risk factor (previous history of abdominal surgery is not a risk factor; unilateral leg edema is a manifestation of a VTE, not a risk factor.)
(hematology) Which of the following interventions are appropriate to include for a patient diagnosed with neutropenia? (Select all that apply). A. Shower daily B. Frequent handwashing C. Private room while hospitalized D. Use soft-bristle tooth brush E. Prevent constipation
A. Shower daily B. Frequent handwashing C. Private room while hospitalized rationale: (D and E are for Thrombocytopenia)
(peri-op) The nurse is creating the plan of care for a patient who is admitted to the nursing unit after orthopedic surgery this morning. What is the most important short-term goal for this patient? A. Relief of pain B. Adequate respiratory function C. Resumption of activities of daily living (ADLs) D. Unimpaired wound healing
B. Adequate respiratory function rationale: Promoting respiratory function post-operatively reduces serious complications such as blood clots, atelectasis, and pneumonia
(leukemia and lymphoma) The nurse is caring for 4 patients with acute myelogenous leukemia. After receiving change-of-shift report, which patient should the nurse assess first? A. A 56-year old with frequent explosive diarrhea B. A 33-year old with a fever of 100.8F C. A 66-year old who has white pharyngeal lesions D. A 23-yar old who is complaining of severe fatigue
B. A 33-year old with a fever of 100.8F Feedback: Neutropenic fever is a medical emergency
(leukemia and lymphoma) A patient who has acute myelogenous leukemia (AML) is considering treatment with a hematopoietic stem cell transplant (HSCT). The best approach for the nurse to assist the patient a treatment decision is to: A. Discuss the need for insurance to cover post-HSCT care. B. Ask whether there are questions or concerns about HSCT. C. Emphasize the positive outcomes of a bone marrow transplant. D. Explain that a cure is not possible with any treatment except HSCT.
B. Ask whether there are questions or concerns about HSCT. Feedback: This is an open-ended question that will likely allow the patient to ask any questions about the treatment (HSCT) they may have
(peri-op) A patient with a total hip replacement is progressing well and expects to be discharged tomorrow. On returning to bed after ambulating, he complains of a new onset of pain at the surgical site. What is the nurse's best action? A. Administer pain medication as ordered. B. Assess the surgical site and the affected extremity. C. Reassure the patient that pain is a direct result of increased activity. D. Assess the patient for signs and symptoms of systemic infection.
B. Assess the surgical site and the affected extremity. feedback: New onset joint pain may indicate a serious complication that the joint could have been dislocated out of place when getting back into the bed due to improper positioning. This needs immediate attention.
(peri-op) When the nurse is performing a physical examination of a patient who smokes and who is preparing for surgery, it is especially important to: A. Calculate the pack-years of smoking history. B. Auscultate the lungs for normal and adventitious breath sounds. C. Encourage the patient to stop smoking during the postoperative period. D. Tell the patient that smoking increases the risk for postoperative respiratory complications.
B. Auscultate the lungs for normal and adventitious breath sounds. rationale: People who smoke are at increased risk for respiratory complications and a thorough respiratory assessment is necessary to know the patient's baseline and to identify potential complications such as atelectasis and pneumonia
(hematology) Which intervention will be included in the nursing care plan for a patient with immune thrombocytopenic purpura? 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.
B. Avoid intramuscular (IM) injections. rationale: IM injections are contraindicated with ITP (or anytime there is a reduce amount of circulating platelets) which could lead to bleeding within the muscle; and without adequate platelet levels, the bleeding will not stop leading CV collapse with continued blood loss
(leukemia and lymphoma) In caring for a patient diagnosed with Hodgkin's lymphoma, the nurse would expect to see which of the following clinical manifestations? (Select all that apply) A. Blood in the stool B. Enlarged lymph nodes C. Fatigue D. Alcohol-induced pain E. Lower extremity edema
B. Enlarged lymph nodes C. Fatigue D. Alcohol-induced pain Feedback: B, C, and D are common S/S of HL. A and E are not typical S/S of this disease
(peri-op) What is the most important preoperative teaching point to discuss with a patient scheduled for abdominal surgery? A. How to care for the wound. B. How to deep breathe and cough. C. What medications will be used during surgery. D. What drains and tubes will be present after surgery.
B. How to deep breathe and cough. rationale: Deep breathing and coughing helps prevent respiratory complications post-surgery.
(cancer) The nurse is admitting an oncology patient to the unit prior to surgery. The nurse notes that the patient has just finished radiation therapy to the chest. The nurse should prioritize assessments related to which potential health problem? A. Impaired gas exchange B. Impaired wound healing C. Cardiac dysrhythmias D. Tumor lysis syndrome
B. Impaired wound healing Feedback: Radiation therapy can cause dry or wet desquamation and thus impaired wound healing.
(peri-op) A patient is on call to the OR for an lower extremity vascular surgery and the nurse administers the ordered preoperative medication. After administering a preoperative medication to the patient, what is a priority for the nurse to do? A. Encourage light ambulation. B. Place the bed in a low position with the side rails up. C. Tell the patient that he will be asleep before he leaves for surgery. D. Take the patient's vital signs every 15 minutes.
B. Place the bed in a low position with the side rails up. rationale: At this point, the patient has been sedated and is at high risk for falling. Care including bed in the low position and side rails up helps prevent falls in a patient with an altered state of mind.
(cancer) A patient receiving chemotherapy develops oral candidiasis. Which nursing care is appropriate for this patient? (Select all that apply.) A. Keep patient NPO B. Provide oral care to patient ac, pc, hs, and prn C. Instruct patient to avoid dairy products D. Encourage patient to avoid fluids with meals E. Educate patient to 'swish and swallow' ordered nystatin
B. Provide oral care to patient ac, pc, hs, and prn E. Educate patient to 'swish and swallow' ordered nystatin rationale: B. Because candidiasis is a yeast infection (Thrush) and frequent oral care is required. E. Nystatin is an anti-fungal and used to treat candidiasis.
(cancer) A patient with a large stomach tumor that is attached to the liver is scheduled to have a debulking procedure. The nurse explains that the expected outcome of this surgery is: A. relief of pain by cutting sensory nerves in the stomach. B. reduction of the tumor burden to enhance adjuvant therapy. C. control of tumor growth by removal of malignant tissue. D. promotion of better nutrition by relieving the pressure in the stomach.
B. reduction of the tumor burden to enhance adjuvant therapy. rationale- Some treatments (such as surgery, radiation, and some chemotherapies) are often utilized or designed to debulk (or shrink) the tumor before adjuvant therapy begins. This reduces the number of cancer cells (in the tumor mass that was removed or killed) and stimulates the remaining disease to begin rapid division afterwards, which then helps the adjuvant treatment work better (targeting fast dividing cells).
(blood transfusion) The nurse is administering one unit of PRBCs to a patient. After 25 minutes, the patient complains of chills, headache, anxiety, and has a temperature of 101.2F. After stopping the transfusion, what action should the nurse take? A. Make sure the patient signed the consent for the blood transfusion B. Administer acetaminophen (Tylenol) ordered prn C. Contact the blood bank to inform them of the transfusion reaction D. Restart the transfusion at a slower rate
C. Contact the blood bank to inform them of the transfusion reaction rationale: These are some of the S/S of a febrile reaction to the blood product. After stopping the transfusion and notifying the health care provider, the nurse should contact the blood bank to inform them and follow their institutional policies and procedures when a transfusion reaction is suspected.
(blood transfusion) The nurse is preparing to administer 1 unit of PRBCs to a patient. Which intravenous solution is compatible with this blood product? A. Lactated Ringers (LR) B. 5% Dextrose and water (D5W) C. Normal saline (NS) D. 5% dextrose and normal saline (D5NS)
C. Normal saline (NS) rationale: 0.9 Normal saline is the ONLY compatible fluid that should be used to prime the tubing and to flush the line after the blood product has been transfused.
(CVAD) A patient is receiving an intravenous antibiotic through a long-term central venous access device that has an open-ended tip. Which of the following is the appropriate method to flush the catheter after administration of the medication? A. Saline B. Heparin C. Saline, then heparin D. Heparin, then saline
C. Saline, then heparin rationale: Saline first to flush previous drug through the catheter and then heparin to act as a space occupier and to reduce blood backflow and clotting of the CVAD.
(peri-op) Following bowel surgery, a patient has been receiving normal saline IV fluids at 100 ml/hr, has a nasogastric tube to low, intermittent suction, and is NPO. An assessment finding that would alert the nurse to a major fluid and electrolyte problem is: A. weight gain. B. flushed, moist skin. C. a decreasing level of consciousness. D. a serum sodium level of 138 mEq/L (138 mmol/L).
C. a decreasing level of consciousness. rationale: A decreasing LOC may indicate that a serious fluid shift and altered serum electrolyte imbalance is present (acid base imbalance or altered sodium levels.
(cancer) A patient is complaining that her skin itches in the area where she is receiving external beam radiation. What is the best response by the nurse: A. "If you place a warm, moist towel on the area for 20 minutes when it starts to itch, that will relieve the discomfort." B. "It's ok to scratch the area as long as your hands are clean." C. "If you avoid tight clothing and direct sunlight, that will prevent the itching." D. "Ask the nurse in the radiation department for an approved lotion to lubricate the area."
D. "Ask the nurse in the radiation department for an approved lotion to lubricate the area." rationale- Although skin care protocols vary, basic skin care principles apply. Lubricate dry skin with non-irritating lotion emollients that contain no metal, alcohol, perfume, or additives. These can be irritating.
(peri-op) During a preoperative assessment, the nurse identifies a risk for latex allergy in the patient who reports an allergy to: A. Iodine. B. Penicillin. C. Eggs and milk. D. Avocados and bananas.
D. Avocados and bananas. rationale: Risk factors for a latex allergy include long-term, multiple exposures to latex products and a history of hay fever, asthma, and certain food allergies to eggs, avocados, bananas, chestnuts, potatoes, and peaches.
(end of life) Which of the following remains the greatest barrier to improving end-of-life care? A. Advances in technology available to prolong life B. Clinician's attitudes toward terminally ill C. Client and family denial about seriousness of the illness D. Focus on managing acute illness to achieve a cure
D. Focus on managing acute illness to achieve a cure rationale: End of life care focuses on issues related to death and dying, when a cure is no longer possible. Goals of care change from trying to obtain a cure to preparing for the inevitable death and focusing on quality of life and symptom management and providing comfort in a holistic manner.
(peri-op) The PACU nurse is caring for a male patient who had a hernia repair. The patient's blood pressure is now 164/92 mm Hg; he has no history of hypertension prior to surgery and his preoperative blood pressure was 112/68 mm Hg. The nurse should assess for what potential causes of hypertension following surgery? A. Dysrhythmias, blood loss, and hyperthermia B. Electrolyte imbalances and neurologic changes C. A parasympathetic reaction and low blood volumes D. Pain, hypoxia, or bladder distention
D. Pain, hypoxia, or bladder distention rationale All of these could cause hypertension in the absence of other obvious causes of high blood pressure. A and C would likely cause hypotension.
(cancer) The charge nurse on a large med-surg unit is notified that 4 female patients will be admitted to the unit. Which patient will need a private room? A. Patient 1: Transfer from PACU after undergoing a bilateral mastectomy; has 2 Jackson-Pratt drains B. Patient 2: Admission from the Emergency Department with pneumonia; on IV antibiotics C. Patient 3: Transfer from ICU with stable angina; on continuous cardiac monitoring D. Patient 4: Admission from the radiology department with newly inserted applicators; scheduled to have brachytherapy started today Rationale:
D. Patient 4: Admission from the radiology department with newly inserted applicators; scheduled to have brachytherapy started today Rationale: patient with brachytherapy needs a private room because they are the source of radiation.
(peri-op) A nurse on the med-surg unit has just received change-of-shift report. All 4 patients had abdominal surgery with general anesthesia on the previous shift. Which of the following patients is a priority to assess first? A. Patient 1: Complains of abdominal pain 6/10; has a PCA pump B. Patient 2: Has not voided in 5 hours; Oxygen saturation = 93% C. Patient 3: Asking for assistance to use the incentive spirometer; requesting to sit up in the chair D. Patient 4: Complains of nausea; IV 5% dextrose and water infusing at 125 ml/hr
D. Patient 4: Complains of nausea; IV 5% dextrose and water infusing at 125 ml/hr rationale: Risk for Aspiration. Airway is the priority. Turn patient's head or elevate HOB to prevent aspiration. Administer (or obtain order for) antiemetic.
