Exam 4 Review

14. A patient with pancytopenia of unknown origin is scheduled for the following diagnostic tests. The nurse will provide a consent form to sign for which test? a.Bone marrow biopsy b.Abdominal ultrasound c.Complete blood count (CBC) d.Activated partial thromboplastin time (aPTT)

ANS: A A bone marrow biopsy is a minor surgical procedure that requires the patient or guardian to sign a surgical consent form. The other procedures do not require a signed consent.

25.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.

ANS: A Because the patient is at risk for spontaneous bleeding, the nurse should check stools for occult blood. A low platelet count does not require an increased fluid intake. Oral hygiene is important, but it is not necessary to provide oral care every 2 hours. The low platelet count does not increase risk for infection, so frequent temperature monitoring is not indicated.

6.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."

ANS: A It is normal for the stools to appear black when a patient is taking iron, and the patient should not call the health care provider about this. The other patient statements are correct.

31.Which patient should the nurse assign as the roommate for a patient who has aplastic anemia? a.A patient with chronic heart failure b.A patient who has viral pneumonia c.A patient who has right leg cellulitis d.A patient with multiple abdominal drains

ANS: A Patients with aplastic anemia are at risk for infection because of the low white blood cell production associated with this type of anemia, so the nurse should avoid assigning a roommate with any possible infectious process.

33. A patient 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. 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.

ANS: A 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. The other data all indicate that bleeding caused by ITP may be occurring and that the platelet transfusion is appropriate.

47.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 mostimportant to communicate to the health care provider? History Physical Assessment Laboratory Results · Fatigue, which has increased over last month · Frequent constipation · Conjunctiva pale pink, moist · Multiple bruises · Clear lung sounds · Hct 33% · WBC 1500/µL · Platelets 70,000/µL a. Neutropenia c. Increasing fatigue b. Constipation d. Thrombocytopenia

ANS: A The low white blood cell count indicates that the patient is at high risk for infection and needs immediate actions to diagnose and treat the cause of the leukopenia. The other information may require further assessment or treatment but does not place the patient at immediate risk for complications.

21. An older adult with chronic human immunodeficiency virus (HIV) infection who takes medications for coronary artery disease and hypertension has chosen to begin early antiretroviral therapy (ART). Which information will the nurse include in patient teaching? a.Many drugs interact with antiretroviral medications. b.HIV infections progress more rapidly in older adults. c.Less frequent CD4+ level monitoring is needed in older adults. d.Hospice care is available for patients with terminal HIV infection.

ANS: A The nurse will teach the patient about potential interactions between antiretrovirals and the medications that the patient is using for chronic health problems. Treatment and monitoring of HIV infection is not affected by age. A patient beginning early ART is not a candidate for hospice. Progression of HIV is not affected by age although it may be affected by chronic disease.

4. An older adult patient who is having an annual check-up tells the nurse, "I feel fine, and I don't want to pay for all these unnecessary cancer screening tests!" Which information should the nurse plan to teach this patient? a. Consequences of aging on cell-mediated immunity b. Decrease in antibody production associated with aging c. Impact of poor nutrition on immune function in older people d. Incidence of cancer-associated infections in older individuals

ANS: A The primary impact of aging on immune function is on T cells, which are important for immune surveillance and tumor immunity. Antibody function is not affected as much by aging. Poor nutrition can also contribute to decreased immunity, but there is no evidence that it is a contributing factor for this patient. Although some types of cancer are associated with specific infections, this patient does not have an active infection.

11.The complete blood count (CBC) indicates that a patient is thrombocytopenic. Which action should the nurse include in the plan of care? a.Avoid intramuscular injections. c.Check temperature every 4 hours. b.Encourage increased oral fluids. d.Increase intake of iron-rich foods.

ANS: A Thrombocytopenia is a decreased number of platelets, which places the patient at high risk for bleeding. Neutropenic patients are at high risk for infection and sepsis and should be monitored frequently for signs of infection. Encouraging fluid intake and iron-rich food intake is not indicated in a patient with thrombocytopenia.

32.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 thrombocytopenia who has oozing gums after a tooth extraction d.The patient with sickle cell anemia who has had nausea and diarrhea for 24 hours

ANS: B A neutropenic patient with a fever is assumed to have an infection and is at risk for rapidly developing sepsis. Rapid assessment, cultures, and initiation of antibiotic therapy are needed. The other patients also require rapid assessment and care but not as urgently as the neutropenic patient.

17. A patient is admitted to the hospital with acute rejection of a kidney transplant. Which intervention will the nurse prepare for this patient? a. Testing for human leukocyte antigen (HLA) match b. Administration of immunosuppressant medications c. Insertion of an arteriovenous graft for hemodialysis d. Placement of the patient on the transplant waiting list

ANS: B Acute rejection is treated with the administration of additional immunosuppressant drugs such as corticosteroids. Because acute rejection is potentially reversible, there is no indication that the patient will require another transplant or hemodialysis. There is no indication for repeat HLA testing.

21. Immediately after the nurse administers an intracutaneous injection of an allergen on the forearm, the patient complains of itching at the site, weakness, and dizziness. What action should the nurse take first? a. Apply antiinflammatory cream. b.Place a tourniquet above the site. c.Administer subcutaneous epinephrine. d.Reschedule the patient's other allergen tests.

ANS: B Application of a tourniquet will decrease systemic circulation of the allergen and should be the first reaction. The other actions may occur, but the tourniquet application slows the allergen progress into the patient's system, allowing treatment of the anaphylactic response. A local antiinflammatory cream may be applied to the site of a cutaneous test if the itching persists. Epinephrine will be needed if the allergic reaction progresses to anaphylaxis. Other testing may be delayed and rescheduled after development of anaphylaxis.

5. A patient who collects honey to earn supplemental income has developed a hypersensitivity to bee stings. Which statement, if made by the patient, would indicate a need for additional teaching? a. "I need to find a different way to earn extra money." b. "I will take oral antihistamines before going to work." c. "I will get a prescription for epinephrine and learn to self-inject it." d. "I should wear a Medic-Alert bracelet indicating my allergy to bee stings."

ANS: B Because the patient is at risk for bee stings and the severity of allergic reactions tends to increase with added exposure to allergen, taking oral antihistamines will not adequately control the patient's hypersensitivity reaction. The other patient statements indicate a good understanding of management of the problem.

7.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

ANS: B Because the patient with aplastic anemia has pancytopenia, the patient is at risk for infection and bleeding. There is no increased risk for seizures, neurogenic shock, or pulmonary edema

1. The nurse provides discharge instructions to a patient who has an immune deficiency involving the T lymphocytes. Which health screening should the nurse include in the teaching plan for this patient? a. Screening for allergies b. Screening for malignancies c. Screening for antibody deficiencies d. Screening for autoimmune disorders

ANS: B Cell-mediated immunity is responsible for the recognition and destruction of cancer cells. Allergic reactions, autoimmune disorders, and antibody deficiencies are mediated primarily by B lymphocytes and humoral immunity.

2. Which example should the nurse use to explain an infant's "passive immunity" to a new mother? a. Vaccinations b. Breastfeeding c. Stem cells in peripheral blood d. Exposure to communicable diseases

ANS: B Colostrum in breast milk provides passive immunity through antibodies from the mother. These antibodies protect the infant for a few months. However, memory cells are not retained, so the protection is not permanent. Active immunity is acquired by being immunized with vaccinations or having an infection. Stem cells are unspecialized cells used to repopulate a person's bone marrow after high-dose chemotherapy

27.Which assessment finding should the nurse caring for a patient with thrombocytopenia communicate immediately 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.

14.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.

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 in a private room.

11.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. c.gastric analysis. b.bilirubin level. d.stool occult blood.

ANS: B Jaundice is caused by the elevation of bilirubin level associated with red blood cell hemolysis. The other tests would not be helpful in monitoring or treating a hemolytic anemia.

34.Which problem reported by a patient with hemophilia is mostimportant for the nurse to communicate to the health care provider? a. Leg bruises c. Skin abrasions b. Tarry stools 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.

5. A pregnant woman with asymptomatic chronic human immunodeficiency virus (HIV) infection is seen at the clinic. The patient states, "I am very nervous about making my baby sick." Which information will the nurse include when teaching the patient? a.The antiretroviral medications used to treat HIV infection are teratogenic. b.Most infants born to HIV-positive mothers are not infected with the virus. c.Because it is an early stage of HIV infection, the infant will not contract HIV. d.Her newborn will be born with HIV unless she uses antiretroviral therapy (ART).

ANS: B Only 25% of infants born to HIV-positive mothers develop HIV infection, even when the mother does not use ART during pregnancy. The percentage drops to 2% when ART is used. Perinatal transmission can occur at any stage of HIV infection (although it is less likely to occur when the viral load is lower). ART can safely be used in pregnancy, although some ART drugs should be avoided.

8. It is important for the nurse providing care for a patient with sickle cell crisis to a.limit the patient's 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.

ANS: B Pain is the most common clinical manifestation of a crisis and usually requires large doses of continuous opioids for control. Fluid intake should be increased to reduce blood viscosity and improve perfusion. Rest is usually ordered to decrease metabolic requirements. Patients are instructed about the need for dietary folic acid, but high-protein, high-calorie diets are not emphasized.

12.Which patient should the nurse assess first? a. Patient with urticaria after receiving an IV antibiotic b. Patient who is sneezing after subcutaneous immunotherapy c. Patient who has graft-versus-host disease and severe diarrhea d. Patient with multiple chemical sensitivities who has muscle stiffness

ANS: B Sneezing after subcutaneous immunotherapy may indicate impending anaphylaxis and assessment and emergency measures should be initiated. The other patients also have findings that need assessment and intervention by the nurse, but do not have evidence of life-threatening complications.

11. Which statement by a patient would alert the nurse to a risk for decreased immune function? a. "I had a chest x-ray 6 months ago." b. "I had my spleen removed after a car accident." c. "I take one baby aspirin every day to prevent stroke." d. "I usually eat eggs or meat for at least two meals a day."

ANS: B Splenectomy increases the risk for septicemia from bacterial infections. The patient's protein intake is good and should improve immune function. Daily aspirin use does not affect immune function. A chest x-ray does not have enough radiation to suppress immune function.

22. A patient who has a history of a transfusion-related acute lung injury (TRALI) is to receive a transfusion of packed red blood cells (PRBCs). Which action by the nurse will decrease the risk for TRALI for this patient? a.Infuse the PRBCs slowly over 4 hours. b.Transfuse only leukocyte-reduced PRBCs. c.Administer the scheduled diuretic before the transfusion. d.Give the PRN dose of antihistamine before the transfusion.

ANS: B TRALI is caused by a reaction between the donor and the patient leukocytes that causes pulmonary inflammation and capillary leaking. The other actions may help prevent respiratory problems caused by circulatory overload or by allergic reactions, but they will not prevent TRALI.

19.Which action will the admitting nurse include in the care plan for a patient who has neutropenia? a.Avoid intramuscular injections. b.Check temperature every 4 hours. c.Omit fruits or vegetables from the diet. d.Place a "No Visitors" sign on the door.

ANS: B The earliest sign of infection in a neutropenic patient is an elevation in temperature. Although unpeeled fresh fruits and vegetables should be avoided, fruits and vegetables that are peeled or cooked are acceptable. Injections may be required for administration of medications such as filgrastim (Neupogen). The number of visitors may be limited and visitors with communicable diseases should be avoided, but a "no visitors" policy is not needed.

6. A patient's complete blood count (CBC) shows a hemoglobin of 19 g/dL and a hematocrit of 54%. Which question should the nurse ask to determine possible causes of this finding? a."Have you had a recent weight loss?" b."Do you have any history of lung disease?" c."Have you noticed any dark or bloody stools?" d."What is your dietary intake of meats and protein?"

ANS: B The hemoglobin and hematocrit results indicate polycythemia, which can be associated with chronic obstructive pulmonary disease. The other questions would be appropriate for patients who are anemic.

16.The nurse is caring for a patient with type A hemophilia being admitted to the hospital with severe pain and swelling in the right knee. The nurse should a.apply heat to the knee. b.immobilize the knee joint. c.assist the patient with light weight bearing. d.perform passive range of motion to the knee.

ANS: B 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 weight-bearing exercise are contraindicated initially, but after the bleeding stops, ROM and physical therapy are started.

38.Several patients call the outpatient clinic and ask to make an appointment as soon as possible. Which patient should the nurse schedule to be seen first? a. A 44-yr-old with sickle cell anemia who says his eyes always look sort of yellow b. A 23-yr-old with no previous health problems who has a nontender lump in the axilla c. A 50-yr-old with early-stage chronic lymphocytic leukemia who reports chronic fatigue d. A 19-yr-old with hemophilia who wants to learn to self-administer factor VII replacement

ANS: B The patient's age and presence of a nontender axillary lump suggest possible lymphoma, which needs rapid diagnosis and treatment. The other patients have questions about treatment or symptoms that are consistent with their diagnosis but do not need to be seen urgently.

8. The nurse taking a health history learns that the patient, who has worked in rubber tire manufacturing, has allergic rhinitis and multiple food allergies. Which action by the nurse is correct? a. Recommend that the patient use latex gloves in preventing blood-borne pathogen contact. b. Document the patient's history and teach about clinical manifestations of a type I latex allergy. c. Encourage the patient to carry an epinephrine kit in case a type IV allergic reaction to latex develops. d. Advise the patient to use oil-based hand creams to decrease contact with natural proteins in latex gloves.

ANS: B The patient's allergy history and occupation indicate a risk of developing a latex allergy. The patient should be taught about symptoms that may occur. Epinephrine is not an appropriate treatment for contact dermatitis that is caused by a type IV allergic reaction to latex. Using latex gloves increases the chance of developing latex sensitivity. Oil-based creams will increase the exposure to latex from latex gloves.

21. 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."

ANS: B This response uses therapeutic communication by addressing the patient's question and giving accurate information. The other responses either give inaccurate information or fail to address the patient's question, which will discourage the patient from asking the nurse for information.

15. A patient treated for human immunodeficiency virus (HIV) infection for 6 years has developed fat redistribution to the trunk with wasting of the arms, legs, and face. What recommendation will the nurse give to the patient? a.Review foods that are higher in protein. b.Teach about the benefits of daily exercise. c.Discuss a change in antiretroviral therapy. d.Talk about treatment with antifungal agents.

ANS: C A frequent first intervention for metabolic disorders is a change in antiretroviral therapy (ART). Treatment with antifungal agents would not be appropriate because there is no indication of fungal infection. Changes in diet or exercise have not proven helpful for this problem.

37.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

ANS: C Administration of subcutaneous medications is included in LPN/LVN education and scope of practice. Patient teaching, assessment, and developing the plan of care require RN level education and scope of practice.

3. A patient informed of a positive rapid antibody test result for human immunodeficiency virus (HIV) is anxious and does not appear to hear what the nurse is saying. What action by the nurse is mostimportant at this time? a.Teach the patient how to reduce risky behaviors. b.Inform the patient about the available treatments. c.Remind the patient about the need to return for retesting to verify the results. d.Ask the patient to identify individuals who had intimate contact with the patient.

ANS: C After an initial positive antibody test result, the next step is retesting to confirm the results. A patient who is anxious is not likely to be able to take in new information or be willing to disclose information about the HIV status of other individuals.

23.The health care provider asks the nurse whether a patient's angioedema has responded to prescribed therapies. Which assessment should the nurse perform? a.Obtain the patient's blood pressure and heart rate. b.Question the patient about any clear nasal discharge. c.Observe for swelling of the patient's lips and tongue. d.Assess the patient's extremities for wheal and flare lesions.

ANS: C Angioedema is characterized by swelling of the eyelids, lips, and tongue. Wheal and flare lesions, clear nasal drainage, and hypotension and tachycardia are characteristic of other allergic reactions.

46.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 for left upper quadrant pain. c. Schedule immunization with the pneumococcal vaccine (e.g., Pneumovax). d. Avoid the use of acetaminophen (Tylenol) for at least 2 weeks prior to surgery.

ANS: C Asplenic patients are at high risk for infection with pneumococcal infections and immunization reduces this risk. There is no need to avoid acetaminophen use before surgery, but nonsteroidal antiinflammatory drugs (NSAIDs) may increase bleeding risk and should be avoided. The enlarged spleen may decrease respiratory depth, and the patient should be encouraged to take deep breaths.

7. The nurse reviewing a clinic patient's medical record notes that the patient missed the previous appointment for weekly immunotherapy. Which action by the nurse is appropriate? a. Schedule an additional dose the following week. b. Administer the scheduled dosage of the allergen. c. Consult with the health care provider about giving a lower allergen dose. d. Re-evaluate the patient's sensitivity to the allergen with a repeat skin test.

ANS: C Because there is an increased risk for adverse reactions after a patient misses a scheduled dose of allergen, the nurse should check with the health care provider before administration of the injection. A skin test is used to identify the allergen and would not be used at this time. An additional dose for the week may increase the risk for a reaction.

10.Which instruction will the nurse plan to include in discharge teaching for a 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.

ANS: C Exposure to crowds increases the patient's risk for infection, the most common cause of sickle cell crisis. There is no restriction on caffeine use. Iron supplementation is generally not recommended. A high-fluid intake is recommended.

5. The nurse assesses a patient with pernicious anemia. Which assessment finding would the nurse expect? a.Yellow-tinged sclerae c.Numbness of the extremities b.Shiny, smooth tongue d.Gum bleeding and tenderness

ANS: C Extremity numbness is associated with cobalamin (vitamin B12) deficiency or pernicious anemia. Loss of the papillae of the tongue occurs with chronic iron deficiency. Yellow-tinged sclera is associated with hemolytic anemia and the resulting jaundice. Gum bleeding and tenderness occur with thrombocytopenia or neutropenia.

16.An older adult patient has a prescription for cyclosporine following a kidney transplant. Which information in the patient's health history has implications for planning patient teaching about the medication at this time? a. The patient restricts salt to 2 grams per day. b. The patient eats green leafy vegetables daily. c. The patient drinks grapefruit juice every day. d. The patient drinks 3 to 4 quarts of fluid each day.

ANS: C Grapefruit juice can increase the toxicity of cyclosporine. The patient should be taught to avoid grapefruit juice. Normal fluid and sodium intake or eating green leafy vegetables will not affect cyclosporine levels or renal function.

10. A patient who had a total hip replacement had an intraoperative hemorrhage 14 hours ago. Which laboratory test result would the nurse expect? a. Hematocrit of 46% b. Hemoglobin of 13.8 g/dL c. Elevated reticulocyte count d. Decreased white blood cell (WBC) count

ANS: C Hemorrhage causes the release of reticulocytes (immature red blood cells) from the bone marrow into circulation. The hematocrit and hemoglobin levels are normal. The WBC count is not affected by bleeding.

8. The nurse notes pallor of the skin and nail beds in a newly admitted patient. The nurse should ensure that which laboratory test has been ordered? a.Platelet count c.Hemoglobin level b.Neutrophil count d.White blood cell count

ANS: C Pallor of the skin or nail beds is indicative of anemia, which would be indicated by a low Hgb level. Platelet counts indicate a person's clotting ability. A neutrophil is a type of white blood cell that helps to fight infection.

9.What instructions about plasmapheresis should the nurse include in the teaching plan for a patient diagnosed with systemic lupus erythematosus (SLE)? a. Plasmapheresis eliminates eosinophils and basophils from blood. b. Plasmapheresis decreases the damage to organs from T lymphocytes. c. Plasmapheresis removes antibody-antigen complexes from circulation. d. Plasmapheresis prevents foreign antibodies from damaging various body tissues.

ANS: C Plasmapheresis is used in SLE to remove antibodies, antibody-antigen complexes, and complement from blood. T lymphocytes, foreign antibodies, eosinophils, and basophils do not directly contribute to the tissue damage in SLE.

24. A nurse has obtained donor tissue typing information about a patient who is waiting for a kidney transplant. Which results should be reported to the transplant surgeon? a.Patient is Rh positive and donor is Rh negative b.Six antigen matches are present in HLA typing c.Results of patient-donor crossmatching are positive d.Panel of reactive antibodies (PRA) percentage is low

ANS: C Positive crossmatching is an absolute contraindication to kidney transplantation because a hyperacute rejection will occur after the transplant. The other information indicates that the tissue match between the patient and potential donor is acceptable.

6.Which patient exposure by the nurse is most likely to require postexposure prophylaxis when the patient's human immunodeficiency virus (HIV) status is unknown? a.Needle stick injury with a suture needle during a surgery b.Splash into the eyes while emptying a bedpan containing stool c.Needle stick with a needle and syringe used for a venipuncture d.Contamination of open skin lesions with patient vaginal secretions

ANS: C Puncture wounds are the most common means for workplace transmission of blood-borne diseases, and a needle with a hollow bore that had been contaminated with the patient's blood would be a high-risk situation. The other situations described would be much less likely to result in transmission of the virus.

23.The nurse designs a program to decrease the incidence of human immunodeficiency virus (HIV) infection in the adolescent and young adult populations. Which information should the nurse assign as the highestpriority? a.Methods to prevent perinatal HIV transmission b.Ways to sterilize needles used by injectable drug users c.Prevention of HIV transmission between sexual partners d.Means to prevent transmission through blood transfusions

ANS: C Sexual transmission is the most common way that HIV is transmitted. The nurse should also provide teaching about perinatal transmission, needle sterilization, and blood transfusion, but the rate of HIV infection associated with these situations is lower.

42. Which finding about a patient with polycythemia vera is mostimportant for the nurse to report to the health care provider? a. Hematocrit 55% c. Calf swelling and pain b. Presence of plethora d. Platelet count 450,000/mL

ANS: C The calf swelling and pain suggest that the patient may have developed a deep vein thrombosis, which will require diagnosis and treatment to avoid complications such as pulmonary embolus. The other findings will also be reported to the health care provider but are expected in a patient with this diagnosis.

40.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 11 g/dL.

ANS: C 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. There is no need to avoid intramuscular injections. The goal for patients with thalassemia major is to maintain a hemoglobin of 10 g/dL or greater.

20.Which of these patients who have arrived at the human immunodeficiency virus (HIV) clinic should the nurse assess first? a.Patient whose rapid HIV-antibody test is positive b.Patient whose latest CD4+ count has dropped to 250/µL c.Patient who has had 10 liquid stools in the last 24 hours d.Patient who has nausea from prescribed antiretroviral drugs

ANS: C The nurse should assess the patient for dehydration and hypovolemia. The other patients also will require assessment and possible interventions, but do not require immediate action to prevent complications such as hypovolemia and shock.

29. A postoperative patient receiving a transfusion of packed red blood cells develops chills, fever, headache, and anxiety 35 minutes after the transfusion is started. After stopping the transfusion, what action should the nurse take? a.Give the PRN diphenhydramine . b.Send a urine specimen to the laboratory. c.Administer PRN acetaminophen (Tylenol). d.Draw blood for a new type and crossmatch.

ANS: C The patient's clinical manifestations are consistent with a febrile, nonhemolytic transfusion reaction. The transfusion should be stopped and antipyretics administered for the fever as ordered. A urine specimen is needed if an acute hemolytic reaction is suspected. Diphenhydramine is used for allergic reactions. This type of reaction does not indicate incorrect crossmatching.

35. A patient with septicemia develops prolonged bleeding from venipuncture sites and blood in the stools. Which action is mostimportant for the nurse to take? a. Avoid other venipunctures. b. Apply dressings to the sites. c. Notify the health care provider. d. Give prescribed proton-pump inhibitors.

ANS: C 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. The other actions are also appropriate, but the most important action should be to notify the health care provider so that DIC treatment can be initiated rapidly.

12.The health care provider's progress note for a patient states that the complete blood count (CBC) shows a "shift to the left." Which assessment finding will the nurse expect? a.Cool extremities c.Elevated temperature b.Pallor and weakness d.Low oxygen saturation

ANS: C The term "shift to the left" indicates that the number of immature polymorphonuclear neutrophils (bands) is elevated and that finding is a sign of infection. There is no indication that the patient is at risk for hypoxemia, pallor or weakness, or cool extremities.

18. The charge nurse is assigning semiprivate rooms for new admissions. Which patient could safely be assigned as a roommate for a patient who has acute rejection of an organ transplant? a. A patient who has viral pneumonia b. A patient with second-degree burns c. A patient who is recovering from an anaphylactic reaction to a bee sting d. A patient with graft-versus-host disease after a recent bone marrow transplant.

ANS: C There is no increased exposure to infection from a patient who had an anaphylactic reaction. Treatment for a patient with acute rejection includes administration of additional immunosuppressants and the patient should not be exposed to increased risk for infection as would occur from patients with viral pneumonia, graft-versus-host disease, and burns.

25. A patient who is receiving immunotherapy has just received an allergen injection. Which assessment finding is mostimportant to communicate to the health care provider? a.The patient's IgG level is increased. b. The injection site is red and swollen. c.The patient's symptoms did not improve in 2 months. d.There is a 2-cm wheal at the site of the allergen injection.

ANS: D A local reaction larger than quarter size may indicate that a decrease in the allergen dose is needed. An increase in IgG indicates that the therapy is effective. Redness and swelling at the site are not unusual. Because immunotherapy usually takes 1 to 2 years to achieve an effect, an improvement in the patient's symptoms is not expected after a few months.

22. A clinic patient is experiencing an allergic reaction to an unknown allergen. Which action is appropriate for the registered nurse (RN) to delegate to a licensed practical/vocational nurse (LPN/LVN)? a.Perform a focused physical assessment. b.Obtain the health history from the patient. c.Teach the patient about the various diagnostic studies. d.Administer a skin test by the cutaneous scratch method.

ANS: D LPN/LVNs are educated and licensed to administer medications under the supervision of an RN. RN-level education and the scope of practice include assessment of health history, focused physical assessment, and patient teaching.

3. A nurse reviews the laboratory data for an older patient. The nurse would be most concerned about which finding? a.Hematocrit of 35% b.Hemoglobin of 11.8 g/dL c.Platelet count of 400,000/µL d.White blood cell (WBC) count of 2800/µL

ANS: D Because the total WBC count is not usually affected by aging, the low WBC count in this patient would indicate that the patient's immune function may be compromised and the underlying cause of the problem needs to be investigated. The platelet count is normal. The slight decrease in hemoglobin and hematocrit are not unusual for an older patient.

13.An expected action by the nurse caring for a patient who has an acute exacerbation of polycythemia vera is to a.place the patient on bed rest. c.avoid use of aspirin products. b.administer iron supplements. d.monitor fluid intake and output.

ANS: D Monitoring hydration status is important during an acute exacerbation because the patient is at risk for fluid overload or underhydration. Aspirin therapy is used to decrease risk for thrombosis. The patient should be encouraged to ambulate to prevent deep vein thrombosis. Iron is contraindicated in patients with polycythemia vera.

10. The nurse should assess the patient undergoing plasmapheresis for which clinical manifestation? a. Shortness of breath c. Transfusion reaction b. High blood pressure d. Extremity numbness

ANS: D Numbness and tingling may occur as the result of the hypocalcemia caused by the citrate used to prevent coagulation. The other clinical manifestations are not associated with plasmapheresis.

15.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

ANS: D Platelet aggregation in HIT causes neutralization of heparin, so 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.

1. The nurse is caring for a patient who is being discharged after an emergency splenectomy following a motor vehicle crash. Which instructions should the nurse include in the discharge teaching? a.Check often for swollen lymph nodes. b.Watch for excess bleeding or bruising. c.Take iron supplements to prevent anemia. d.Wash hands and avoid persons who are ill.

ANS: D Splenectomy increases the risk for infection, especially with gram-positive bacteria. The risks for lymphedema, bleeding, and anemia are not increased after a person has a splenectomy.

13.Which nursing action will be most useful in assisting a college student to adhere to a newly prescribed antiretroviral therapy (ART) regimen? a.Give the patient detailed information about possible medication side effects. b.Remind the patient of the importance of taking the medications as scheduled. c.Encourage the patient to join a support group for students who are HIV positive. d.Check the patient's class schedule to help decide when the drugs should be taken.

ANS: D The best approach to improve adherence is to learn about important activities in the patient's life and adjust the ART around those activities. The other actions are also useful, but they will not improve adherence as much as individualizing the ART to the patient's schedule.

15.The nurse reviews the laboratory test results of a patient admitted with abdominal pain. Which information will be mostimportant for the nurse to communicate to the health care provider? a.Monocytes 4% b.Hemoglobin 13.6 g/dL c.Platelet count 168,000/µL d.White blood cell (WBC) count 15,500/µL

ANS: D The elevation in WBCs indicates that the patient has an inflammatory or infectious process ongoing, which may be the cause of the patient's pain, and that further diagnostic testing is needed. The monocytes are at a normal level. The hemoglobin and platelet counts are normal.

14. A patient with human immunodeficiency virus (HIV) infection has developed Mycobacterium avium complex infection. Which outcome would be appropriate for the nurse to include in the plan of care? a.The patient will be free from injury. b.The patient will receive immunizations. c.The patient will have adequate oxygenation. d.The patient will maintain intact perineal skin.

ANS: D The major manifestation of M. avium infection is loose, watery stools, which would increase the risk for perineal skin breakdown. The other outcomes would be appropriate for other complications (e.g., pneumonia, dementia, influenza) associated with HIV infection.

1. A 62-year old man with chronic anemia is experiencing increased fatigue and occasional palpitations at rest. The nurse would expect the patient's laboratory test findings to include a.an RBC count of 4,500,000/mL. b.a hematocrit (Hct) value of 38%. c.normal red blood cell (RBC) indices. d.a hemoglobin (Hgb) of 8.6 g/dL (86 g/L).

ANS: D The patient's clinical manifestations indicate moderate anemia, which is consistent with a Hgb of 6 to 10 g/dL. The other values are all within the range of normal.

30. A patient in the emergency department complains of back pain and difficulty breathing 15 minutes after a transfusion of packed red blood cells is started. The nurse's firstaction should be to a.administer oxygen therapy at a high flow rate. b.obtain a urine specimen to send to the laboratory. c.notify the health care provider about the symptoms. d.disconnect the transfusion and infuse normal saline.

ANS: D The patient's symptoms indicate a possible acute hemolytic reaction caused by the transfusion. The first action should be to disconnect the transfusion and infuse normal saline. The other actions also are needed but are not the highest priority.

7. A young adult female patient who is human immunodeficiency virus (HIV) positive has a new prescription for efavirenz (Sustiva). Which information is mostimportant to include in the medication teaching plan? a.Take this medication on an empty stomach. b.Take this medication with a full glass of water. c.You may have vivid and bizarre dreams as a side effect. d.Continue to use contraception while taking this medication.

ANS: D To prevent harm, it is most critical to inform patients that efavirenz can cause fetal anomalies and should not be used in patients who may be or may become pregnant. The other information is also accurate, but it does not directly prevent harm. The medication should be taken on an empty stomach with water and patients should be informed that many people who use the drug have reported vivid and sometimes bizarre dreams.

1. A patient who is receiving an IV antibiotic develops wheezes and dyspnea. In which order should the nurse implement these prescribed actions? (Put a comma and a space between each answer choice [A, B, C, D, E]). a. Discontinue the antibiotic. b. Give diphenhydramine IV. c. Inject epinephrine IM or IV. d. Prepare an infusion of dopamine. e. Provide 100% oxygen using a nonrebreather mask.

ANS: A, E, C, B, D The nurse should initially discontinue the antibiotic because it is the likely cause of the allergic reaction. Next, oxygen delivery should be maximized, followed by treatment of bronchoconstriction with epinephrine administered IM or IV. Diphenhydramine will work more slowly than epinephrine, but will help prevent progression of the reaction. Because the patient currently does not have evidence of hypotension, the dopamine infusion can be prepared last.

2.Which menu choice indicates that the patient understands the nurse's teaching about recommended dietary choices for iron-deficiency anemia? a.Omelet and whole wheat toast c.Strawberry and banana fruit plate b.Cantaloupe and cottage cheese d.Cornmeal muffin and orange juice

ANS: A Eggs and whole grain breads are high in iron. The other choices are appropriate for other nutritional deficiencies but are not the best choice for a patient with iron-deficiency anemia.

3. A patient is being evaluated for possible atopic dermatitis. The nurse expects elevation of which laboratory value? a. IgE c. Basophils b. IgA d. Neutrophils

ANS: A Serum IgE is elevated in an allergic response (type 1 hypersensitivity disorders). The eosinophil level will be elevated rather than neutrophil or basophil counts. IgA is located in body secretions and would not be tested when evaluating a patient who has symptoms of atopic dermatitis.

19.Eight years after seroconversion, a human immunodeficiency virus (HIV)-infected patient has a CD4+cell count of 800/µL and an undetectable viral load. What is the prioritynursing intervention at this time? a.Encourage adequate nutrition, exercise, and sleep. b.Teach about the side effects of antiretroviral agents. c.Explain opportunistic infections and antibiotic prophylaxis. d.Monitor symptoms of acquired immunodeficiency syndrome (AIDS).

ANS: A The CD4+level for this patient is in the normal range, indicating that the patient is the stage of asymptomatic chronic infection when the body is able to produce enough CD4+ cells to maintain a normal CD4+ count. Maintaining healthy lifestyle behaviors is an important goal in this stage. AIDS and increased incidence of opportunistic infections typically develop when the CD4+ count is much lower than normal. Although the initiation of ART is highly individual, it would not be likely that a patient with a normal CD4+ level would receive ART.

11.Which information about a patient population would be most useful to help the nurse plan for human immunodeficiency virus (HIV) testing needs? a.Age c.Symptoms b.Lifestyle d.Sexual orientation

ANS: A The current Centers for Disease Control and Prevention policy is to offer routine testing for HIV to all individuals age 13 to 64 years. Although lifestyle, symptoms, and sexual orientation may suggest increased risk for HIV infection, the goal is to test all individuals in this age range.

17. To evaluate the effectiveness of antiretroviral therapy (ART), which laboratory test result will the nurse review? a.Viral load testing c.Rapid HIV antibody testing b.Enzyme immunoassay d.Immunofluorescence assay

ANS: A The effectiveness of ART is measured by the decrease in the amount of virus detectable in the blood. The other tests are used to detect HIV antibodies, which remain positive even with effective ART.

13.Ten days after receiving a bone marrow transplant, a patient develops a skin rash. What would the nurse suspect is the cause of the rash? a. The donor T cells are attacking the patient's skin cells. b. The patient needs treatment to prevent hyperacute rejection. c. The patient's antibodies are rejecting the donor bone marrow. d. The patient is experiencing a delayed hypersensitivity reaction.

ANS: A The patient's history and symptoms indicate that the patient is experiencing graft-versus-host disease, in which the donated T cells attack the patient's tissues. The history and symptoms are not consistent with rejection or delayed hypersensitivity.

22. The registered nurse (RN) caring for an HIV-positive patient admitted with tuberculosis can delegate which action to unlicensed assistive personnel (UAP)? a.Teach the patient how to dispose of tissues with respiratory secretions. b.Stock the patient's room with the necessary personal protective equipment. c.Interview the patient to obtain the names of family members and close contacts. d.Tell the patient's family members the reason for the use of airborne precautions.

ANS: B A patient diagnosed with tuberculosis would be placed on airborne precautions. Because all health care workers are taught about the various types of infection precautions used in the hospital, the UAP can safely stock the room with personal protective equipment. Obtaining contact information and patient teaching are higher-level skills that require RN education and scope of practice.

18.The nurse is caring for a patient who is human immunodeficiency virus (HIV) positive and taking antiretroviral therapy (ART). Which information is mostimportant for the nurse to address when planning care? a.The patient complains of feeling "constantly tired." b.The patient can't explain the effects of indinavir (Crixivan). c.The patient reports missing some doses of zidovudine (AZT). d.The patient reports having no side effects from the medications.

ANS: C Because missing doses of ART can lead to drug resistance, this patient statement indicates the need for interventions such as teaching or changes in the drug scheduling. Fatigue is a common side effect of ART. The nurse should discuss medication actions and side effects with the patient, but this is not as important as addressing the skipped doses of AZT.

2. The nurse assesses a patient who has numerous petechiae on both arms. Which question should the nurse ask the patient? a."Are you taking any oral contraceptives?" b."Have you been prescribed antiseizure drugs?" c."Do you take medication containing salicylates?" d."How long have you taken antihypertensive drugs?"

ANS: C Salicylates interfere with platelet function and can lead to petechiae and ecchymoses. Antiseizure drugs may cause anemia but not clotting disorders or bleeding. Oral contraceptives increase a person's clotting risk. Antihypertensives do not usually cause problems with decreased clotting.

20. A patient is anxious and reports difficulty breathing after being stung by a wasp. What is the nurse's priorityaction? a.Provide high-flow oxygen. c.Assess the patient's airway. b.Administer antihistamines. d.Remove the stinger from the site.

ANS: C The initial action with any patient with difficulty breathing is to assess and maintain the airway. The patient's symptoms of anxiety and difficulty breathing may have other causes than anaphylaxis, so additional assessment is warranted. The other actions are part of the emergency management protocol for anaphylaxis, but the priority is airway assessment and maintenance.

9. The nurse examines the lymph nodes of a patient during a physical assessment. Which assessment finding would be of mostconcern to the nurse? a.A 2-cm nontender supraclavicular node b.A 1-cm mobile and nontender axillary node c.An inability to palpate any superficial lymph nodes d.Firm inguinal nodes in a patient with an infected foot

ANS: A Enlarged and nontender nodes are suggestive of malignancies such as lymphoma. Firm nodes are an expected finding in an area of infection. The superficial lymph nodes are usually not palpable in adults, but if they are palpable, they are normally 0.5 to 1 cm and nontender.

1. The nurse is advising a clinic patient who was exposed a week ago to human immunodeficiency virus (HIV) through unprotected sexual intercourse. The patient's antigen and antibody test has just been reported as negative for HIV. What instructions should the nurse give to this patient? a."You will need to be retested in 2 weeks." b."You do not need to fear infecting others." c."Since you don't have symptoms and you have had a negative test, you do not have HIV)." d."We won't know for years if you will develop acquired immunodeficiency syndrome (AIDS)."

ANS: A HIV screening tests detect HIV-specific antibodies or antigens, but typically it takes a several week delay after initial infection before HIV can be detected on a screening test. Combination antibody and antigen tests (also known as fourth-generation tests) decrease the window period to within 3 weeks after infection. It is not known based on this information whether the patient is infected with HIV or can infect others.

1. The nurse is caring for a patient infected with human immunodeficiency virus (HIV) who has just been diagnosed with asymptomatic chronic HIV infection. Which prophylactic measures will the nurse include in the plan of care (select all that apply)? a.Hepatitis B vaccine b.Pneumococcal vaccine c.Influenza virus vaccine d.Trimethoprim-sulfamethoxazole e.Varicella zoster immune globulin

ANS: A, B, C Asymptomatic chronic HIV infection is a stage between acute HIV infection and a diagnosis of symptomatic chronic HIV infection. Although called asymptomatic, symptoms (e.g., fatigue, headache, low-grade fever, night sweats) often occur. Prevention of other infections is an important intervention in patients who are HIV positive, and these vaccines are recommended as soon as the HIV infection is diagnosed. Antibiotics and immune globulin are used to prevent and treat infections that occur later in the course of the disease when the CD4+counts have dropped or when infection has occurred

3. The nurse plans a presentation for community members about how to decrease the risk for antibiotic-resistant infections. Which information will the nurse include in the teaching plan (select all that apply)? a.Antibiotics may sometimes be prescribed to prevent infection. b.Continue taking antibiotics until all of the prescription is gone. c.Unused antibiotics that are more than a year old should be discarded. d.Antibiotics are effective in treating influenza associated with high fevers. e.Hand washing is effective in preventing many viral and bacterial infections.

ANS: A, B, E All prescribed doses of antibiotics should be taken. In some situations, such as before surgery, antibiotics are prescribed to prevent infection. There should not be any leftover antibiotics because all prescribed doses should be taken. However, if there are leftover antibiotics, they should be discarded immediately because the number left will not be enough to treat a future infection. Hand washing is generally considered the single most effective action in decreasing infection transmission. Antibiotics are ineffective in treating viral infections such as influenza.

17. A young adult who has 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. c.thrombin time. b.bleeding time. d.prothrombin time.

ANS: B The bleeding time is affected by von Willebrand disease. Platelet count, prothrombin time, and thrombin time are normal in von Willebrand disease.

12. A patient who has been receiving IV heparin infusion and oral warfarin (Coumadin) for a deep vein thrombosis (DVT) is diagnosed with heparin-induced thrombocytopenia (HIT) when the platelet level drops to 110,000/µL. Which action will the nurse include in the plan of care? a.Prepare for platelet transfusion. b.Discontinue the heparin infusion. c.Administer prescribed warfarin (Coumadin). d.Use low-molecular-weight heparin (LMWH).

ANS: B All heparin is discontinued when 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.

39.After receiving change-of-shift report for several patients with neutropenia, which patient should the nurse assess first? a. A 56-yr-old with frequent explosive diarrhea b. A 33-yr-old with a fever of 100.8° F (38.2° C) c. A 66-yr-old who has white pharyngeal lesions d. A 23-yr-old who is complaining of severe fatigue

ANS: B Any fever in a neutropenic patient indicates infection and can quickly lead to sepsis and septic shock. Rapid assessment and (if prescribed) initiation of antibiotic therapy within 1 hour are needed. The other patients also need to be assessed but do not exhibit symptoms of potentially life-threatening problems.

18. A routine complete blood count for an active older man indicates possible 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.

ANS: B Bone marrow biopsy is needed to make the diagnosis and determine the specific type of myelodysplastic syndrome. The other treatments may be necessary if there is progression of the myelodysplastic syndrome, but the initial action for this asymptomatic patient will be a bone marrow biopsy.

15. The nurse teaches a patient about drug therapy after a kidney transplant. Which statement by the patient would indicate a need for further instructions? a. "I need to be monitored closely for development of malignant tumors." b. "After a couple of years I will be able to stop taking the cyclosporine." c. "If I develop acute rejection episode, I will need additional types of drugs." d. "The drugs are combined to inhibit different ways the kidney can be rejected."

ANS: B Cyclosporine, a calcineurin inhibitor, will need to be continued for life. The other patient statements are accurate and indicate that no further teaching is necessary about those topics.

3. A patient who is receiving methotrexate for severe rheumatoid arthritis develops a megaloblastic anemia. The nurse will anticipate teaching the patient about increasing oral intake of a.iron. c.cobalamin (vitamin B12). b.folic acid. d.ascorbic acid (vitamin C).

ANS: B Methotrexate use can lead to folic acid deficiency. Supplementation with oral folic acid supplements is the usual treatment. The other nutrients would not correct folic acid deficiency, although they would be used to treat other types of anemia.

5. 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.

ANS: B Nursing care for patients with anemia should alternate periods of rest and activity to encourage activity without causing undue fatigue. There is no indication that the patient has a bleeding disorder, so a diet high in vitamin K or teaching about how to avoid injury is not needed. Protective isolation might be used for a patient with aplastic anemia, but it is not indicated for hemolytic anemia.

23. A patient who has acute myelogenous leukemia (AML) is considering treatment with a hematopoietic stem cell transplant (HSCT). The bestapproach for the nurse to assist the patient with 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.

ANS: B Offering the patient an opportunity to ask questions or discuss concerns about HSCT will encourage the patient to voice concerns about this treatment and will allow the nurse to assess whether the patient needs more information about the procedure. Treatment of AML using chemotherapy is another option for the patient. It is not appropriate for the nurse to ask the patient to consider insurance needs in making this decision.

10.The nurse palpates enlarged cervical lymph nodes on a patient diagnosed with acute human immunodeficiency virus (HIV) infection. Which action would be appropriate for the nurse to take? a.Instruct the patient to apply ice to the neck. b.Explain to the patient that this is an expected finding. c.Request that an antibiotic be prescribed for the patient. d.Advise the patient that this indicates influenza infection.

ANS: B Persistent generalized lymphadenopathy is common in the early stages of HIV infection. No antibiotic is needed because the enlarged nodes are probably not caused by bacteria. Lymphadenopathy is common with acute HIV infection and is therefore not likely the flu. Ice will not decrease the swelling in persistent generalized lymphadenopathy

19. A patient in the health care provider's office for allergen testing using the cutaneous scratch method develops itching and swelling at the skin site. Which action should the nurse take first? a.Monitor the patient's edema. b.Administer a dose of epinephrine. c.Provide a prescription for oral antihistamines d.Ask the patient about the use of new skin products.

ANS: B Rapid administration of epinephrine when excessive itching or swelling at the skin site is observed can prevent the progression to anaphylaxis. The initial symptoms of anaphylaxis are itching and edema at the site of the exposure. The nurse should not wait and assess for development of additional edema. Hypotension, tachycardia, dilated pupils, and wheezes occur later. Exposure to skin products does not address the immediate concern of a possible anaphylactic reaction.

26. A patient who has 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 the 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.

ANS: B The patient may be taught to self-administer filgrastim injections. Although chemotherapy may be stopped with severe neutropenia (neutrophil count <500/µL), administration of filgrastim usually allows the chemotherapy to continue. Patients with neutropenia are at higher risk for infection when exposed to other patients in the hospital. HEPA filters are expensive and are used in the hospital, where the number of pathogens is much higher than in the patient's home environment.

14. A patient seeks care in the emergency department after sharing needles for heroin injection with a friend who has hepatitis B. To provide immediate protection from infection, what medication will the nurse expect to administer? a. Corticosteroids c.Hepatitis B vaccine b. Gamma globulin d. Fresh frozen plasma

ANS: B The patient should first receive antibodies for hepatitis B from injection of gamma globulin. The hepatitis B vaccination series should be started to provide active immunity. Fresh frozen plasma and corticosteroids will not be effective in preventing hepatitis B in the patient.

16. Which information shown in the table below about a patient who has just arrived in the emergency department is mosturgent for the nurse to communicate to the health care provider? Assessment Complete Blood Count Patient History · BP 110/68 · Pulse 98 beats/min · Brisk capillary refill · Multiple ecchymoses on arms · Hgb 10.6 g/dL · Hct 30% · WBC 5100/µL · Platelets 19,500/µL · Occasional aspirin use · Abdominal pain x 1 week · Large, dark stool this morning a.Heart rate c.Abdominal pain b.Platelet count d.White blood cell count

ANS: B The platelet count is severely decreased and places the patient at risk for spontaneous bleeding. The other information is also pertinent but not as indicative of the need for rapid treatment as the platelet count.

4. A patient with pancytopenia has a bone marrow aspiration from the left posterior iliac crest. Which action would be importantfor the nurse to take after the procedure? a.Elevate the head of the bed to 45 degrees. b.Have the patient lie on the left side for 1 hour. c.Apply a sterile 2-inch gauze dressing to the site. d.Use a half-inch sterile gauze to pack the wound.

ANS: B To decrease the risk for bleeding, the patient should lie on the left side for 30 to 60 minutes. After a bone marrow biopsy, the wound is small and will not be packed with gauze. A pressure dressing is used to cover the aspiration site. There is no indication to elevate the patient's head.

28.The nurse is planning to administer a transfusion of packed red blood cells (PRBCs) to a patient with blood loss from gastrointestinal hemorrhage. Which action can the nurse delegate to unlicensed assistive personnel (UAP)? a.Verify the patient identification (ID) according to hospital policy. b.Obtain the temperature, blood pressure, and pulse before the transfusion. c.Double-check the product numbers on the PRBCs with the patient ID band. d.Monitor the patient for shortness of breath or chest pain during the transfusion.

ANS: B UAP education includes measurement of vital signs. UAP would report the vital signs to the registered nurse (RN). The other actions require more education and a larger scope of practice and should be done by licensed nursing staff members.

7. The nurse is reviewing laboratory results and notes a patient's activated partial thromboplastin time (aPTT) level of 28 seconds. The nurse should notify the health care provider in anticipation of adjusting which medication? a.Aspirin c.Warfarin b.Heparin d.Erythropoietin

ANS: B aPTT assesses intrinsic coagulation by measuring factors I, II, V, VIII, IX, X, XI, XII. aPTT is increased (prolonged) in heparin administration. aPTT is used to monitor whether heparin is at a therapeutic level (needs to be greater than the normal range of 25 to 35 sec). Prothrombin time (PT) and international normalized ratio (INR) are most commonly used to test for therapeutic levels of warfarin (Coumadin). Aspirin affects platelet function. Erythropoietin is used to stimulate red blood cell production.

2.According to the Center for Disease Control and Prevention (CDC) guidelines, which personal protective equipment will the nurse put on before assessing a patient who is on contact precautions for Clostridium difficilediarrhea (select all that apply)? a.Mask b.Gown c.Gloves d.Shoe covers e.Eye protection

ANS: B, C Because the nurse will have substantial contact with the patient and bedding when doing an assessment, gloves and gowns are needed. Eye protection and masks are needed for patients in contact precautions only when spraying or splashing is anticipated. Shoe covers are not recommended in the CDC guidelines.

6. Which information about intradermal skin testing should the nurse teach to a patient with possible allergies? a. "Do not eat anything for about 6 hours before the testing." b. "Take an oral antihistamine about an hour before the testing." c. "Plan to wait in the clinic for 20 to 30 minutes after the testing." d. "Reaction to the testing will take about 48 to 72 hours to occur."

ANS: C Allergic reactions usually occur within minutes after injection of an allergen, and the patient will be monitored for at least 20 minutes for anaphylactic reactions after the testing. Medications that might modify the response, such as antihistamines, should be avoided before allergy testing. There is no reason to be NPO for skin testing. Results with intradermal testing occur within minutes.

4. A 52-yr-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, a."I need to start eating more red meat and liver." b."I will stop having a glass of wine with dinner." c."I could choose nasal spray rather than injections of vitamin B12." d."I will need to take a proton pump inhibitor such as omeprazole (Prilosec)."

ANS: C Because pernicious anemia prevents the absorption of vitamin B12, this patient requires injections or intranasal administration of cobalamin. Alcohol use does not cause cobalamin deficiency. Proton pump inhibitors decrease the absorption of vitamin B12. Eating more foods rich in vitamin B12is not helpful because the lack of intrinsic factor prevents absorption of the vitamin.

16.The nurse prepares to administer the following medications to a hospitalized patient with human immunodeficiency (HIV). Which medication is mostimportant to administer at the scheduled time? a.Nystatin tablet b.Oral acyclovir (Zovirax) c.Oral saquinavir (Invirase) d.Aerosolized pentamidine (NebuPent)

ANS: C It is important that antiretrovirals be taken at the prescribed time every day to avoid developing drug-resistant HIV. The other medications should also be given as close as possible to the correct time, but they are not as essential to receive at the same time every day.

4. A patient who is diagnosed with acquired immunodeficiency syndrome (AIDS) tells the nurse, "I feel obsessed with morbid thoughts about dying." Which response by the nurse is appropriate? a."Thinking about dying will not improve the course of AIDS." b."Do you think that taking an antidepressant might be helpful?" c."Can you tell me more about the thoughts that you are having?" d."It is important to focus on the good things about your life now."

ANS: C More assessment of the patient's psychosocial status is needed before taking any other action. The statements, "Thinking about dying will not improve the course of AIDS" and "It is important to focus on the good things in life" or suggesting an antidepressant discourage the patient from sharing any further information with the nurse and decrease the nurse's ability to develop a trusting relationship with the patient.

12. A patient who uses injectable illegal drugs asks the nurse about preventing acquired immunodeficiency syndrome (AIDS). Which response by the nurse is best? a."Clean drug injection equipment before each use." b."Ask those who share equipment to be tested for HIV." c."Consider participating in a needle-exchange program." d."Avoid sexual intercourse when using injectable drugs."

ANS: C Participation in needle-exchange programs has been shown to decrease and control the rate of HIV infection. Cleaning drug equipment before use also reduces risk, but it might not be consistently practiced. HIV antibodies do not appear for several weeks to months after exposure, so testing drug users would not be very effective in reducing risk for HIV exposure. It is difficult to make appropriate decisions about sexual activity when under the influence of drugs.

9.Which statement by a patient indicates 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."

ANS: D Because infection is the most common cause of a sickle cell crisis, influenza, Haemophilus influenzae,pneumococcal pneumonia, and hepatitis immunizations should be administered. Although continuous dose opioids and oxygen may be administered during a crisis, patients do not receive these therapies to prevent crisis. Hydroxyurea (Hydrea) is a medication used to decrease the number of sickle cell crises.

9. The nurse will mostlikely prepare a medication teaching plan about antiretroviral therapy (ART) for which patient? a.Patient who is currently HIV negative but has unprotected sex with multiple partners b.Patient who was infected with HIV 15 years ago and now has a CD4+ count of 840/µL c. HIV-positive patient with a CD4+ count of 160/µL who drinks a fifth of whiskey daily d. Patient who tested positive for HIV 2 years ago and now has cytomegalovirus (CMV) retinitis

ANS: D CMV retinitis is an AIDS-defining illness and indicates that the patient is appropriate for ART even though the HIV infection period is relatively short. An HIV-negative patient would not be offered ART. A patient with a CD4+ count in the normal range would not typically be started on ART. A patient who drinks alcohol heavily would be unlikely to be able to manage the complex drug regimen and would not be appropriate for ART despite the low CD4+ count.

2. A patient who has a positive test for human immunodeficiency virus (HIV) antibodies is admitted to the hospital with Pneumocystis jirovecipneumonia (PCP) and a CD4+T-cell count of less than 200 cells/mL. Based on diagnostic criteria established by the Centers for Disease Control and Prevention (CDC), which statement by the nurse is correct? a."The patient will develop symptomatic HIV infection within 1 year." b."The patient meets the criteria for a diagnosis of acute HIV infection." c."The patient will be diagnosed with asymptomatic chronic HIV infection." d."The patient has developed acquired immunodeficiency syndrome (AIDS)."

ANS: D Development of PCP meets the diagnostic criteria for AIDS. The other responses indicate earlier stages of HIV infection than is indicated by the PCP infection.

8. A patient who is human immunodeficiency virus (HIV)-infected has a CD4+ cell count of 400/µL. Which factor is mostimportant for the nurse to determine before the initiation of antiretroviral therapy (ART) for this patient? a.CD4+ cell count trajectory b.HIV genotype and phenotype c.Patient's tolerance for potential medication side effects d.Patient's ability to follow a complex medication regimen

ANS: D Drug resistance develops quickly unless the patient takes ART medications on a strict, regular schedule. In addition, drug resistance endangers both the patient and community. The other information is also important to consider, but patients who are unable to manage and follow a complex drug treatment regimen should not be considered for ART.

13.The health care provider orders a liver and spleen scan for a patient who has been in a motor vehicle crash. Which action should the nurse take before this procedure? a.Check for any iodine allergy. c.Administer prescribed sedatives. b.Insert a large-bore IV catheter. d.Assist the patient to a flat position.

ANS: D During a liver and spleen scan, a radioactive isotope is injected IV, and images from the radioactive emission are used to evaluate the structure of the spleen and liver. An indwelling IV catheter and sedation are not needed. The patient is placed in a flat position before the scan.

20.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 c.Total lymphocyte count b.Reticulocyte count d.Absolute neutrophil count

ANS: D Filgrastim increases the neutrophil count and function in neutropenic patients. Although total lymphocyte, platelet, and reticulocyte counts are also important to monitor in this patient, the absolute neutrophil count is used to evaluate the effects of filgrastim.