Final SATA
Which nursing interventions should the nurse implement when caring for a client diagnosed with hemophilia A? Select all that apply. 1. Instruct the client to use a razor blade to shave. 2. Avoid administering enemas to the client. 3. Encourage participation in noncontact sports. 4. Teach the client how to apply direct pressure if bleeding occurs. 5. Explain the importance of not flossing gums.
ANS: 2, 3, 4 2.Enemas, rectal thermometers, and intra-muscular injections can pose a risk of tissue and vascular trauma that can precipitate bleeding. 3.Even minor trauma can lead to serious bleeding episodes; safer activities such as swimming or golf should be recommended. 4.Direct pressure occludes bleeding vessels.
Some of the causes of leukemia are thought to be: (Select all that apply.) a. exposure to radiation. b. exposure to pesticides. c. exposure to benzene. d. frequent bacterial infections. e. virulent viral infections.
ANS: A, B, C Bacterial and viral infections are not considered to be causes of leukemia.
A patient develops neutropenia after receiving chemotherapy. Which information about ways to prevent infection will the nurse include in the teaching plan (select all that apply)? A. Cook food thoroughly before eating. b. Choose low fiber, low residue foods. c. Avoid public transportation such as buses. d. Use rectal suppositories if needed for constipation. e. Talk to the oncologist before having any dental work done.
ANS: A, C, E Eating only cooked food and avoiding public transportation will decrease infection risk. A high-fiber diet is recommended for neutropenic patients to decrease constipation. Because bacteria may enter the circulation during dental work or oral surgery, the patient may need to postpone dental work or take antibiotics.
The nurse is aware that the patient with a nutritional anemia is lacking the nutrients: (Select all that apply.) a. proteins. b. vitamin B12. c. folic acid. d. zinc. e. iron.
ANS: A, C, E Nutritional anemia occurs due to the lack of proteins, folic acid, and iron.
A student nurse is learning about blood transfusion compatibilities. What information does this include? (Select all that apply.) a. Donor blood type A can donate to recipient blood type AB. b. Donor blood type B can donate to recipient blood type O. c. Donor blood type AB can donate to anyone. d. Donor blood type O can donate to anyone. e. Donor blood type A can donate to recipient blood type B.
ANS: A, D Blood type A can be donated to people who have blood types A or AB. Blood type O can be given to anyone. Blood type B can be donated to people who have blood types B or AB. Blood type AB can only go to recipients with blood type AB.
To assess cyanosis in a patient with a dark complexion, the nurse should inspect the: (Select all that apply.) a. conjunctiva. b. gums. c. roof of the mouth. d. nail beds. e. palms of the hands.
ANS: B, C A person with a dark complexion can be assessed for cyanosis by examining the gums and the roof of the mouth. Cyanosis is not usually apparent in the conjunctiva or palms of the hands. The nail beds tend to be darker in dark-skinned individuals so this would not render an accurate assessment of cyanosis.
The nurse makes a visual aid differentiating between mild, moderate, and severe anemia. The signs and symptoms of mild anemia include: (Select all that apply.) a. hemoglobin of 14.4 g/dL. b. palpitations. c. dyspnea on exertion. d. pallor. e. fatigue.
ANS: B, C In mild anemia, hemoglobin is below 14 g/dL. The mild anemic is not pale or abnormally fatigued.
A client has received a bone marrow transplant and is waiting for engraftment. What actions by the nurse are most appropriate? (Select all that apply.) a. Not allowing any visitors until engraftment b. Limiting the protein in the clients diet c. Placing the client in protective precautions d. Teaching visitors appropriate hand hygiene e. Telling visitors not to bring live flowers or plants
ANS: C, D, E The client waiting for engraftment after bone marrow transplant has no white cells to protect him or her against infection. The client is on protective precautions and visitors are taught hand hygiene. No fresh flowers or plants are allowed due to the standing water in the vase or container that may harbor organisms. Limiting protein is not a healthy option and will not promote engraftment.
A client has a platelet count of 25,000/mm3. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Assist with oral hygiene using a firm toothbrush. b. Give the client an enema if he or she is constipated. c. Help the client choose soft foods from the menu. d. Shave the male client with an electric razor. e. Use a lift sheet when needed to re-position the client.
ANS: C, D, E This client has thrombocytopenia and requires bleeding precautions. These include oral hygiene with a soft-bristled toothbrush or swabs, avoiding rectal trauma, eating soft foods, shaving with an electric razor, and using a lift sheet to re-position the client.
A nurse is preparing to administer IV chemotherapy. What supplies does this nurse need? (Select all that apply.) a. Chemo gloves b. Facemask c. Isolation gown d. N95 respirator e. Shoe covers
ANS: A, B, C The Occupational Safety and Health Administration (OSHA) and the Oncology Nurses Society have developed safety guidelines for those preparing or administering IV chemotherapy. These include double gloves (or chemo gloves), a facemask, and a gown. An N95 respirator and shoe covers are not required.
A client has thrombocytopenia. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Apply the clients shoes before getting the client out of bed. b. Assist the client with ambulation. c. Shave the client with a safety razor only. d. Use a lift sheet to move the client up in bed. e. Use the Waterpik on a low setting for oral care.
ANS: A, B, D Clients with thrombocytopenia are at risk of significant bleeding even with minor injuries. The nurse instructs the UAP to put the clients shoes on before getting the client out of bed, assist with ambulation, shave the client with an electric razor, use a lift sheet when needed to reposition the client, and use a soft-bristled toothbrush for oral care.
A client receiving chemotherapy has a white blood cell count of 1000/mm3. What actions by the nurse are most appropriate? (Select all that apply.) a. Assess all mucous membranes every 4 to 8 hours. b. Do not allow the client to eat meat or poultry. c. Listen to lung sounds and monitor for cough. d. Monitor the venous access device appearance with vital signs. e. Take and record vital signs every 4 to 8 hours.
ANS: A, C, D, E Depending on facility protocol, the nurse should assess this client for infection every 4 to 8 hours by assessing all mucous membranes, listening to lung sounds, monitoring for cough, monitoring the appearance of the venous access device, and recording vital signs. Eating meat and poultry is allowed.
A student studying leukemias learns the risk factors for developing this disorder. Which risk factors does this include? (Select all that apply.) a. Chemical exposure b. Genetically modified foods c. Ionizing radiation exposure d. Vaccinations e. Viral infections
ANS: A, C, E Chemical and ionizing radiation exposure and viral infections are known risk factors for developing leukemia. Eating genetically modified food and receiving vaccinations are not known risk factors.
The nurse explains that the function of blood includes: (Select all that apply.) a. absorbing nutrients. b. moving blood gases. c. regulating pH by buffering. d. regulating fluid distribution. e. regulating body temperature.
ANS: B, C, D, E Blood transports, not absorbs, nutrients.
The nurse monitoring a patient who is receiving a transfusion will stop the transfusion in the event of the patient complaining of: (Select all that apply.) a. feeling cold. b. a headache. c. back pain. d. a rash. e. urticaria.
ANS: B, C, D, E The complaint of feeling chilled is caused by the infusion of the chilled blood. The transfusion is not stopped; the patient is given a blanket. All other options are events that indicate a reaction to the transfusion and should cause the infusion to be stopped and the saline infusion to be opened into the line to keep the IV line open.
A nurse works in a gerontology clinic. What age-related changes cause the nurse to alter standard assessment techniques from those used for younger adults? (Select all that apply.) a. Dentition deteriorates with more cavities. b. Nail beds may be thickened or discolored. c. Progressive loss of hair occurs with age. d. Sclerae begin to turn yellow or pale. e. Skin becomes dry as the client ages.
ANS: B, C, E Common findings in older adults include thickened or discolored nail beds, dry skin, and thinning hair. The nurse adapts to these changes by altering assessment techniques. Having more dental caries and changes in the sclerae are not normal age-related changes.
A client has Hodgkins lymphoma, Ann Arbor stage Ib. For what manifestations should the nurse assess the client? (Select all that apply.) a. Headaches b. Night sweats c. Persistent fever d. Urinary frequency e. Weight loss
ANS: B, C, E In this stage, the disease is located in a single lymph node region or a single nonlymph node site. The client displays night sweats, persistent fever, and weight loss. Headache and urinary problems are not related.
A client with chronic anemia has had many blood transfusions. What medications does the nurse anticipate teaching the client about adding to the regimen? (Select all that apply.) a. Azacitidine (Vidaza) b. Darbepoetin alfa (Aranesp) c. Decitabine (Dacogen) d. Epoetin alfa (Epogen) e. Methylprednisolone (Solu-Medrol)
ANS: B, D Darbepoetin alfa and epoetin alfa are both red blood cell colony-stimulating factors that will help increase the production of red blood cells. Azacitidine and decitabine are used for myelodysplastic syndromes. Methylprednisolone is a steroid and would not be used for this problem.
The biologic response modifier drugs include: (Select all that apply.) a. interleukins. b. colony-stimulating factors. c. monoclonal antibodies. d. cyclosporines. e. gene therapies.
ANS: A, B, C, E Cyclosporines are drugs that are used to prevent tissue transplant rejection and are considered a carcinogen for non-Hodgkins lymphoma. In addition to the biologic response modifiers (BRM) listed, vaccines are also a BRM.
A nurse is preparing to administer a blood transfusion to an older adult. Understanding age-related changes, what alterations in the usual protocol are necessary for the nurse to implement? (Select all that apply.) a. Assess vital signs more often. b. Hold other IV fluids running. c. Premedicate to prevent reactions. d. Transfuse smaller bags of blood. e. Transfuse each unit over 8 hours.
ANS: A, B The older adult needs vital signs monitored as often as every 15 minutes for the duration of the transfusion because changes may be the only indication of a transfusion-related problem. To prevent fluid overload, the nurse obtains a prescription to hold other running IV fluids during the transfusion. The other options are not warranted.
To help conserve energy for the severely anemic patient, the nurse will: (Select all that apply.) a. manage care so that the patient can have frequent rest periods. b. assist with activities of daily living. c. place personal care items close at hand. d. arrange for small meals with between-meal snacks. e. ensure that exercise sessions are planned during the morning.
ANS: A, B, C, D Exercise sessions are not going to be planned for the severely anemic patient. By planning care using all the other options, the patient can be spared fatigue.
The lymphatic system is composed of: (Select all that apply.) a. thymus. b. lymph glands. c. lymph channels. d. spleen. e. tonsils.
ANS: A, B, C, D The tonsils are not considered a part of the lymphatic system.
The nurse recommends to a patient with iron deficiency anemia to include foods high in iron, such as: (Select all that apply.) a. liver. b. lima beans. c. prune juice. d. cabbage. e. dried apricots.
ANS: A, B, C, E Cabbage is not high in iron.
The nurse explains that age-related changes that occur in the hematologic system include: (Select all that apply.) a. decrease in blood volume. b. decrease in bone marrow production c. decreased rate of blood cell production. d. increased immune response. e. increased clotting time.
ANS: A, B, C, E The immune response is slower in the older adult.
A student nurse is helping a registered nurse with a blood transfusion. Which actions by the student are most appropriate? (Select all that apply.) a. Hanging the blood product using normal saline and a filtered tubing set b. Taking a full set of vital signs prior to starting the blood transfusion c. Telling the client someone will remain at the bedside for the first 5 minutes d. Using gloves to start the clients IV if needed and to handle the blood product e. Verifying the clients identity, and checking blood compatibility and expiration time
ANS: A, B, D Correct actions prior to beginning a blood transfusion include hanging the product with saline and the correct filtered blood tubing, taking a full set of vital signs prior to starting, and using gloves. Someone stays with the client for the first 15 to 30 minutes of the transfusion. Two registered nurses must verify the clients identity and blood compatibility.
A client has heparin-induced thrombocytopenia (HIT). The student nurse asks how this is treated. About what drugs does the nurse instructor teach? (Select all that apply.) a. Argatroban (Argatroban) b. Bivalirudin (Angiomax) c. Clopidogrel (Plavix) d. Lepirudin (Refludan) e. Methylprednisolone (Solu-Medrol)
ANS: A, B, D The standard drugs used to treat HIT are argatroban, bivalirudin, and lepirudin. The other drugs are not used. Clopidogrel is an antiplatelet agent used to reduce the likelihood of stroke or myocardial infarction. Methylprednisolone is a steroid used to reduce inflammation.
Aplastic anemia has its etiology in a variety of drugs, such as: (Select all that apply.) a. antimetabolite cancer drugs. b. phenylbutazone (Butazolidin). c. oral contraception drugs. d. chloramphenicol (Chloromycetin). e. sulfonamides.
ANS: A, B, D, E Oral contraceptives are not known to cause aplastic anemia.
The nurse is teaching a client who is receiving sodium warfarin (Coumadin). Which topics does the nurse include in the teaching plan? (Select all that apply.) a.Foods high in vitamin K b. Using acetaminophen (Tylenol) for minor pain c.Daily exercise and weight management d. Use of a safety razor and soft toothbrush e. Blood testing regimen
ANS: A, B, D, E The client on warfarin will need to know which foods are high in vitamin K because vitamin K intake must be consistent to avoid interfering with the anticoagulant properties of warfarin. Clients should not take aspirin or NSAIDs for minor pain owing to their anticoagulant properties. Clients must use safety razors and soft toothbrushes to avoid bleeding episodes. The client on warfarin needs regular blood tests for prothrombin time (PT) and international normalized ratio (INR). Daily exercise and weight management are not specifically important to this client.
The classifications of malignant neoplasms are: (Select all that apply.) a. carcinomas. b. lymphomas. c. fibromas. d. lipomas. e. sarcomas.
ANS: A, B, E The categories of malignancy are sarcomas, carcinomas, leukemias, and lymphomas. Fibromas and lipomas are benign.
A student nurse learns that the spleen has several functions. What functions do they include? (Select all that apply.) a. Breaks down hemoglobin b. Destroys old or defective red blood cells (RBCs) c. Forms vitamin K for clotting d. Stores extra iron in ferritin e. Stores platelets not circulating
ANS: A, B, E Functions of the spleen include breaking down hemoglobin released from RBCs, destroying old or defective RBCs, and storing the platelets that are not in circulation. Forming vitamin K for clotting and storing extra iron in ferritin are functions of the liver.
An older client asks the nurse why people my age have weaker immune systems than younger people. What responses by the nurse are best? (Select all that apply.) a. Bone marrow produces fewer blood cells. b. You may have decreased levels of circulating platelets. c. You have lower levels of plasma proteins in the blood. d. Lymphocytes become more reactive to antigens. e. Spleen function declines after age 60.
ANS: A, C The aging adult has bone marrow that produces fewer cells and decreased blood volume with fewer plasma proteins. Platelet numbers remain unchanged, lymphocytes become less reactive, and spleen function stays the same.
The nurse is monitoring a client with liver failure. Which assessments does the nurse perform when monitoring for bleeding in this client? (Select all that apply.) a. Gums b. Lung sounds c. Urine d. Stool e. Hair
ANS: A, C, D The liver is the site for production of clotting factors. Without these factors, the client is at risk for bleeding. Common areas of bleeding include the gums and mucous membranes, bladder, and gastrointestinal tract. Lung sounds and hair are part of the assessment but are not essential in the presence of liver failure and hematologic abnormalities.
The patient with AML has a platelet count of 95,000. What interventions should be included in the plan of care for this patient? (Select all that apply.) a. Observe for melena and hematuria. b. Brush and floss at least twice daily. c. Measure abdominal girth daily. d. Apply ice and pressure to puncture sites. e. Use electric razor.
ANS: A, C, D, E A low platelet makes the patient prone to excessive bleeding. The nurse should monitor for bleeding into the stool and urine. Soft toothbrushes will decrease the likelihood of the gums bleeding. An increase in the abdominal girth will alert the nurse to the possibility of internal bleeding. Ice and pressure on puncture sites aid in stopping bleeding. An electric razor reduces the chance of the patient being cut during shaving.
A nurse working with clients with sickle cell disease (SCD) teaches about self-management to prevent exacerbations and sickle cell crises. What factors should clients be taught to avoid? (Select all that apply.) a. Dehydration b. Exercise c. Extreme stress d. High altitudes e. Pregnancy
ANS: A, C, D, E Several factors cause red blood cells to sickle in SCD, including dehydration, extreme stress, high altitudes, and pregnancy. Strenuous exercise can also cause sickling, but not unless it is very vigorous.
The student nurse caring for clients who have cancer understands that the general consequences of cancer include which client problems? (Select all that apply.) a. Clotting abnormalities from thrombocythemia b. Increased risk of infection from white blood cell deficits c. Nutritional deficits such as early satiety and cachexia d. Potential for reduced gas exchange e. Various motor and sensory deficits
ANS: B, C, D, E The general consequences of cancer include reduced immunity and blood-producing functions, altered GI structure and function, decreased respiratory function, and motor and sensory deficits. Clotting problems often occur due to thrombocytopenia (not enough platelets), not thrombocythemia (too many platelets).
A nursing student learns that many drugs can impair the immune system. Which drugs does this include? (Select all that apply.) a. Acetaminophen (Tylenol) b. Amphotericin B (Fungizone) c. Ibuprofen (Motrin) d. Metformin (Glucophage) e. Nitrofurantoin (Macrobid)
ANS: B, C, E Amphotericin B, ibuprofen, and nitrofurantoin all can disrupt the hematologic (immune) system. Acetaminophen and metformin do not.