NCLEX 3500: Hematological and Immune Disorders

Which finding would the nurse identify as abnormal? 1. Red blood cells (RBCs): 4.9 million/μl 2. Platelets: 115,000/μl 3. White blood cells (WBCs): 7,000/μl 4. Hematocrit: 45%

Answer 2: RATIONALES: Normal values are 150,000 to 300,000 platelets/μl; 5,000 to 10,000 WBCs/μl; 4.5 to 5.5 million RBCs/μl; and an average hematocrit of 45%.

A client receiving ferrous sulfate (Fer-Iron) therapy to treat an iron deficiency reports taking an antacid frequently to relieve heartburn. Which instruction should the nurse provide? 1. "Take ferrous sulfate and the antacid together." 2. "Take ferrous sulfate and the antacid at least 2 hours apart." 3. "Avoid taking an antacid altogether." 4. "Take ferrous sulfate and the antacid at least 1 hour apart."

Answer 2: RATIONALES: The nurse should instruct the client to take ferrous sulfate and an antacid at least 2 hours apart because antacids bind with iron in the GI tract, decreasing the rate or extent of iron absorption.

A client takes prednisone (Deltasone), as prescribed, for rheumatoid arthritis. During follow-up visits, the nurse should assess the client for common adverse reactions to this drug, such as: 1. tetany and tremors. 2. anorexia and weight loss. 3. fluid retention and weight gain. 4. abdominal cramps and diarrhea.

Answer 3: RATIONALES: Common adverse reactions to prednisone and other steroids include sodium retention, fluid retention, and weight gain. Tetany and tremors are occasional adverse reactions to certain other drugs. Anorexia, abdominal cramps, and diarrhea are common adverse reactions to many drugs, but not to steroids.

The nurse is preparing to administer a unit of blood to a client who's anemic. After its removal from the refrigerator, the blood should be administered within: 1. 1 hour. 2. 2 hours. 3. 4 hours. 4. 6 hours.

Answer 3: RATIONALES: After the blood is removed from the refrigerator, it must be administered within 4 hours. Refrigeration delays the growth of bacteria in the blood. Six hours is too long because the extended time out of refrigeration increases the risk of contamination and growth of bacteria. If the blood is administered too rapidly, within 1 or 2 hours, the client could experience fluid overload.

A client has been taking a decongestant for allergic rhinitis. During a follow-up visit, which of the following suggests that the decongestant has been effective? 1. Increased salivation 2. Increased tearing 3. Reduced sneezing 4. Headache

Answer 3: RATIONALES: Decongestants relieve congestion and sneezing and reduce labored respirations. When effective, decongestants dry the mucous membranes; therefore, the client shouldn't experience increased salivation or tearing. Because decongestants alleviate congestion, they also relieve headaches, which may be caused by congestion.

A nurse is teaching high school students about transmission of the human immunodeficiency virus (HIV). Which comment by a student warrants clarification by the nurse? 1. "A man should wear a latex condom during intimate sexual contact." 2. "I've heard about people who got AIDS from blood transfusions." 3. "I won't donate blood because I don't want to get AIDS." 4. "I.V. drug users can get HIV from sharing needles."

Answer 3: RATIONALES: HIV is transmitted through infected blood, semen, and certain other body fluids. Although a transfusion with infected blood may cause HIV infection in the recipient, a person can't become infected by donating blood. The other options reflect accurate understanding of HIV transmission.

Which iron-rich foods should the nurse encourage an anemic client requiring iron therapy to eat? 1. Shrimp and tomatoes 2. Lobster and squash 3. Cheese and bananas 4. Lamb and peaches

Answer 4: RATIONALES: Iron-rich foods include lamb and peaches. Shrimp, tomatoes, lobster, squash, cheese, and bananas aren't high in iron content.

The physician prescribes didanosine (ddI [Videx]), 200 mg P.O. every 12 hours, for a client with acquired immunodeficiency syndrome (AIDS) who is intolerant to zidovudine (azidothymidine, AZT [Retrovir]). Which condition in the client's history warrants cautious use of this drug? 1. Peripheral neuropathy 2. Diabetes mellitus 3. Hypertension 4. Asthma

Answer 1: RATIONALES: A history of peripheral neuropathy, renal or hepatic impairment, hyperuricemia, or pancreatitis warrants cautious use of didanosine because these disorders increase the risk of adverse effects. Diabetes mellitus, hypertension, and asthma aren't significant history findings for a client who is to receive didanosine.

The client with rheumatoid arthritis reports GI irritation after taking piroxicam (Feldene). To prevent GI upset, the nurse should provide which instruction? 1. "Space the administration every 4 hours." 2. "Take piroxicam with food or an antacid." 3. "Use the drug for a short time only." 4. "Decrease the piroxicam dosage."

Answer 2: RATIONALES: Taking piroxicam with food or an antacid decreases the risk of GI upset. The client may take the full piroxicam dosage once daily or may divide it in half and take a smaller dose every 12 hours; dosing every 4 hours isn't recommended. Because piroxicam may not produce therapeutic effects for 2 to 4 weeks, the client should take it for more than a short time. The client shouldn't adjust the dosage of piroxicam or any medication unless directed by a physician.

The nurse assesses a client shortly after kidney transplant surgery. Which postoperative finding must the nurse report to the physician immediately? 1. Serum potassium level of 4.9 mEq/L 2. Serum sodium level of 135 mEq/L 3. Temperature of 99.2° F (37.3° C) 4. Urine output of 20 ml/hour

Answer 4: RATIONALES: Because kidney transplantation carries the risk of transplant rejection, infection, and other serious complications, the nurse should monitor the client's urinary function closely. A decrease from the normal urine output of 30 ml/hour is significant and warrants immediate physician notification. The other options are normal assessment findings.

A client must receive a blood transfusion of packed red blood cells (RBCs) for severe anemia. What I.V. fluid should the nurse use to prime the tubing before hanging this blood product? 1. Dextrose 5% in water 2. Dextrose 5% in normal saline solution 3. Lactated Ringer's solution 4. Normal saline solution

Answer 4: RATIONALES: Normal saline solution is used for administering blood transfusions. Lactated Ringer's solution or dextrose solutions may cause blood clotting or RBC hemolysis.

A 56-year-old client diagnosed with acquired immunodeficiency syndrome (AIDS) is admitted to the emergency department with a closed head injury after being found unconscious on the kitchen floor by her neighbor. Based on information from the client's neighbor, the staff suspects domestic abuse. The client has a restraining order against the husband. The husband repeatedly attempts to visit the client. Which nursing action ensures client safety? 1. Place the client in a reverse isolation room and post an isolation sign on the door restricting visitors. 2. Instruct the client that she should put on her call light if her husband enters her room. 3. Admit the client to the pediatric unit under an assumed name so that the husband can't find her. 4. Inform hospital security personnel of the restraining order and formulate an action plan with security that protects the client.

Answer 4: RATIONALES: The nurse should inform hospital security personnel about the restraining order and formulate an action plan with security that protects the client. Option 1 isolates the client and doesn't incorporate protective measures. Option 2 may alert hospital staff but doesn't allow for implementation of safety measures. Measures should be in place to stop the husband before he enters the client's room. Option 3 doesn't protect the client from harm.

Clients with cancer who receive multiple blood transfusions are at risk for forming antibodies against the blood. What precautions should the nurse take when administering blood to a client with a history of multiple transfusions? 1. Use a blood filter to filter the leukocytes. 2. Ask all clients about previous blood product administration. 3. Administer allogeneic blood products. 4. Make sure that leukocyte reduced blood products are prescribed.

Answer 4: RATIONALES: The nurse should make sure that leukocyte reduced blood products are prescribed to reduce the risk of a blood transfusion reaction caused by antibody formation. Filter use doesn't guarantee leukocyte removal. The nurse can ask the client about previous blood transfusions, but that doesn't protect the client from a transfusion reaction. Allogeneic blood products aren't always possible in clients with a history of multiple blood transfusions.

A client with a myocardial infarction is admitted to an acute care facility. During the admission history, the nurse learns that the client also has hypertension and progressive systemic sclerosis. For a client with this disease, the nurse is most likely to formulate which nursing diagnosis? 1. Risk for impaired skin integrity 2. Constipation 3. Ineffective thermoregulation 4. Risk for imbalanced nutrition: More than body requirements

Answer 1: RATIONALES: Progressive systemic sclerosis is a connective tissue disease characterized by fibrosis and degenerative changes of the skin, synovial membranes, and digital arteries. Therefore, the nurse is most likely to formulate a nursing diagnosis of Risk for impaired skin integrity. Because clients with the disease are prone to diarrhea from GI tract hypermotility (caused by pathologic changes), Constipation is an unlikely nursing diagnosis. Progressive systemic sclerosis doesn't cause ineffective thermoregulation. GI hypermotility may lead to malabsorption, and esophageal dysfunction may cause dysphagia; these conditions put the client with the disease at risk for inadequate nutrition, making Risk for imbalanced nutrition: More than body requirements an improbable nursing diagnosis.

Nurses were identified by the Centers for Disease Control and Prevention (CDC) as the people most likely to care for clients infected after the intentional release of the smallpox virus. Based on CDC guidelines, which group should volunteer to receive the small pox vaccine? 1. Nurses ages 50 and older who work in the emergency departments of community hospitals. 2. Nurses who served in the military who are now working in public health settings. 3. Nurses born after 1971 who are employed as triage nurses in large medical center emergency departments. 4. Nurses vaccinated against smallpox as children who are now working in a pediatric unit.

Answer 1: RATIONALES: The CDC recommends the small pox vaccine for nurses who received the vaccine as a child (which includes those older than age 50) who work in the emergency department; emergency department nurses are most likely to care for those infected with the smallpox virus. Nurses born after 1971 weren't previously vaccinated against smallpox so the vaccine isn't presently recommended for those nurses. Military history doesn't dictate whether or not the vaccine is recommended. Nurses who work in the pediatric unit aren't at high risk for smallpox exposure; therefore, the vaccine isn't recommended for this group.

While monitoring a client for the development of disseminated intravascular coagulation (DIC), the nurse should take note of which assessment parameters? 1. Platelet count, prothrombin time, and partial thromboplastin time 2. Platelet count, blood glucose levels, and white blood cell (WBC) count 3. Thrombin time, calcium levels, and potassium levels 4. Fibrinogen level, WBC, and platelet count

Answer 1: RATIONALES: The diagnosis of DIC is based on the results of laboratory studies of prothrombin time, platelet count, thrombin time, partial thromboplastin time, and fibrinogen level as well as client history and other assessment factors. Blood glucose levels, WBC count, calcium levels, and potassium levels aren't used to confirm a diagnosis of DIC.

A client is diagnosed with megaloblastic anemia caused by vitamin B12 deficiency. The physician begins the client on cyanocobalamin (Betalin-12), 100 mcg I.M. daily. Which substance influences vitamin B12 absorption? 1. Intrinsic factor 2. Hydrochloric acid 3. Histamine 4. Liver enzyme

Answer 1: RATIONALES: Vitamin B12 absorption depends on intrinsic factor, which is secreted by parietal cells in the stomach. The vitamin binds with intrinsic factor and is absorbed in the ileum. Hydrochloric acid, histamine, and liver enzymes don't influence vitamin B12 absorption.

A clinical nurse specialist (CNS) is orienting a new graduate registered nurse to an oncology unit where blood product transfusions are frequently administered. In discussing ABO compatibility, the CNS presents several hypothetical scenarios. A well-informed new graduate would know the greatest likelihood of an acute hemolytic reaction would occur when giving: 1. A-positive blood to an A-negative client. 2. O-negative blood to an O-positive client. 3. O-positive blood to an A-positive client. 4. B-positive blood to an AB-positive client.

Answer 1: RATIONALES: An acute hemolytic reaction occurs when there is an ABO or Rh incompatibility. For example, giving A blood to a B client would cause a hemolytic reaction. Likewise, giving Rh-positive blood to an Rh-negative client would cause a hemolytic reaction. It's safe to give Rh-negative blood to an Rh-positive client if there is a blood type compatibility. O-negative blood is the universal donor and can be given to all other blood types. AB clients can receive either A or B blood as long as there isn't an Rh incompatibility.

Twenty-four hours after undergoing kidney transplantation, a client develops a hyperacute rejection. To correct this problem, the nurse should prepare the client for: 1. removal of the transplanted kidney. 2. high-dose I.V. cyclosporine (Sandimmune) therapy. 3. bone marrow transplant. 4. intra-abdominal instillation of methylprednisolone sodium succinate (Solu-Medrol).

Answer 1: RATIONALES: Hyperacute rejection isn't treatable; the only way to stop this reaction is to remove the transplanted organ or tissue. Although cyclosporine is used to treat acute transplant rejection, it doesn't halt hyperacute rejection. Bone marrow transplant isn't effective against hyperacute rejection of a kidney transplant. Methylprednisolone sodium succinate may be given I.V. to treat acute organ rejection, but it's ineffective against hyperacute rejection.

The nurse is teaching a client who will be discharged soon how to change a sterile dressing on the right leg. During the teaching session, the nurse notices redness, swelling, and induration at the wound site. What do these signs suggest? 1. Infection 2. Dehiscence 3. Hemorrhage 4. Evisceration

Answer 1: RATIONALES: Infection produces such signs as redness, swelling, induration, warmth, and possibly drainage. Dehiscence, which refers to the separation of a wound, may cause unexplained fever and tachycardia, unusual wound pain, and prolonged paralytic ileus. Hemorrhage can result in increased pulse and respiratory rate, decreased blood pressure, restlessness, thirst, and cold, clammy skin. Evisceration produces visible protrusion of organs, usually through an incision.

For a client with an exacerbation of rheumatoid arthritis, the physician prescribes the corticosteroid prednisone (Deltasone). When caring for this client, the nurse should monitor for which adverse drug reactions? 1. Increased weight, hypertension, and insomnia 2. Vaginal bleeding, jaundice, and inflammation 3. Stupor, breast lumps, and pain 4. Dyspnea, numbness, and headache

Answer 1: RATIONALES: Prednisone can cause a wide range of adverse reactions, including increased weight caused by fluid retention, hypertension, insomnia, ecchymoses, suppressed inflammation, behavioral changes, and myopathy. However, it doesn't produce the S&S listed in options 2, 3, and 4.

In an individual with Sjögren's syndrome, nursing care should focus on: 1. moisture replacement. 2. electrolyte balance. 3. nutritional supplementation. 4. arrhythmia management.

Answer 1: RATIONALES: Sjögren's syndrome is an autoimmune disorder leading to progressive loss of lubrication of the skin, GI tract, ears, nose, and vagina. Moisture replacement is the mainstay of therapy. Though malnutrition and electrolyte imbalance may occur as a result of Sjögren's syndrome's effect on the GI tract, it isn't the predominant problem. Arrhythmias aren't a problem associated with Sjögren's syndrome.

A 33-year-old client who tested positive for human immunodeficiency virus (HIV) and has pancreatitis is admitted to the medical unit. The nurse director from another unit comes into the medical unit nurses' station and begins reading the client's chart. The staff nurse questions the director about reading the client's chart. The director states that the client is her neighbor's son. What action should the nurse take to protect the client's right to privacy? 1. Inform the nurse director she's violating the client's right to privacy and ask her to return the chart. 2. Remind the nurse director not to share the client's medical information with anyone because of his HIV status. 3. Report the incident to the medical director. 4. Ask the nurse director if she has permission to read the client 's chart, and if she does not, tell her she needs to obtain it before further reading.

Answer 1: RATIONALES: Under the Health Insurance Portability and Accountability Act (HIPAA), personal health information may not be used for purposes not related to health care. The nurse director found reading the chart isn't providing health care to the client and, therefore, doesn't require access to the chart. The nurse should confront the nurse director and ask her to return the client's chart. The director shouldn't have access to this client's healthcare information regardless of his HIV status. If she doesn't comply with the nurse's request, the nurse should report the incident to her nurse manager, so the infraction can be reported through the proper channels. The staff nurse shouldn't report the incident to the medical director. Option 4 doesn't protect client confidentiality.

A client is admitted to the facility with an exacerbation of her chronic systemic lupus erythematosus (SLE). She gets angry when her call bell isn't answered immediately. The most appropriate response to her would be: 1. "You seem angry. Would you like to talk about it?" 2. "Calm down. You know that stress will make your symptoms worse." 3. "Would you like to talk about the problem with the nursing supervisor?" 4. "I can see you're angry. I'll come back when you've calmed down."

Answer 1: RATIONALES: Verbalizing the observed behavior is a therapeutic communication technique in which the nurse acknowledges what the client is feeling. Offering to listen to the client express her anger can help both the nurse and the client understand its cause and begin to deal with it. Although stress can exacerbate the symptoms of SLE, telling the client to calm down doesn't acknowledge her feelings. Offering to get the nursing supervisor also ignores the client's feelings. Ignoring the client's feelings suggests that the nurse has no interest in what the client has said.

The nurse encourages a client with an immunologic disorder to eat a nutritionally balanced diet to promote optimal immunologic function. Autoimmunity has been linked to excessive ingestion of: 1. protein. 2. fat. 3. vitamin A. 4. zinc.

Answer 2: RATIONALES: A diet containing excessive fat seems to contribute to autoimmunity — overreaction of the body against constituents of its own tissues. Immune dysfunction has been linked to deficient — not excessive — intake of protein, vitamin A, and zinc.

When administering a blood transfusion to a client with multiple traumatic injuries, the nurse monitors closely for evidence of a transfusion reaction. Shortly after the transfusion begins, the client complains of chest pain, nausea, and itching. When urticaria, tachycardia, and hypotension develop, the nurse stops the transfusion and notifies the physician. The nurse suspects which type of hypersensitivity reaction? 1. Type I (immediate, anaphylactic) hypersensitivity reaction 2. Type II (cytolytic, cytotoxic) hypersensitivity reaction 3. Type III (immune complex) hypersensitivity reaction 4. Type IV (cell-mediated, delayed) hypersensitivity reaction

Answer 2: RATIONALES: ABO incompatibility, such as from an incompatible blood transfusion, is a type II hypersensitivity reaction. Transfusions of more than 100 ml of incompatible blood can cause severe and permanent renal damage, circulatory shock, and even death. Drug-induced hemolytic anemia is another example of a type II reaction. A type I hypersensitivity reaction occurs in anaphylaxis, atopic diseases, and skin reactions. A type III hypersensitivity reaction occurs in Arthus reaction, serum sickness, systemic lupus erythematosus (SLE), and acute glomerulonephritis. A type IV hypersensitivity reaction occurs in tuberculosis, contact dermatitis, and transplant rejection.

Which nursing instructions help parents of a child with hemophilia provide a safe home environment for their child? 1. Pad the corners of coffee tables when your child is a toddler and provide kneepads for sports when the child is older. 2. Establish a written emergency plan including what to do in specific situations and the names and phone numbers of emergency contacts. 3. Be a role model to your child by wearing a helmet when riding a bike so your child will too. 4. Talk to your child about home safety and have him problem-solve hypothetical situations about his health.

Answer 2: RATIONALES: Establishing a written emergency plan that includes what to do in specific situations helps the family provide safety measures for their child with hemophilia. Option 1 doesn't help provide a safe home environment for children of all ages. Option 3 is only applicable to children who are old enough to emulate their parent's behaviors. Option 4 doesn't help provide a safe environment; it addresses problem solving.

The nurse is observing a client receiving antiplatelet therapy for adverse reactions. Antiplatelet drugs most commonly produce which hypersensitivity reaction? 1. Difficulty hearing 2. Bronchospasm 3. Confusion 4. Agranulocytosis

Answer 2: RATIONALES: Hypersensitivity reactions to antiplatelet drugs, particularly anaphylaxis, can occur; the most common is the induction of bronchospasm with asthmalike symptoms. Difficulty hearing and confusion are adverse reactions associated with aspirin only. Agranulocytosis is associated with sulfinpyrazone.

During a routine checkup, the nurse evaluates a client with rheumatoid arthritis. To assess for the most obvious disease manifestations first, the nurse checks for: 1. muscle weakness. 2. joint abnormalities. 3. painful subcutaneous nodules. 4. gait disturbances.

Answer 2: RATIONALES: Joint abnormalities are the most obvious manifestations of rheumatoid arthritis. A systemic disease, rheumatoid arthritis attacks all connective tissue. Nonarticular connective tissue, such as collagen in the lungs, heart, muscles, vessels, pleura, and tendons, may be involved diffusely. Vasculitis may affect the eyes, nervous system, and skin, causing thrombosis and ischemia. Although muscle weakness may occur from limited use of the joint where the muscle attaches, such weakness isn't the most obvious sign of rheumatoid arthritis; also, it occurs only after joint abnormalities arise. Subcutaneous nodules, although common in rheumatoid arthritis, are painless. The disease may cause gait disturbances, but these follow joint abnormalities.

A client with anemia has been admitted to the medical-surgical unit. Which assessment findings are characteristic of iron-deficiency anemia? 1. Nights sweats, weight loss, and diarrhea 2. Dyspnea, tachycardia, and pallor 3. Nausea, vomiting, and anorexia 4. Itching, rash, and jaundice

Answer 2: RATIONALES: Signs of iron-deficiency anemia include dyspnea, tachycardia, and pallor, as well as fatigue, listlessness, irritability, and headache. Night sweats, weight loss, and diarrhea may signal acquired immunodeficiency syndrome (AIDS). Nausea, vomiting, and anorexia may be signs of hepatitis B. Itching, rash, and jaundice may result from an allergic or hemolytic reaction.

A client with thrombocytopenia, secondary to leukemia, develops epistaxis. The nurse should instruct the client to: 1. lie supine with his neck extended. 2. sit upright, leaning slightly forward. 3. blow his nose and then put lateral pressure on his nose. 4. hold his nose while bending forward at the waist.

Answer 2: RATIONALES: Sitting upright and leaning slightly forward avoids increasing vascular pressure in the nose and helps the client avoid aspirating blood. Lying supine won't prevent aspiration of the blood. Nose blowing can dislodge any clotting that has occurred. Bending at the waist increases vascular pressure in the nose and promotes bleeding rather than halting it.

A client with rheumatoid arthritis is being discharged with a prescription for aspirin (Ecotrin), 600 mg P.O. every 6 hours. The nurse should instruct the client to notify the physician if which adverse drug reaction occurs? 1. Dysuria 2. Tinnitus 3. Leg cramps 4. Constipation

Answer 2: RATIONALES: The client with rheumatoid arthritis typically takes a relatively high dosage of aspirin for its anti-inflammatory effect. The nurse should instruct the client to report signs and symptoms of aspirin toxicity, such as tinnitus (ringing in the ears). The other options aren't associated with aspirin use or toxicity.

A female client with human immunodeficiency virus (HIV) receives family-planning counseling. Which statement about safer sex practices for persons with HIV is accurate? 1. If the client and her sexual partners are HIV-positive, unprotected sex is permitted. 2. A latex condom with spermicide provides the best protection against HIV transmission during sexual intercourse. 3. Contraceptive methods like birth control pills, implants, and injections are recommended to prevent HIV transmission. 4. The intrauterine device is recommended for a client with HIV.

Answer 2: RATIONALES: A latex condom with spermicide provides the best protection against HIV transmission during sexual intercourse. The nurse should caution the client not to have unprotected sex because continued exposure to HIV in a seropositive client may hasten the course of the disease or result in infection with another strain of HIV. The birth control pill, implants, and injections offer no protection against HIV transmission. The intrauterine device isn't recommended for a client with HIV because it may increase her susceptibility to pelvic inflammatory disease.

A client diagnosed with systemic lupus erythematosus (SLE) comes to the emergency department with severe back pain. She reports that she first felt pain after manually opening her garage door and that she is taking prednisone daily. What adverse effect of long-term corticosteroid therapy is most likely responsible for the pain? 1. Hypertension 2. Osteoporosis 3. Muscle wasting 4. Truncal obesity

Answer 2: RATIONALES: All of the options listed above are adverse effects of long-term corticosteroid therapy; however, osteoporosis frequently causes compression fractures of the spine. The other adverse effects aren't likely to cause severe back pain.

A client with autoimmune thrombocytopenia and a platelet count of 8,000/μ:l develops epistaxis and melena. Treatment with corticosteroids and immunoglobulins has been unsuccessful, and the physician recommends a splenectomy. The client states, "I don't need surgery — this will go away on its own." In considering her response to the client, the nurse must depend on the ethical principle of: 1. beneficence. 2. autonomy. 3. advocacy. 4. justice.

Answer 2: RATIONALES: Autonomy ascribes the right of the individual to make his own decisions. In this case, the client is capable of making his own decision and the nurse should support his autonomy. Beneficence and justice aren't the principles that directly relate to the situation. Advocacy is the nurse's role in supporting the principle of autonomy.

A 32-year-old pregnant client who developed deep vein thrombosis (DVT) in her right leg is receiving heparin I.V. on the medical floor. Physical therapy is ordered to maintain her mobility and prevent additional DVTs. A nursing assistant working on the medical unit helps the client with bathing, range-of-motion exercises, and personal care. Which collaborative multidisciplinary considerations should the care plan address? 1. The client is at risk for heparin-induced thrombocytopenia; therefore, the care plan should include sequential compression device application and strict bedrest. 2. The client is at risk for heparin-induced thrombocytopenia; therefore, the care plan should include reporting any evidence of bleeding or easy bruising. 3. The client is at risk for developing another DVT; therefore, the care plan should include reporting redness, tenderness, or edema in the other lower extremity. 4. The client is pregnant and receiving I.V. heparin, placing the client at risk for premature labor; therefore, the care plan should include reporting signs of premature labor.

Answer 2: RATIONALES: Feedback from physical therapy and other caregivers should be incorporated into the care plan to ensure safety and optimal outcomes. Options 1 and 3 don't incorporate collaborative care. Option 4 doesn't address the consequences of thrombocytopenia, which may occur with I.V. heparin therapy.

A client with suspected lymphoma is scheduled for lymphangiography. The nurse should inform the client that this procedure may cause which harmless, temporary change? 1. Purplish stools 2. Bluish urine 3. Redness of the upper part of the feet 4. Coldness of the soles

Answer 2: RATIONALES: Lymphangiography may turn the urine blue temporarily; it doesn't alter stool color. For several months after the procedure, the upper part of the feet may appear blue, not red. Lymphangiography doesn't affect the soles.

The nurse is caring for a 32-year-old client admitted with pernicious anemia. Which set of findings should the nurse expect when assessing the client? 1. Pallor, bradycardia, and reduced pulse pressure 2. Pallor, tachycardia, and a sore tongue 3. Sore tongue, dyspnea, and weight gain 4. Angina, double vision, and anorexia

Answer 2: RATIONALES: Pallor, tachycardia, and a sore tongue are all characteristic findings in pernicious anemia. Other clinical manifestations include anorexia; weight loss; a smooth, beefy red tongue; a wide pulse pressure; palpitations; angina; weakness; fatigue; and paresthesia of the hands and feet. Bradycardia, reduced pulse pressure, weight gain, and double vision aren't characteristic findings in pernicious anemia.

A client was recently discharged with a peripherally inserted central catheter, and the home care nurse begins teaching him how to care for the catheter. The client states "I'm so confused. The nurses in the hospital started to show me how to care for this catheter, but I don't think I'll be able to keep it all straight." Which response by the nurse is most appropriate? 1. "Don't worry. That's why your doctor ordered home care for you. If you aren't able to learn how to care for the catheter, we can do it for you." 2. "We'll make sure that you feel comfortable caring for your catheter. Can you show me what the nurses in the hospital showed you?" 3. "Your insurance only covers two nursing visits, so you'll need to learn quickly." 4. "Don't underestimate yourself; you'll know how to care for your catheter in no time."

Answer 2: RATIONALES: The client received instruction before discharge, so the home care nurse should ask the client to demonstrate what he learned while hospitalized. The home care nurse can then develop her teaching plan based on the client's learning needs. Option 1 doesn't promote client autonomy. The nurse shouldn't increase the client's anxiety level by mentioning that insurance only covers two home visits. Option 4 minimizes the client's concerns.

A client with end-stage acquired immunodeficiency syndrome (AIDS) has profound manifestations of Cryptosporidium infection caused by the protozoa. In planning the client's care, the nurse should focus on his need for: 1. pain management. 2. fluid replacement. 3. antiretroviral therapy. 4. high-calorie nutrition.

Answer 2: RATIONALES: The protozoal enteric infection caused by Cryptosporidium results in profuse watery diarrhea. Because diarrhea will lead to dehydration, the nurse should focus on fluid replacement. Pain management is also a concern in the care of a client with AIDS. However, with Cryptosporidium, the main concern is hydration. Antiretroviral therapy is most useful when a client with human immunodeficiency virus (HIV) doesn't have opportunistic infections. With the wasting associated with AIDS, high-calorie nutrition is important but with Cryptosporidium-related diarrhea, hydration takes precedence.

The nurse is assigned to a client with polymyositis. Which expected outcome in the care plan relates to a potential problem associated with polymyositis? 1. "Client will lose 2 lb per week on a calorie-restricted diet." 2. "Client will exhibit no signs or symptoms of aspiration." 3. "Client will exhibit bowel and bladder continence." 4. "Client will exhibit alertness and orientation to person, place, and time."

Answer 2: RATIONALES: This expected outcome relates to symmetrical muscle weakness — a potential problem associated with polymyositis that may lead to speaking and swallowing problems. A client with a potential swallowing problem is at risk for inadequate nutrition and wouldn't be placed on a calorie-restricted diet; an expected outcome focusing on maintaining weight would be more appropriate than option 1. Polymyositis doesn't affect bowel or bladder function or mental status, eliminating options 3 and 4.

After receiving a dose of penicillin, a client develops dyspnea and hypotension. The nurse suspects the client is experiencing anaphylactic shock. What should the nurse do first? 1. Page an anesthesiologist immediately and prepare to intubate the client. 2. Administer epinephrine, as prescribed, and prepare to intubate the client if necessary. 3. Administer the antidote for penicillin, as prescribed, and continue to monitor the client's vital signs. 4. Insert an indwelling urinary catheter and begin to infuse I.V. fluids as ordered.

Answer 2: RATIONALES: To reverse anaphylactic shock, the nurse first should administer epinephrine, a potent bronchodilator as prescribed. The physician is likely to order additional medications, such as antihistamines and corticosteroids; if these medications don't relieve the respiratory compromise associated with anaphylaxis, the nurse should prepare to intubate the client. No antidote for penicillin exists; however, the nurse should continue to monitor the client's vital signs. A client who remains hypotensive may need fluid resuscitation and fluid intake and output monitoring; however, administering epinephrine is the first priority.

Which nonpharmacologic interventions should the nurse include in the care plan for a client who has moderate rheumatoid arthritis (RA)? 1. Massaging inflamed joints 2. Avoiding range-of-motion (ROM) exercises 3. Applying splints to inflamed joints 4. Using assistive devices at all times 5. Selecting clothing that has Velcro fasteners 6. Applying moist heat to joints

Answer 3,5,6 RATIONALES: Supportive, nonpharmacologic measures for the client with RA include applying splints to rest inflamed joints, using Velcro fasteners on clothes to aid in dressing, and applying moist heat to joints to relax muscles and relieve pain. Inflamed joints should never be massaged because doing so can aggravate inflammation. A physical therapy program, including ROM exercises and carefully individualized therapeutic exercises, prevents loss of joint function. Assistive devices should be used only when marked loss of ROM occurs.

The nurse is caring for a client with thrombocytopenia. What is the best way to protect this client? 1. Limit visits by family members. 2. Encourage the client to use a wheelchair. 3. Use the smallest needle possible for injections. 4. Maintain accurate fluid intake and output records.

Answer 3: RATIONALES: Because thrombocytopenia alters coagulation, it poses a high risk of bleeding. To help prevent capillary bleeding, the nurse should use the smallest needle possible when administering injections. The nurse doesn't need to limit visits by family members because they don't pose any danger to the client. The nurse should provide comfort measures and maintain the client on bed rest; activities such as using a wheelchair can cause bleeding. The nurse records fluid intake and output to monitor hydration; however, this action doesn't protect the client from a complication of thrombocytopenia.

A client is diagnosed with rheumatoid arthritis, an autoimmune disorder. When teaching the client and family about autoimmune disorders, the nurse should provide which information? 1. Clients with autoimmune disorders may have false-negative but not false-positive serologic tests. 2. Advanced medical intervention can cure most autoimmune disorders. 3. Autoimmune disorders include connective tissue (collagen) disorders. 4. Autoimmune disorders are distinctive, aiding differential diagnosis.

Answer 3: RATIONALES: Connective tissue disorders are considered autoimmune disorders. Clients with autoimmune disorders may have either false-positive or false-negative serologic tests for syphilis. Other common laboratory findings in these clients include Coombs-positive hemolytic anemia, thrombocytopenia, leukopenia, immunoglobulin excesses or deficiencies, antinuclear antibodies, antibodies to deoxyribonucleic acid and ribonucleic acid, rheumatoid factors, elevated muscle enzymes, and changes in acute phase-reactive proteins. No cure exists for autoimmune disorders; treatment centers on controlling symptoms. Autoimmune disorders aren't distinctive; they share common features, making differential diagnosis difficult.

The nurse is assigned to a client with acquired immunodeficiency syndrome (AIDS). When handling the client's blood and body fluids, the nurse uses standard precautions, which include: 1. wearing gloves to touch client. 2. wearing a gown, gloves, and protective eyewear when obtaining a urine specimen via catheterization. 3. disposing of needles uncapped. 4. wearing gloves when applying eyedrops.

Answer 3: RATIONALES: Disposing of needles uncapped is a standard precaution; most accidental needle sticks result from missed needle recapping. Standard precautions also include not cutting, breaking, or bending a needle after use because doing so may release aerosolized blood from the needle shaft; not leaving used needles lying around; and disposing of needles only in appropriately labeled, impermeable needle containers. Gloves aren't necessary when touching the client, and urine collection by catheterization doesn't require use of gloves, gown, and protective eyewear.

The couple with the lowest risk of having a child with sickle cell disease is the one in which the: 1. father is HbS and the mother is HbS. 2. father is HbS and the mother is HbAS. 3. father is HbA and the mother is HbS. 4. father is HbAS and the mother is HbAS.

Answer 3: RATIONALES: If the father has normal hemoglobin (HbA) and the mother has sickle cell disease (HbS), the couple has a 0% chance of having a child with sickle cell disease. If both parents have sickle disease, the couple has a 100% chance of having a child with sickle cell disease. If the father has sickle cell disease and the mother has sickle cell trait (HbAS), the couple has a 50% chance of having a child with sickle cell disease. If both parents have sickle cell trait, the couple has a 25% chance of having a child with sickle cell disease.

Which immunoglobulin is specific to an allergic response? 1. IgA 2. IgB 3. IgE 4. IgG

Answer 3: RATIONALES: Immunoglobulin E (IgE) is involved with an allergic reaction. IgA combines with antigens and activates complement. IgB coats the surface of B lymphocytes. IgG is the principle immunoglobulin formed in response to most infectious agents. While obtaining a health history, the nurse learns that the client is allergic to bee stings.

The nurse is teaching a client with pernicious anemia who requires vitamin B12 replacement therapy. Which statement indicates that the client understands the treatment program? 1. "I'll swallow one vitamin B12 pill every morning for 2 weeks." 2. "I'll take a vitamin B12 pill once each month for life." 3. "I'll need an injection of vitamin B12 every month for life." 4. "I'll only need daily injections of vitamin B12 until my blood count improves."

Answer 3: RATIONALES: In pernicious anemia, the gastric mucosa doesn't secrete intrinsic factor, a protein necessary for vitamin B12 absorption. Without intrinsic factor, vitamin B12 replacements taken orally won't be absorbed; therefore, vitamin B12 must be administered through the I.M. or deep subcutaneous routes. Clients must take vitamin B12 each day for 2 weeks initially, then weekly for several months, then once each month for life.

A client on the oncology floor is prescribed a blood transfusion. The nurse explains the procedure and informs the client that an informed consent form must be signed before the blood can be administered. The client asks why consent is necessary. Which response by the nurse best explains why consent is necessary for blood transfusions? 1. "The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requires a signed informed consent from all clients receiving blood transfusions." 2. "We can only administer blood transfusions without a signed informed consent in the event of an emergency." 3. "The consent allows you to make an informed decision about the indications, possible alternatives, risks, and benefits of a blood transfusion." 4. "When clients who require blood sign an informed consent, it indicates they understand blood transfusions can be hazardous."

Answer 3: RATIONALES: Informed consent provides clients with information needed to make informed decisions about their health care. Clients need information about their health care regardless of the requirements mandated by JCAHO. Option 2 doesn't explain the purpose of signing a consent form. Informed consent provides the client with more information about blood transfusions than the hazards.

After an extensive diagnostic workup, a client is diagnosed with systemic lupus erythematosus (SLE). Which statement about the incidence of SLE is true? 1. SLE is most common in women between ages 45 and 60. 2. SLE affects more whites than blacks. 3. SLE tends to occur in families. 4. SLE is more common in underweight than overweight persons.

Answer 3: RATIONALES: SLE has a familial basis. Also, when one twin has the disease, the other twin has a 60% to 70% chance of developing it, suggesting a genetic predisposition. SLE strikes nearly 10 times as many women as men and is most common in women between ages 15 and 40. SLE affects more black women than white women; its incidence is about 1 in every 250 black women, compared to 1 in every 700 white women. Being overweight, not underweight, is thought to increase autoimmunity and thus heighten the risk for SLE and other autoimmune disorders.

A client with acquired immunodeficiency syndrome (AIDS) is prescribed zidovudine (azidothymidine, AZT [Retrovir]), 200 mg P.O. every 4 hours. When teaching the client about this drug, the nurse should provide which instruction? 1. "Take zidovudine with meals." 2. "Take zidovudine on an empty stomach." 3. "Take zidovudine every 4 hours around the clock." 4. "Take over-the-counter (OTC) drugs to treat minor adverse reactions."

Answer 3: RATIONALES: To be effective, zidovudine must be taken every 4 hours around the clock. Food doesn't affect absorption of this drug, so the client may take zidovudine either with food or on an empty stomach. To avoid serious drug interactions, the client should check with the physician before taking OTC medications.

A client with allergic rhinitis is prescribed loratadine (Claritin). On a follow-up visit, the client tells the nurse, "I take one 10-mg tablet of Claritin with a glass of water two times daily." The nurse concludes that the client requires additional teaching about this medication because: 1. loratadine isn't available in 10-mg tablets. 2. loratadine should be taken on an empty stomach. 3. loratadine should be taken once daily for allergic rhinitis. 4. Claritin isn't the trade name for loratadine.

Answer 3: RATIONALES: When prescribed for allergic rhinitis, loratadine is usually taken once, not twice, daily. Loratadine is available in 10-mg tablets, should be taken on an empty stomach, and is dispensed under the trade name Claritin.

A client diagnosed with idiopathic thrombocytopenia purpura (ITP) needs a peripherally inserted central catheter placed. When explaining the catheter to the client, the nurse explains that one advantage of using a catheter is that it can be used: 1. to administer blood products and I.V. fluids only. 2. in clients with infections in the blood. 3. to accomplish long term access to central veins. 4. for 2 weeks without being replaced.

Answer 3: RATIONALES: A peripherally inserted central catheter provides long-term access (longer than 2 weeks) to central veins. It can be used to administer blood products, medications, I.V. fluids, and total parenteral nutrition (TPN). Moreover, the peripherally inserted central catheter can be used to obtain blood specimens. As with any other central venous catheter, this catheter shouldn't be inserted when systemic infection (infection in the blood) is present.

A client with human immunodeficiency virus (HIV) undergoes intradermal anergy testing using Candida and mumps antigen. During the 3 days following the tests, there is no induration or evidence of reaction at the intradermal injection sites. The most accurate conclusion the nurse can make is: 1. the client has no previous exposure to the antigens injected. 2. the results demonstrate the client has antibodies to the antigens. 3. the client is immunodeficient and won't have a skin response. 4. the client isn't allergic to the antigens and therefore doesn't react.

Answer 3: RATIONALES: Anergy testing determines the level of immune response an individual has to common microbes. A normal response is a local skin reaction to all the antigens injected intradermally. Absence of a response within 3 days suggests the individual is immunodeficient and can't produce a normal immune response. It doesn't imply nonexposure to the antigens, which are environmentally prevalent. Demonstration of antibodies to the antigens would be a positive skin reaction. An expected reaction to the antigens isn't considered an allergic or hypersensitive reaction.

A client has had heavy menstrual bleeding for 6 months. Her gynecologist diagnoses microcytic hypochromic anemia and prescribes ferrous sulfate (Feosol), 300 mg P.O. daily. Before initiating iron therapy, the nurse reviews the client's medical history. Which condition would contraindicate the use of ferrous sulfate? 1. Pregnancy 2. Asthma 3. Ulcerative colitis 4. Severely impaired liver function

Answer 3: RATIONALES: Conditions that contraindicate the use of ferrous sulfate include primary hemochromatosis, infectious kidney disease during the acute phase, peptic ulcer, regional enteritis, ulcerative colitis, and known hypersensitivity to iron. Iron dextran requires cautious use in pregnant or breast-feeding clients and in those with severely impaired liver function, significant allergies, or asthma.

A client diagnosed with metastatic cancer is preparing for discharge. The physician prescribes morphine sulfate controlled-release tablets 100 mg every 12 hours as needed after discharge. What legal rights and responsibilities should the nurse address when teaching the client about morphine sulfate use? 1. "You must avoid driving or other activities that require alertness while taking controlled-release morphine sulfate." 2. "Morphine sulfate is an opioid and you may develop tolerance. This is an expected response and isn't harmful." 3. "Federal law prevents refills of this medication. Your doctor will give you a new prescription when you need more medicine." 4. "If you no longer require the morphine sulfate controlled release tablets for your cancer pain, don't take any leftover pills for other disorders."

Answer 3: RATIONALES: Federal law prevents the refill of opioids. Therefore, the client will need to contact the physician for a new prescription when the current prescription is empty. The client should be instructed to avoid driving or operating hazardous machinery while under the effects of morphine; however, this is a safety issue not a legal one. Long-term morphine sulfate use may lead to drug tolerance; however, this isn't a legal issue surrounding its use. The client with metastatic cancer will most likely require pain medication for the rest of her life.

The nurse is preparing a client with systemic lupus erythematosus (SLE) for discharge. Which instruction should the nurse include in the teaching plan? 1. "Exposure to sunlight will help control skin rashes." 2. "There are no activity limitations between flare-ups." 3. "Monitor your body temperature." 4. "Corticosteroids may be stopped when symptoms are relieved."

Answer 3: RATIONALES: Fever can signal an exacerbation and should be reported to the physician. Sunlight and other sources of ultraviolet light may precipitate severe skin reactions and exacerbate the disease. Fatigue can cause a flare-up of SLE. Clients should be encouraged to pace activities and plan rest periods. Corticosteroids must be gradually tapered because they can suppress the function of the adrenal gland. Abruptly stopping corticosteroids can cause adrenal insufficiency, a potentially life-threatening situation.

A complete blood count is commonly performed before a client goes into surgery. What does this test seek to identify? 1. Potential hepatic dysfunction indicated by decreased blood urea nitrogen (BUN) and creatinine levels 2. Low levels of urine constituents normally excreted in the urine 3. Abnormally low hematocrit (HCT) and hemoglobin (Hb) levels 4. Electrolyte imbalance that could affect the blood's ability to coagulate properly

Answer 3: RATIONALES: Low preoperative HCT and Hb levels indicate the client may require a blood transfusion before surgery. If the HCT and Hb levels decrease during surgery because of blood loss, the potential need for a transfusion increases. Possible renal failure is indicated by elevated BUN or creatinine levels. Urine constituents aren't found in the blood. Coagulation is determined by the presence of appropriate clotting factors, not electrolytes.

The nurse is caring for a client with acquired immunodeficiency syndrome (AIDS). To adhere to standard precautions, the nurse should: 1. maintain strict isolation. 2. keep the client in a private room, if possible. 3. wear gloves when providing mouth care. 4. wear a gown when delivering the client's food tray.

Answer 3: RATIONALES: Standard precautions stipulate that a health care worker wear gloves when contact with any client's blood or body fluids is anticipated, such as when providing mouth care. Maintaining strict isolation isn't needed because human immunodeficiency virus is spread by contact with contaminated blood or body fluids, which can be avoided by following standard precautions. A private room wouldn't provide barrier protection, which is needed for standard precautions. Wearing a gown is appropriate only when anticipating splashing of blood or body fluids.

A client who agreed to become an organ donor is pronounced dead. What is the most important factor in selecting a transplant recipient? 1. Blood relationship 2. Sex and size 3. Compatible blood and tissue types 4. Need

Answer 3: RATIONALES: The donor and recipient must have compatible blood and tissue types. They should be fairly close in size and age. When a living donor is considered, it's preferable to have a relative donate the organ. Need is important but it can't be the critical factor if a compatible donor isn't available.

A client newly diagnosed with acute lymphocytic leukemia (ALL) has a right subclavian central venous catheter in place. The nurse who's caring for the client is teaching a graduate nurse about central venous catheter care. The nurse should instruct the graduate nurse to change the central venous catheter dressing every: 1. shift. 2. 24 hours. 3. 48 hours. 4. 72 hours.

Answer 3: RATIONALES: The nurse should instruct the graduate nurse to change the central venous catheter dressing every 48 hours or when the dressing becomes damaged or soiled.

The nurse is planning care for a client with human immunodeficiency virus (HIV). She's being assisted by a licensed practical nurse (LPN). Which statements by the LPN indicate her understanding of HIV transmission? 1. "I'll wear a gown, mask, and gloves for all client contact." 2. "I don't need to wear any personal protective equipment because nurses have a low risk of occupational exposure." 3. "I'll wear a mask if the client has a cough caused by an upper respiratory infection." 4. "I'll wear a mask, gown, and gloves when splashing of body fluids is likely." 5. "I'll wash my hands after client care."

Answer 4,5: RATIONALES: Standard precautions include wearing gloves for any known or anticipated contact with blood or other body fluids, tissue, mucous membranes, or nonintact skin. If the task may result in splashing or splattering of blood or body fluids to the face, a mask and goggles or face shield should be worn. If the task may result in splashing or splattering of blood or body fluids to the body, a fluid-resistant gown or apron should be worn. Hands should be washed before and after client care and after removing gloves. A gown, mask, and gloves aren't necessary for client care unless contact with body fluids, tissue, mucous membranes, or nonintact skin is expected. Nurses have an increased, not decreased, risk of occupational exposure to blood-borne pathogens. HIV isn't transmitted in sputum unless blood is present.

A client with pernicious anemia is receiving parenteral vitamin B12 therapy. Which client statement indicates effective teaching about this therapy? 1. "I will receive parenteral vitamin B12 therapy until my signs and symptoms disappear." 2. "I will receive parenteral vitamin B12 therapy until my vitamin B12 level returns to normal." 3. "I will receive parenteral vitamin B12 therapy monthly for 6 months to a year." 4. "I will receive parenteral vitamin B12 therapy for the rest of my life."

Answer 4: RATIONALES: Because a client with pernicious anemia lacks intrinsic factor, oral vitamin B12 can't be absorbed. Therefore, parenteral vitamin B12 therapy is recommended and required for life.

When taking a dietary Hx from a newly admitted client, the nurse should remember that which of the following foods is a common allergen? 1. Bread 2. Carrots 3. Oranges 4. Strawberries

Answer 4: RATIONALES: Common food allergens include berries, peanuts, Brazil nuts, cashews, shellfish, and eggs. Bread, carrots, and oranges rarely cause allergic reactions.

A client seeks medical evaluation for fatigue, night sweats, and a 20-lb weight loss in 6 weeks. To confirm that the client has been infected with the human immunodeficiency virus (HIV), the nurse expects the physician to order: 1. E-rosette immunofluorescence. 2. quantification of T-lymphocytes. 3. enzyme-linked immunosorbent assay (ELISA). 4. Western blot test with ELISA.

Answer 4: RATIONALES: HIV infection is detected by analyzing blood for antibodies to HIV, which form approximately 2 to 12 weeks after exposure to HIV and denote infection. The Western blot test — electrophoresis of antibody proteins — is more than 98% accurate in detecting HIV antibodies when used in conjunction with the ELISA. It isn't specific when used alone. E-rosette immunofluorescence is used to detect viruses in general; it doesn't confirm HIV infection. Quantification of T-lymphocytes is a useful monitoring test but isn't diagnostic for HIV. The ELISA test detects HIV antibody particles but may yield inaccurate results; a positive ELISA result must be confirmed by the Western blot test.

Which laboratory test value is elevated in clients who smoke and can't be used as a general indicator of cancer? 1. Acid phosphatase level 2. Serum calcitonin level 3. Alkaline phosphatase level 4. Carcinoembryonic antigen level

Answer 4: RATIONALES: In clients who smoke, the level of carcinoembryonic antigen is elevated. Therefore, it can't be used as a general indicator of cancer. However, it is helpful in monitoring cancer treatment because the level usually falls to normal within 1 month if treatment is successful. An elevated acid phosphatase level may indicate prostate cancer. An elevated alkaline phosphatase level may reflect bone metastasis. An elevated serum calcitonin level usually signals thyroid cancer.

A 40-year-old client with mild dementia related to end-stage acquired immunodeficiency syndrome (AIDS) is preparing for discharge. She has decided against further curative treatment and wishes to return home. Before discharge, she develops ocular cytomegalovirus (CMV). Her physician recommends treatment with a Ganciclovir-impregnated implant (Vitrasert), which requires a surgical procedure. The client 's husband feels the implant won't help the patient and asks the nurse if the implant will cure CMV. Which answer from the nurse best answers the husband's question reflecting client advocacy? 1. "The implant won't cure the virus. I'll tell the physician that you don't want her to have the procedure." 2. "The implant won't cure the virus but it may protect her sight. Just because your wife has dementia doesn't mean she shouldn't be given the opportunity to see." 3. "The implant won't cure the virus in your wife's eye. The dementia she has means she is terminally ill. You are right to refuse further treatments because nothing more will help her." 4. "The implant won't cure the virus, but it may help preserve her vision. If she can't see you or her surroundings, it may worsen her dementia and make caring for her at home more difficult."

Answer 4: RATIONALES: In option 4, the nurse is advocating for the client's wishes. She is explaining the client's wishes for no further curative treatment, yet promoting an improved quality of life and safety while the client is being cared for at home. Option 1 answers the husband's question, but it doesn't advocate for the client's needs. Option 2 provides factual information, but it's delivered in a confrontational manner. Option 3 also provides factual information but doesn't show client advocacy.

A client with idiopathic thrombocytopenic purpura (ITP), an autoimmune disorder, is admitted to an acute care facility. Concerned about hemorrhage, the nurse monitors the client's platelet count and observes closely for signs and symptoms of bleeding. The client is at greatest risk for cerebral hemorrhage when the platelet count falls below: 1. 135,000/μl. 2. 75,000/μl. 3. 20,000/μl. 4. 500/μl.

Answer 4: RATIONALES: The client with ITP is at greatest risk for cerebral hemorrhage when the platelet count falls below 500/μl. A platelet count of 135,000/μl is normal and wouldn't occur in a client with ITP. Although platelet counts of 75,000/μl and 20,000/μl are below normal and increase the client's risk for bleeding, they don't increase the risk as much as a platelet count below 500/μl.

Two weeks ago, a client underwent repair of an abdominal aortic aneurysm. Now she has several postoperative complications, including wound infection and failure to wean from the ventilator. While suctioning the client, the nurse notes that her sputum is copious, foul-smelling, and green-tinged . A specimen is sent for culture and sensitivity testing. When the test results indicate a Pseudomonas aeruginosa, infection, the physician prescribes gentamicin sulfate (Garamycin), 80 mg I.V. every 8 hours. The nurse should infuse this drug over at least: 1. 5 minutes. 2. 10 minutes. 3. 20 minutes. 4. 30 minutes.

Answer 4: RATIONALES: The nurse should infuse gentamicin sulfate I.V. over at least 30 minutes. Infusing the drug more rapidly may increase the client's risk of adverse reactions.

A client is receiving a blood transfusion. If this client experiences an acute hemolytic reaction, which nursing intervention is the most important? 1. Immediately stop the transfusion, infuse dextrose 5% in water (D5W), and call the physician. 2. Slow the transfusion and monitor the client closely. 3. Stop the transfusion, notify the blood bank, and administer antihistamines. 4. Immediately stop the transfusion, infuse normal saline solution, notify the blood bank, and call the physician.

Answer 4: RATIONALES: When a transfusion reaction occurs, the transfusion should be immediately stopped, normal saline solution should be infused to maintain venous access, and the blood bank and physician should be notified immediately. Other nursing actions include saving the blood bag and tubing, rechecking the blood type and identification numbers on the blood tags, monitoring vital signs, obtaining necessary laboratory blood and urine samples, providing proper documentation, and monitoring and treating for shock. Because they can cause red blood cell hemolysis, dextrose solutions shouldn't be infused with blood products. Antihistamines may be administered for a mild allergic reaction.

The nurse is caring for a client who is receiving antibiotics to treat a gram-negative bacterial infection. Because antibiotics destroy the body's normal flora, the nurse must monitor the client for: 1. platelet dysfunction. 2. oliguria and dysuria. 3. stomatitis. 4. diarrhea.

Answer 4: RATIONALES: Broad-spectrum antibiotics that destroy aerobic and anaerobic bacteria also destroy the normal flora of the GI tract, which are responsible for absorbing water and certain nutrients (such as vitamin K). Destruction of the GI flora, in turn, leads to diarrhea. Although antibiotics may cause platelet dysfunction, stomatitis, renal dysfunction (indicated by oliguria and dysuria), and liver dysfunction, these adverse effects don't result from destruction of the GI flora.

A client in a late stage of acquired immunodeficiency syndrome (AIDS) shows signs of AIDS-related dementia. Which nursing diagnosis takes highest priority? 1. Bathing or hygiene self-care deficit 2. Ineffective cerebral tissue perfusion 3. Dysfunctional grieving 4. Risk for injury

Answer 4: RATIONALES: In a client with AIDS, deterioration of the central nervous system (CNS) can lead to AIDS-related dementia. This type of dementia impairs cognition and judgment, placing the client at risk for injury. Although bathing or hygiene self-care deficit and Dysfunctional grieving may be relevant in AIDS, these diagnoses don't take precedence for a client with AIDS-related dementia. Because CNS deterioration results from infection, Ineffective cerebral tissue perfusion isn't applicable.

The physician orders tests to determine if a client has systemic lupus erythematosus (SLE). Which test result confirms an SLE diagnosis? 1. Increased total serum complement levels 2. Negative antinuclear antibody test 3. Negative lupus erythematosus cell test 4. An above-normal anti-deoxyribonucleic acid (DNA) test

Answer 4: RATIONALES: Laboratory results specific for SLE include an above-normal anti-DNA test, a positive antinuclear antibody test, and a positive lupus erythematosus cell test. Because the anti-DNA test rarely is positive in other diseases, this test is important in diagnosing SLE. (The anti-DNA antibody level may be depressed in clients who are in remission from SLE.) Decreased total serum complement levels indicate active SLE.

A client with rheumatoid arthritis is about to begin aspirin therapy to reduce inflammation. When teaching the client about aspirin, the nurse discusses adverse reactions to prolonged aspirin therapy. These include: 1. weight gain. 2. fine motor tremors. 3. respiratory acidosis. 4. bilateral hearing loss.

Answer 4: RATIONALES: Prolonged use of aspirin and other salicylates sometimes causes bilateral hearing loss of 30 to 40 decibels. Usually, this adverse effect resolves within 2 weeks after the therapy is discontinued. Aspirin doesn't lead to weight gain or fine motor tremors. Large or toxic salicylate doses may cause respiratory alkalosis, not respiratory acidosis.

Following a splenectomy, a client has a hemoglobin (Hb) level of 7.5 g/dl and has vertigo when getting out of bed. The nurse suspects abnormal orthostatic changes. The vital sign values that would most support the nurse's analysis are: 1. a rise in blood pressure and heart rate. 2. a rise in blood pressure and a drop in heart rate. 3. a drop in blood pressure and heart rate. 4. a drop in blood pressure and a rise in heart rate.

Answer 4: RATIONALES: The client had blood loss during the splenectomy and developed subsequent anemia. With a subnormal Hb level and vertigo when getting out of bed, the nurse is accurate in suspecting orthostasis. Orthostatic changes develop from hypovolemia and cause a drop in blood pressure and a compensatory rise in the heart rate when the client rises from a lying position.

In teaching a female client who is HIV-positive about pregnancy, the nurse would know more teaching is necessary when the client says: 1. "The baby can get the virus from my placenta." 2. "I'm planning on starting on birth control pills." 3. "Not everyone who has the virus gives birth to a baby who has the virus." 4. "I'll need to have a C-section if I become pregnant and have a baby."

Answer 4: RATIONALES: The human immunodeficiency virus (HIV) is transmitted from mother to child via the transplacental route, but a Cesarean section delivery isn't necessary when the mother is HIV-positive. The use of birth control will prevent the conception of a child who might have HIV. It's true that a mother who's HIV-positive can give birth to a baby who's HIV-negative.

When obtaining this client's medication history, the nurse should determine if the client keeps which medication on hand? 1. diphenhydramine hydrochloride (Benadryl) 2. pseudoephedrine hydrochloride (Sudafed) 3. guaifenesin (Robitussin) 4. loperamide (Imodium)

Answer 1: RATIONALES: A client who is allergic to bee stings should keep diphenhydramine on hand because its antihistamine action can prevent a severe allergic reaction. Pseudoephedrine is a decongestant, which is used to treat cold symptoms. Guaifenesin is an expectorant, which is used for coughs. Loperamide is an antidiarrheal agent.

The wife of a 27-year-old client with end-stage acquired immunodeficiency syndrome (AIDS) is caring for her husband at home. The hematologist recommends hospice care and the couple agrees. During the initial admission visit, the hospice nurse provides information to the client and his family about an advance directive. During the next day's visit, the client states that since he and his wife filled out the advance directive form, he feels abandoned by his physician. Which statement by the hospice nurse best addresses the client's concerns? 1. "Your physician will continue to care for you. The advance directive simply puts in writing the care you want, so he will be able to provide it if you can't tell him yourself." 2. "You don't need to feel that way. Your physician is required by law to sign your orders and the hospice nurses will be contacting him with updates on your condition." 3. "Many people first feel that way when they are admitted into hospice. While the focus of your care has changed from curative to supportive, your physician will still continue directing it." 4. "It's understandable to feel that way. But clients with end-stage AIDS who have advanced directives generally experience a less painful death that those individuals who don't."

Answer 1: RATIONALES: Option 1 provides correct information about advance directives. The advance directive outlines the client's treatment wishes should he be unable to communicate his wishes at any time during his illness. The physician continues to provide care for clients admitted to hospice care. Option 2 invalidates the client's fears and doesn't emphasize the physician's role or the client's role in his care plan. Option 3 doesn't address the purpose of the advance directive, and it discusses treatment options that may not have been discussed with the client. Option 4 doesn't provide evidence-based information about advance directives.

The nurse provides care for a client with deep partial-thickness burns. What could cause a reduced hematocrit (HCT) in this client? 1. Hypoalbuminemia with hemoconcentration 2. Volume overload with hemodilution 3. Metabolic acidosis 4. Lack of erythropoietin factor

Answer 2: RATIONALES: Reduced HCT is caused by hemodilution, when the concentration of erythrocytes and other blood elements is lowered by volume overload. This is a result of interstitial-to-plasma fluid shift. Hypoalbuminemia causes the movement of fluid from the vascular component to the interstitial space and results in hemoconcentration. Metabolic acidosis does cause the red blood components to be fragile but isn't applicable in this situation. Erythropoietin factor would only be reduced if kidney failure occurred.

In a client who has human immunodeficiency virus (HIV) infection, CD4+ levels are measured to determine the: 1. presence of opportunistic infections. 2. level of the viral load. 3. extent of immune system damage. 4. resistance to antigens.

Answer 3: RATIONALES: CD4+ levels in the blood of an individual with HIV infection determine the extent of damage to the individual's immune system. The test indicates the individual's risk of an opportunistic infection but doesn't identify specific infections. Viral loads and resistance to specific antigens are determined using other diagnostic tests.

During chemotherapy for lymphocytic leukemia, a client develops abdominal pain, fever, and "horse barn" smelling diarrhea. It would be most important for the nurse to advise the physician to order: 1. enzyme-linked immunosuppressant assay (ELISA) test. 2. electrolyte panel and hemogram. 3. stool for Clostridium difficile test. 4. flat plate X-ray of the abdomen.

Answer 3: RATIONALES: Immunosuppressed clients — for example, clients receiving chemotherapy, — are at risk for infection with C. difficile, which causes "horse barn" smelling diarrhea. Successful treatment begins with an accurate diagnosis, which includes a stool test. The ELISA test is diagnostic for human immunodeficiency virus (HIV) and isn't indicated in this case. An electrolyte panel and hemogram may be useful in the overall evaluation of a client but aren't diagnostic for specific causes of diarrhea. A flat plate of the abdomen may provide useful information about bowel function but isn't indicated in the case of "horse barn" smelling diarrhea.

When preparing a client with acquired immunodeficiency syndrome (AIDS) for discharge to the home, the nurse should be sure to include which instruction? 1. "Put on disposable gloves before bathing." 2. "Sterilize all plates and utensils in boiling water." 3. "Avoid sharing such articles as toothbrushes and razors." 4. "Avoid eating foods from serving dishes shared by other family members."

Answer 3: RATIONALES: The human immunodeficiency virus (HIV), which causes AIDS, is most concentrated in the blood. For this reason, the client shouldn't share personal articles that may be blood-contaminated, such as toothbrushes and razors, with other family members. HIV isn't transmitted by bathing or by eating from plates, utensils, or serving dishes used by a person with AIDS.

A client is diagnosed with human immunodeficiency virus (HIV). After recovering from the initial shock of the diagnosis, the client expresses a desire to learn as much as possible about HIV and acquired immunodeficiency syndrome (AIDS). When teaching the client about the immune system, the nurse states that adaptive immunity is provided by which type of white blood cell? 1. Neutrophil 2. Basophil 3. Monocyte 4. Lymphocyte

Answer 4: RATIONALES: The lymphocyte provides adaptive immunity — recognition of a foreign antigen and formation of memory cells against the antigen. Adaptive immunity is mediated by B and T lymphocytes and can be acquired actively or passively. The neutrophil is crucial to phagocytosis. The basophil plays an important role in the release of inflammatory mediators. The monocyte functions in phagocytosis and monokine production.

A client is receiving chemotherapy for cancer. The nurse reviews the client's laboratory report and notes that he has thrombocytopenia. To which nursing diagnosis should the nurse give the highest priority? 1. Activity intolerance 2. Impaired tissue integrity 3. Impaired oral mucous membranes 4. Ineffective tissue perfusion: Cerebral, cardiopulmonary, GI

Answer 4: RATIONALES: These are all appropriate nursing diagnoses for the client with thrombocytopenia. However, the risk of cerebral and GI hemorrhage and hypotension pose the greatest risk to the physiological integrity of the client.

A home care nurse is making the initial home visit to a client with lung cancer who had a peripherally inserted central catheter placed during hospitalization for an upper respiratory infection. During the visit, the nurse must administer an antibiotic, teach the client how to care for the catheter, and provide information about when to notify the home care agency and physician. When the nurse arrives at the client's home, the client's face is flushed and he complains of feeling tired. Which actions should the nurse take first? 1. Call the physician to update him on the client's condition and administer the antibiotic. 2. Obtain the client's vital signs and then administer the antibiotic. 3. Obtain the client's vital signs and assess breath sounds. 4. Administer the antibiotic, obtain vital signs, assess breath sounds, and then begin the teaching session.

Answer: 3 RATIONALES: The nurse should assess the client to see why his condition has changed since discharge. After assessment, the nurse should notify the physician of the change in the client's condition. The nurse shouldn't just obtain vital signs and administer the antibiotic without further assessing the client. It's inappropriate for the nurse to begin a teaching session when the client isn't physically able.

A client with acquired immunodeficiency syndrome (AIDS) is admitted with Pneumocystis carinii pneumonia. During a bath, the client begins to cry and says that most friends and relatives have stopped visiting and calling. What should the nurse do? 1. Continue with the bath and tell the client not to worry. 2. Ask the physician to obtain a psychiatric consultation. 3. Listen and show interest as the client expresses feelings. 4. State that these friends' behavior shows that they aren't true friends.

Answer: 3 RATIONALES: The nurse should listen actively and nonjudgmentally as the client expresses feelings. Telling the client not to worry would provide false reassurance. A psychiatric consultation would be appropriate only after further assessment. Stating that the client's friends aren't true friends would discount the client's feelings.

The nurse is working in a support group for clients with acquired immunodeficiency syndrome (AIDS). Which point is most important for the nurse to stress? 1. Avoiding the use of recreational drugs and alcohol 2. Refraining from telling anyone about the diagnosis 3. Following safer-sex practices 4. Telling potential sex partners about the diagnosis, as required by law

Correct Answer: 3 RATIONALES: It's essential that clients with AIDS follow safer-sex practices to prevent transmission of the human immunodeficiency virus (HIV). Although it's helpful if clients with AIDS avoid using recreational drugs and alcohol, it's more important that I.V. drug users use clean needles and dispose of used needles for purposes of avoiding transmission. Whether the client with AIDS chooses to tell anyone about the diagnosis is his decision; there is no legal obligation to do so.

The nurse practitioner assesses a client in the physician's office. Which assessment findings support a suspicion of systemic lupus erythematosus (SLE)? 1. Facial erythema, profuse proteinuria, pleuritis, fever, and weight loss 2. Pericarditis, photosensitivity, polyarthralgia, and painful mucous membrane ulcers 3. Weight gain, hypervigilance, hypothermia, and edema of the legs 4. Hypothermia, weight gain, lethargy, and edema of the arms

Answer 1: RATIONALES: An autoimmune disorder characterized by chronic inflammation of the connective tissues, SLE causes fever, weight loss, malaise, fatigue, skin rashes, and polyarthralgia. Nearly half of clients with SLE have facial erythema, the classic butterfly rash. SLE also may cause profuse proteinuria (excretion of more than 0.5 g/day of protein), pleuritis, pericarditis, photosensitivity, and painless mucous membrane ulcers. Weight gain, hypervigilance, hypothermia, and edema of the legs and arms don't suggest SLE.

Which blood type would the nurse identify as the rarest? 1. A 2. B 3. AB 4. O

Answer 3: RATIONALES: Group AB individuals comprise only about 4% of the population, and therefore are the rarest blood type. Type O is the most common (approximately 45% of the population), followed by Type A (41%) and Type B (10%).

A client who is receiving cyclosporine (Sandimmune) must practice good oral hygiene, including regular brushing and flossing of the teeth, to minimize gingival hyperplasia. Good oral hygiene also is essential to minimize gingival hyperplasia during long-term therapy with certain drugs. Which drug falls into this category? 1. procainamide (Pronestyl) 2. azathioprine (Imuran) 3. phenytoin (Dilantin) 4. allopurinol (Zyloprim)

Answer: 3 RATIONALES: Gingival hyperplasia may occur with long-term administration of phenytoin, an anticonvulsant. This adverse effect presumably is dose related. Frequent toothbrushing removes food particles and helps prevent infection; regular dental care and frequent gum massage also are recommended. Gingival hyperplasia isn't a reported adverse effect of procainamide, azathioprine, or allopurinol.

Which white blood cells are involved in releasing histamine during an allergic reaction? 1. Basophils 2. Eosinophils 3. Monocytes 4. Neutrophils

Answer 1: RATIONALES: Basophils are responsible for releasing histamine. Eosinophils' major function is phagocytosis of antigen-antibody complexes that are formed in allergic reactions. Monocytes and neutrophils are predominately phagocytic.

Which is the most numerous type of white blood cell (WBC)? 1. Neutrophil 2. Eosinophil 3. Basophil 4. Lymphocyte

Answer 1: RATIONALES: Neutrophils are the most numerous of the WBCs, comprising about 65%. Lymphocytes are the second most abundant. Eosinophils account for about 2% while basophils are the least abundant.

A client with acquired immunodeficiency syndrome (AIDS) is receiving zidovudine (azidothymidine, AZT [Retrovir]). To check for adverse drug effects, the nurse should monitor the results of which laboratory test? 1. Red blood cell (RBC) count 2. Fasting blood glucose 3. Serum calcium 4. Platelet count

Answer 1: RATIONALES: Because anemia (characterized by a decrease in RBCs) is a major adverse effect of zidovudine, the nurse should monitor the client's RBC count and assess for signs and symptoms of decreased cellular oxygenation. Zidovudine doesn't affect the blood glucose level, serum calcium level, or platelet count.

A client with systemic lupus erythematosus (SLE) has the classic rash of lesions on the cheeks and bridge of the nose. What term does the nurse use to describe this characteristic pattern? 1. Butterfly rash 2. Papular rash 3. Pustular rash 4. Bull's eye rash

Answer 1: RATIONALES: In the classic lupus rash, lesions appear on the cheeks and the bridge of the nose, creating a characteristic butterfly pattern. The rash may vary in severity from malar erythema to discoid lesions (plaque). Papular and pustular rashes aren't associated with SLE. The bull's eye rash is classic in client's with Lyme's disease.

Which step must be done first when administering a blood transfusion? 1. Verify the blood product and client identity. 2. Verify the physician's order. 3. Verify client identity and blood product with another nurse. 4. Assess the I.V. site.

Answer 2: RATIONALES: The nurse must first verify the physician's order and then make sure the informed consent form is signed. Next, the nurse should make sure that an appropriate size I.V. catheter is in place and she should assess the site for patency. After doing so, the nurse should verify the blood product and client identity with another nurse.

For a client diagnosed with idiopathic thrombocytopenia purpura (ITP), which nursing intervention is appropriate? 1. Teaching coughing and deep-breathing techniques to help prevent infection 2. Administering platelets, as ordered, to maintain an adequate platelet count 3. Giving aspirin, as prescribed, to control body temperature 4. Administering stool softeners, as ordered, to prevent straining during defecation

Answer 4: RATIONALES: The nurse should take measures to prevent bleeding because the client with ITP is at increased risk for bleeding. Straining at stool causes the Valsalva maneuver, which may raise intracranial pressure (ICP), thus increasing the risk for intracerebral bleeding. Therefore, the nurse should give stool softeners to prevent straining, which may result from constipation. Teaching coughing techniques would be inappropriate because coughing raises ICP. Platelets rarely are transfused prophylactically in clients with ITP because the cells are destroyed, providing little therapeutic benefit. Aspirin interferes with platelet function and is contraindicated in clients with ITP.

Which nursing diagnosis should the nurse expect to see in a care plan for a client in sickle cell crisis? 1. Imbalanced nutrition: Less than body requirements related to poor intake 2. Disturbed sleep pattern related to external stimuli 3. Impaired skin integrity related to pruritus 4. Acute pain related to sickle cell crisis

Answer: 4 RATIONALES: In sickle cell crisis, sickle-shaped red blood cells clump together in a blood vessel, which causes occlusion, ischemia, and extreme pain. Therefore, option 4 is the appropriate choice. Although nutrition is important, poor nutritional intake isn't necessarily related to sickle cell crisis. During sickle cell crisis, pain or another internal stimulus is more likely to disturb the client's sleep than external stimuli. Although clients with sickle cell anemia can develop chronic leg ulcers caused by small vessel blockage, they don't typically experience pruritus.