NCLEX: Fluids, Electrolytes, Blood Products
The dehydrated patient is receiving a hypertonic solution. What assessments must be done to avoid risk factors of these solutions (select all that apply)? - Lung sounds - Bowel sounds - Blood pressure - Serum sodium level - Serum potassium level
- Lung sounds - Blood pressure - Serum sodium level BP, lung sounds, and serum sodium levels must be monitored frequently because of the risk for excess intravascular volume with hypertonic solutions.
While performing patient teaching regarding hypercalcemia, which statements are appropriate (select all that apply)? - Have patient restrict fluid intake to less than 2000 mL/day. - Renal calculi may occur as a complication of hypercalcemia. - Weight-bearing exercises can help keep calcium in the bones. - The patient should increase daily fluid intake to 3000 to 4000 mL. - Treatment of heartburn can best be managed with Tums as needed.
- Renal calculi may occur as a complication of hypercalcemia. - Weight-bearing exercises can help keep calcium in the bones. - The patient should increase daily fluid intake to 3000 to 4000 mL. A daily fluid intake of 3000 to 4000 mL is necessary to enhance calcium excretion and prevent the formation of renal calculi, a potential complication of hypercalcemia. Tums are a calcium-based antacid that should not be used in patients with hypercalcemia. Weight-bearing exercise does enhance bone mineralization.
You are caring for a patient admitted with diabetes mellitus, malnutrition, and massive GI bleed. In analyzing the morning lab results, the nurse understands that a potassium level of 5.5 mEq/L could be caused by which factors in this patient (select all that apply)? - The potassium level may be increased if the patient has renal nephropathy. - The patient may be excreting extra sodium and retaining potassium because of malnutrition. - The potassium level may be increased as a result of dehydration that accompanies high blood glucose levels. - There may be excess potassium being released into the blood as a result of massive transfusion of stored hemolyzed blood. - The patient has been overeating raisins, baked beans, and salt substitute that increase the potassium level.
- The potassium level may be increased if the patient has renal nephropathy. - The potassium level may be increased as a result of dehydration that accompanies high blood glucose levels. - There may be excess potassium being released into the blood as a result of massive transfusion of stored hemolyzed blood. Hyperkalemia may result from hyperglycemia, renal insufficiency, and/or cell death. Diabetes mellitus, along with the stress of hospitalization and illness, can lead to hyperglycemia. Renal insufficiency is a complication of diabetes. Malnutrition does not cause sodium excretion accompanied by potassium retention. Thus it is not a contributing factor to this patient's potassium level. Stored hemolyzed blood can cause hyperkalemia when large amounts are transfused rapidly. The patient with a massive GI bleed would have an NG tube and not be eating.
A 22-year-old male is admitted to the emergency department with a stab wound to the abdomen. The patient's vital signs are blood pressure 82/56 mm Hg, pulse 132 beats/minute, respirations 28 breaths/minute, and temperature 97.9° F (36.6° C). Which fluid, if ordered by the health care provider, should the nurse question? - 0.9% saline - 0.45% saline - Packed red blood cells - Lactated Ringer's solution
0.45% saline IV administration of 0.45% saline is hypotonic and is used for maintenance fluid replacement and dilutes the extracellular fluid. Intravenous solutions used for volume expansion for hypovolemic shock include lactated Ringer's solution and 0.9% saline. If hypovolemia is due to blood loss, blood may be administered.
When planning the care of a patient with dehydration, what would the nurse instruct the unlicensed assistive personnel (UAP) to report? - 60 mL urine output in 90 minutes - 1200 mL urine output in 24 hours - 300 mL urine output per 8-hour shift - 20 mL urine output for 2 consecutive hours
20 mL urine output for 2 consecutive hours The minimal urine output necessary to maintain kidney function is 30 mL/hr. If the output is less than this for 2 consecutive hours, the nurse should be notified so that additional fluid volume replacement therapy can be instituted.
When planning care for adult patients, which oral intake is adequate to meet daily fluid needs of a stable patient? - 500 to 1500 mL - 1200 to 2200 mL - 2000 to 3000 mL - 3000 to 4000 mL
2000 to 3000 mL Daily fluid intake and output is usually 2000 to 3000 mL. This is sufficient to meet the needs of the body and replace both sensible and insensible fluid losses. These would include urine output and fluids lost through the respiratory system, skin, and GI tract.
The patient was admitted for a paracentesis to remove ascites fluid. Five liters of fluid was removed. What IV solution may be used to pull fluid into the intravascular space after the paracentesis? - 0.9% sodium chloride - 25% albumin solution - Lactated Ringer's solution - 5% dextrose in 0.45% saline
25% albumin solution After a paracentesis of 5 L or greater of ascites fluid, 25% albumin solution may be used as a volume expander. Normal saline, lactated Ringer's, and 5% dextrose in 0.45% saline will not be effective for this action.
A patient who is prescribed an anticoagulant requests an aspirin (acetylsalicylic acid) for headache relief. What is the nurse's best action? a. Inform the patient of potential drug interactions with anticoagulants. b. Explain that a common initial adverse effect is a headache for this drug. c. Explain that acetylsalicylic acid is contraindicated and administer ibuprofen. d. Administer 650 mg of acetylsalicylic acid and reassess pain in 30 minutes.
A
The nurse notes a patient's international normalized ratio (INR) value of 2.5. What is the meaning of this reported value? a. The patient's warfarin dose is within the therapeutic range. b. The patient needs the subcutaneous heparin dose increased. c. The patient is not receiving enough warfarin for a therapeutic effect. d. The patient is receiving too much heparin and is at risk for bleeding.
A
Which medication is an antiplatelet drug? a. Clopidogrel (Plavix) b. Alteplase (Activase) c. Heparin (Hemochron) d. Enoxaparin (Lovenox)
A
The nurse on a medical-surgical unit identifies that which patient has the highest risk for metabolic alkalosis? - A patient with a traumatic brain injury - A patient with type 1 diabetes mellitus - A patient with acute respiratory failure - A patient with nasogastric tube suction
A patient with nasogastric tube suction Excessive nasogastric suctioning may cause metabolic alkalosis. Brain injury may cause hyperventilation and respiratory alkalosis. Type 1 diabetes mellitus (diabetic ketoacidosis) is associated with metabolic acidosis. Acute respiratory failure may lead to respiratory acidosis.
The nurse recognizes that the patient understands the teaching about warfarin (Coumadin) when the patient verbalizes an increased risk of bleeding with concurrent use of which herbal product? (Select all that apply.) a. Garlic b. Ginkgo c. Dong quai d. Glucosamine e. St. John's wort
A,B,C,E
For a patient receiving an IV infusion of alteplase (Activase), which nursing actions should be taken? (Select all that apply.) a. Assess for cardiac dysrhythmias. b. Administer injections intramuscularly. c. Record vital signs and report changes. d. Monitor for an increase in liver enzymes. e. Observe for signs and symptoms of bleeding.
A,C,E
A patient is to receive an infusion of 250 mL of platelets over 2 hours through tubing that is labeled: 1 mL equals 10 drops. How many drops per minute will the nurse infuse?
ANS: 21 To infuse 250 mL over 2 hours, the calculated drip rate is 20.8 drops/min or 21 drops/min. DIF: Cognitive Level: Apply (application) REF: 649 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
A patient with immune thrombocytopenic purpura (ITP) has an order for a platelet transfusion. Which information indicates that the nurse should consult with the health care provider before obtaining and administering platelets? a. Platelet count is 42,000/L. b. Petechiae are present on the chest. c. Blood pressure (BP) is 94/56 mm Hg. d. Blood is oozing from the venipuncture site.
ANS: A Platelet transfusions are not usually indicated until the platelet count is below 10,000 to 20,000/L unless the patient is actively bleeding. Therefore the nurse should clarify the order with the health care provider before giving the transfusion. The other data all indicate that bleeding caused by ITP may be occurring and that the platelet transfusion is appropriate. DIF: Cognitive Level: Apply (application) REF: 622 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
Which action will the nurse include in the plan of care for a patient admitted with multiple myeloma? a. Monitor fluid intake and output. b. Administer calcium supplements. c. Assess lymph nodes for enlargement. d. Limit weight bearing and ambulation.
ANS: A A high fluid intake and urine output helps prevent the complications of kidney stones caused by hypercalcemia and renal failure caused by deposition of Bence-Jones protein in the renal tubules. Weight bearing and ambulation are encouraged to help bone retain calcium. Lymph nodes are not enlarged with multiple myeloma. Calcium supplements will further increase the patient's calcium level and are not used. DIF: Cognitive Level: Apply (application) REF: 646 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
An appropriate nursing intervention for a patient with non-Hodgkin's lymphoma whose platelet count drops to 18,000/μL during chemotherapy is to a. check all stools for occult blood. b. encourage fluids to 3000 mL/day. c. provide oral hygiene every 2 hours. d. check the temperature every 4 hours.
ANS: A Because the patient is at risk for spontaneous bleeding, the nurse should check stools for occult blood. A low platelet count does not require an increased fluid intake. Oral hygiene is important, but it is not necessary to provide oral care every 2 hours. The low platelet count does not increase risk for infection, so frequent temperature monitoring is not indicated. DIF: Cognitive Level: Apply (application) REF: 644 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
Which menu choice indicates that the patient understands the nurse's teaching about recommended dietary choices for iron-deficiency anemia? a. Omelet and whole wheat toast c. Strawberry and banana fruit plate b. Cantaloupe and cottage cheese d. Cornmeal muffin and orange juice
ANS: A Eggs and whole grain breads are high in iron. The other choices are appropriate for other nutritional deficiencies but are not the best choice for a patient with iron-deficiency anemia. DIF: Cognitive Level: Apply (application) REF: 610 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
Which information obtained by the nurse assessing a patient admitted with multiple myeloma is most important to report to the health care provider? a. Serum calcium level is 15 mg/dL. b. Patient reports no stool for 5 days. c. Urine sample has Bence-Jones protein. d. Patient is complaining of severe back pain.
ANS: A Hypercalcemia may lead to complications such as dysrhythmias or seizures, and should be addressed quickly. The other patient findings will also be discussed with the health care provider but are not life threatening. DIF: Cognitive Level: Analyze (analysis) REF: 645 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
Which patient statement to the nurse indicates a need for additional instruction about taking oral ferrous sulfate? a. "I will call my health care provider if my stools turn black." b. "I will take a stool softener if I feel constipated occasionally." c. "I should take the iron with orange juice about an hour before eating." d. "I should increase my fluid and fiber intake while I am taking iron tablets."
ANS: A It is normal for the stools to appear black when a patient is taking iron, and the patient should not call the health care provider about this. The other patient statements are correct. DIF: Cognitive Level: Apply (application) REF: 609 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
Which patient should the nurse assign as the roommate for a patient who has aplastic anemia? a. A patient with chronic heart failure b. A patient who has viral pneumonia c. A patient who has right leg cellulitis d. A patient with multiple abdominal drains
ANS: A Patients with aplastic anemia are at risk for infection because of the low white blood cell production associated with this type of anemia, so the nurse should avoid assigning a roommate with any possible infectious process. DIF: Cognitive Level: Apply (application) REF: 614 OBJ: Special Questions: Multiple Patients TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment
After receiving change-of-shift report for several patients with neutropenia, which patient should the nurse assess first? a. A 56-yr-old with frequent explosive diarrhea b. A 33-yr-old with a fever of 100.8° F (38.2° C) c. A 66-yr-old who has white pharyngeal lesions d. A 23-yr-old who is complaining of severe fatigue
ANS: B Any fever in a neutropenic patient indicates infection and can quickly lead to sepsis and septic shock. Rapid assessment and (if prescribed) initiation of antibiotic therapy within 1 hour are needed. The other patients also need to be assessed but do not exhibit symptoms of potentially life-threatening problems. DIF: Cognitive Level: Analyze (analysis) REF: 632 OBJ: Special Questions: Prioritization | Special Questions: Multiple Patients TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment
Which intervention will be included in the nursing care plan for a patient with immune thrombocytopenic purpura? a. Assign the patient to a private room. b. Avoid intramuscular (IM) injections. c. Use rinses rather than a soft toothbrush for oral care. d. Restrict activity to passive and active range of motion.
ANS: B IM or subcutaneous injections should be avoided because of the risk for bleeding. A soft toothbrush can be used for oral care. There is no need to restrict activity or place the patient in a private room. DIF: Cognitive Level: Apply (application) REF: 622 TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment
Which patient requires the most rapid assessment and care by the emergency department nurse? a. The patient with hemochromatosis who reports abdominal pain b. The patient with neutropenia who has a temperature of 101.8° F c. The patient with thrombocytopenia who has oozing gums after a tooth extraction d. The patient with sickle cell anemia who has had nausea and diarrhea for 24 hours
ANS: B A neutropenic patient with a fever is assumed to have an infection and is at risk for rapidly developing sepsis. Rapid assessment, cultures, and initiation of antibiotic therapy are needed. The other patients also require rapid assessment and care but not as urgently as the neutropenic patient. DIF: Cognitive Level: Analyze (analysis) REF: 632 OBJ: Special Questions: Multiple Patients | Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment
After a severe auto accident, a patient has been taken to the trauma unit and has an estimated blood loss of more than 30% of his blood volume. The nurse prepares to administer which product?" a Albumin b Whole blood c Packed red blood cells d Fresh frozen plasma
ANS: B A patient who has lost a massive amount (over 25%) of blood volume would receive whole blood. PRBCs are given to increase the oxygen-carrying capacity in patients with anemia, in patients with substantial hemoglobin deficits, and in patients who have lost up to 25% of their total blood volume. A patient with a coagulation disorder or a clotting-factor deficiency would receive fresh frozen plasma; albumin is used to expand fluid volume.
A patient who has been receiving IV heparin infusion and oral warfarin (Coumadin) for a deep vein thrombosis (DVT) is diagnosed with heparin-induced thrombocytopenia (HIT) when the platelet level drops to 110,000/μL. Which action will the nurse include in the plan of care? a. Prepare for platelet transfusion. b. Discontinue the heparin infusion. c. Administer prescribed warfarin (Coumadin). d. Use low-molecular-weight heparin (LMWH).
ANS: B All heparin is discontinued when HIT is diagnosed. The patient should be instructed to never receive heparin or LMWH. Warfarin is usually not given until the platelet count has returned to 150,000/μL. The platelet count does not drop low enough in HIT for a platelet transfusion, and platelet transfusions increase the risk for thrombosis. DIF: Cognitive Level: Apply (application) REF: 622 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
Which collaborative problem will the nurse include in a care plan for a patient admitted to the hospital with idiopathic aplastic anemia? a. Potential complication: seizures b. Potential complication: infection c. Potential complication: neurogenic shock d. Potential complication: pulmonary edema
ANS: B Because the patient with aplastic anemia has pancytopenia, the patient is at risk for infection and bleeding. There is no increased risk for seizures, neurogenic shock, or pulmonary edema. DIF: Cognitive Level: Apply (application) REF: 614 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
The nurse is preparing to transfuse a patient with a unit of packed red blood cells (PRBCs). Which intravenous solution is correct for use with the PRBC transfusion?" a 5% dextrose in water (D5W) b 0.9% sodium chloride (NS) c 5% dextrose in 0.45% sodium chloride (D5NS) d 5% dextrose in lactated Ringer's solution (D5LR)
ANS: B Blood products should be given only with normal saline 0.9% because D5W will also cause hemolysis of the blood product.
A routine complete blood count for an active older man indicates possible myelodysplastic syndrome. The nurse will plan to teach the patient about a. blood transfusion. b. bone marrow biopsy. c. filgrastim (Neupogen) administration. d. erythropoietin (Epogen) administration.
ANS: B Bone marrow biopsy is needed to make the diagnosis and determine the specific type of myelodysplastic syndrome. The other treatments may be necessary if there is progression of the myelodysplastic syndrome, but the initial action for this asymptomatic patient will be a bone marrow biopsy. DIF: Cognitive Level: Apply (application) REF: 634 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
The nurse is preparing to give a potassium supplement. Which laboratory test should be checked before the patient receives a dose of potassium?" a Complete blood count b Serum potassium level c Serum sodium level d Liver function studies
ANS: B Contraindications to potassium replacement products include hyperkalemia from any cause. It is important to know the patient's electrolyte levels before beginning electrolyte replacement therapy. Giving potassium supplements to a patient whose serum potassium levels are already high may cause worsening of the hyperkalemia. The other options are incorrect.
Which assessment finding should the nurse caring for a patient with thrombocytopenia communicate immediately to the health care provider? a. The platelet count is 52,000/μL. b. The patient is difficult to arouse. c. There are purpura on the oral mucosa. d. There are large bruises on the patient's back.
ANS: B Difficulty in arousing the patient may indicate a cerebral hemorrhage, which is life threatening and requires immediate action. The other information should be documented and reported but would not be unusual in a patient with thrombocytopenia. DIF: Cognitive Level: Analyze (analysis) REF: 623 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
The nurse notes scleral jaundice in a patient being admitted with hemolytic anemia. The nurse will plan to check the laboratory results for the a. Schilling test. c. gastric analysis. b. bilirubin level. d. stool occult blood.
ANS: B Jaundice is caused by the elevation of bilirubin level associated with red blood cell hemolysis. The other tests would not be helpful in monitoring or treating a hemolytic anemia. DIF: Cognitive Level: Apply (application) REF: 615 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
Which problem reported by a patient with hemophilia is most important for the nurse to communicate to the health care provider? a. Leg bruises c. Skin abrasions b. Tarry stools d. Bleeding gums
ANS: B Melena is a sign of gastrointestinal bleeding and requires collaborative actions such as checking hemoglobin and hematocrit and administration of coagulation factors. The other problems indicate a need for patient teaching about how to avoid injury but are not indicators of possible serious blood loss. DIF: Cognitive Level: Analyze (analysis) REF: 628 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
A patient who is receiving methotrexate for severe rheumatoid arthritis develops a megaloblastic anemia. The nurse will anticipate teaching the patient about increasing oral intake of a. iron. b. folic acid. c. cobalamin (vitamin B12). d. ascorbic acid (vitamin C).
ANS: B Methotrexate use can lead to folic acid deficiency. Supplementation with oral folic acid supplements is the usual treatment. The other nutrients would not correct folic acid deficiency, although they would be used to treat other types of anemia. DIF: Cognitive Level: Apply (application) REF: 612 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
An appropriate nursing intervention for a hospitalized patient with severe hemolytic anemia is to a. provide a diet high in vitamin K. b. alternate periods of rest and activity. c. teach the patient how to avoid injury. d. place the patient on protective isolation.
ANS: B Nursing care for patients with anemia should alternate periods of rest and activity to encourage activity without causing undue fatigue. There is no indication that the patient has a bleeding disorder, so a diet high in vitamin K or teaching about how to avoid injury is not needed. Protective isolation might be used for a patient with aplastic anemia, but it is not indicated for hemolytic anemia. DIF: Cognitive Level: Apply (application) REF: 608 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
A patient who has acute myelogenous leukemia (AML) is considering treatment with a hematopoietic stem cell transplant (HSCT). The best approach for the nurse to assist the patient with a treatment decision is to a. discuss the need for insurance to cover post-HSCT care. b. ask whether there are questions or concerns about HSCT. c. emphasize the positive outcomes of a bone marrow transplant. d. explain that a cure is not possible with any treatment except HSCT.
ANS: B Offering the patient an opportunity to ask questions or discuss concerns about HSCT will encourage the patient to voice concerns about this treatment and will allow the nurse to assess whether the patient needs more information about the procedure. Treatment of AML using chemotherapy is another option for the patient. It is not appropriate for the nurse to ask the patient to consider insurance needs in making this decision. DIF: Cognitive Level: Apply (application) REF: 635 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity
The nurse is preparing to transfuse a patient with a unit of packed red blood cells (PRBCs). Which patient would be best treated with this transfusion?" a A patient with a coagulation disorder b A patient with severe anemia c A patient who has lost a massive amount of blood after an accident d A patient who has a clotting-factor deficiency
ANS: B PRBCs are given to increase the oxygen-carrying capacity in patients with anemia, in patients with substantial hemoglobin deficits, and in patients who have lost up to 25% of their total blood volume. Patients with coagulation disorder or clotting-factor deficiency would receive fresh frozen plasma; a patient who has lost a massive amount of blood would receive whole blood.
It is important for the nurse providing care for a patient with sickle cell crisis to a. limit the patient's intake of oral and IV fluids. b. evaluate the effectiveness of opioid analgesics. c. encourage the patient to ambulate as much as tolerated. d. teach the patient about high-protein, high-calorie foods.
ANS: B Pain is the most common clinical manifestation of a crisis and usually requires large doses of continuous opioids for control. Fluid intake should be increased to reduce blood viscosity and improve perfusion. Rest is usually ordered to decrease metabolic requirements. Patients are instructed about the need for dietary folic acid, but high-protein, high-calorie diets are not emphasized. DIF: Cognitive Level: Apply (application) REF: 618 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
A patient who has a history of a transfusion-related acute lung injury (TRALI) is to receive a transfusion of packed red blood cells (PRBCs). Which action by the nurse will decrease the risk for TRALI for this patient? a. Infuse the PRBCs slowly over 4 hours. b. Transfuse only leukocyte-reduced PRBCs. c. Administer the scheduled diuretic before the transfusion. d. Give the PRN dose of antihistamine before the transfusion.
ANS: B TRALI is caused by a reaction between the donor and the patient leukocytes that causes pulmonary inflammation and capillary leaking. The other actions may help prevent respiratory problems caused by circulatory overload or by allergic reactions, but they will not prevent TRALI. DIF: Cognitive Level: Apply (application) REF: 651 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
A young adult who has von Willebrand disease is admitted to the hospital for minor knee surgery. The nurse will review the coagulation survey to check the a. platelet count. c. thrombin time. b. bleeding time. d. prothrombin time.
ANS: B The bleeding time is affected by von Willebrand disease. Platelet count, prothrombin time, and thrombin time are normal in von Willebrand disease. DIF: Cognitive Level: Understand (comprehension) REF: 626 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
Which laboratory result will the nurse expect to show a decreased value if a patient develops heparin-induced thrombocytopenia (HIT)? a. Prothrombin time b. Erythrocyte count c. Fibrinogen degradation products d. Activated partial thromboplastin time
ANS: D Platelet aggregation in HIT causes neutralization of heparin, so the activated partial thromboplastin time will be shorter, and more heparin will be needed to maintain therapeutic levels. The other data will not be affected by HIT. DIF: Cognitive Level: Understand (comprehension) REF: 622 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
Which action will the admitting nurse include in the care plan for a patient who has neutropenia? a. Avoid intramuscular injections. b. Check temperature every 4 hours. c. Omit fruits or vegetables from the diet. d. Place a "No Visitors" sign on the door.
ANS: B The earliest sign of infection in a neutropenic patient is an elevation in temperature. Although unpeeled fresh fruits and vegetables should be avoided, fruits and vegetables that are peeled or cooked are acceptable. Injections may be required for administration of medications such as filgrastim (Neupogen). The number of visitors may be limited and visitors with communicable diseases should be avoided, but a "no visitors" policy is not needed. DIF: Cognitive Level: Apply (application) REF: 632 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
The nurse is caring for a patient with type A hemophilia being admitted to the hospital with severe pain and swelling in the right knee. The nurse should a. apply heat to the knee. b. immobilize the knee joint. c. assist the patient with light weight bearing. d. perform passive range of motion to the knee.
ANS: B The initial action should be total rest of the knee to minimize bleeding. Ice packs are used to decrease bleeding. Range of motion (ROM) and weight-bearing exercise are contraindicated initially, but after the bleeding stops, ROM and physical therapy are started. DIF: Cognitive Level: Apply (application) REF: 626 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
A patient who has acute myelogenous leukemia develops an absolute neutrophil count of 850/μL while receiving outpatient chemotherapy. Which action by the outpatient clinic nurse is most appropriate? a. Discuss the need for hospital admission to treat the neutropenia. b. Teach the patient to administer filgrastim (Neupogen) injections. c. Plan to discontinue the chemotherapy until the neutropenia resolves. d. Order a high-efficiency particulate air (HEPA) filter for the patient's home.
ANS: B The patient may be taught to self-administer filgrastim injections. Although chemotherapy may be stopped with severe neutropenia (neutrophil count <500/μL), administration of filgrastim usually allows the chemotherapy to continue. Patients with neutropenia are at higher risk for infection when exposed to other patients in the hospital. HEPA filters are expensive and are used in the hospital, where the number of pathogens is much higher than in the patient's home environment. DIF: Cognitive Level: Apply (application) REF: 633 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
Several patients call the outpatient clinic and ask to make an appointment as soon as possible. Which patient should the nurse schedule to be seen first? a. A 44-yr-old with sickle cell anemia who says his eyes always look sort of yellow b. A 23-yr-old with no previous health problems who has a nontender lump in the axilla c. A 50-yr-old with early-stage chronic lymphocytic leukemia who reports chronic fatigue d. A 19-yr-old with hemophilia who wants to learn to self-administer factor VII replacement
ANS: B The patient's age and presence of a nontender axillary lump suggest possible lymphoma, which needs rapid diagnosis and treatment. The other patients have questions about treatment or symptoms that are consistent with their diagnosis but do not need to be seen urgently. DIF: Cognitive Level: Analyze (analysis) REF: 641 OBJ: Special Questions: Multiple Patients TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment
A patient who has acute myelogenous leukemia (AML) asks the nurse whether the planned chemotherapy will be worth undergoing. Which response by the nurse is appropriate? a. "If you do not want to have chemotherapy, other treatment options include stem cell transplantation." b. "The side effects of chemotherapy are difficult, but AML frequently goes into remission with chemotherapy." c. "The decision about treatment is one that you and the doctor need to make rather than asking what I would do." d. "You don't need to make a decision about treatment right now because leukemias in adults tend to progress slowly."
ANS: B This response uses therapeutic communication by addressing the patient's question and giving accurate information. The other responses either give inaccurate information or fail to address the patient's question, which will discourage the patient from asking the nurse for information. DIF: Cognitive Level: Apply (application) REF: 636 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity
The nurse is planning to administer a transfusion of packed red blood cells (PRBCs) to a patient with blood loss from gastrointestinal hemorrhage. Which action can the nurse delegate to unlicensed assistive personnel (UAP)? a. Verify the patient identification (ID) according to hospital policy. b. Obtain the temperature, blood pressure, and pulse before the transfusion. c. Double-check the product numbers on the PRBCs with the patient ID band. d. Monitor the patient for shortness of breath or chest pain during the transfusion.
ANS: B UAP education includes measurement of vital signs. UAP would report the vital signs to the registered nurse (RN). The other actions require more education and a larger scope of practice and should be done by licensed nursing staff members. DIF: Cognitive Level: Apply (application) REF: 632 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment
During diuretic therapy, the nurse monitors the fluid and electrolyte status of the patient. Which assessment findings are symptoms of hyponatremia? (Select all that apply.)" a Red, flushed skin b Lethargy c Decreased urination d Hypotension e Stomach cramps f Elevated temperature
ANS: B, D, E Hyponatremia is manifested by lethargy, hypotension, stomach cramps, vomiting, diarrhea, and seizures. The other options are symptoms of hypernatremia.
A patient with possible disseminated intravascular coagulation arrives in the emergency department with a blood pressure of 82/40, temperature of 102° F (38.9° C), and severe back pain. Which prescribed action will the nurse implement first? a. Administer morphine sulfate 4 mg IV. b. Give acetaminophen (Tylenol) 650 mg. c. Infuse normal saline 500 mL over 30 minutes. d. Schedule complete blood count and coagulation studies.
ANS: C The patient's blood pressure indicates hypovolemia caused by blood loss and should be addressed immediately to improve perfusion to vital organs. The other actions are also appropriate and should be rapidly implemented, but improving perfusion is the priority for this patient. DIF: Cognitive Level: Analyze (analysis) REF: 629 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
Which action for a patient with neutropenia is appropriate for the registered nurse (RN) to delegate to a licensed practical/vocational nurse (LPN/LVN)? a. Assessing the patient for signs and symptoms of infection b. Teaching the patient the purpose of neutropenic precautions c. Administering subcutaneous filgrastim (Neupogen) injection d. Developing a discharge teaching plan for the patient and family
ANS: C Administration of subcutaneous medications is included in LPN/LVN education and scope of practice. Patient teaching, assessment, and developing the plan of care require RN level education and scope of practice. DIF: Cognitive Level: Apply (application) REF: 649 OBJ: Special Questions: Delegation TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment
When a patient with splenomegaly is scheduled for splenectomy, which action will the nurse include in the preoperative plan of care? a. Discourage deep breathing to reduce risk for splenic rupture. b. Teach the patient to use ibuprofen for left upper quadrant pain. c. Schedule immunization with the pneumococcal vaccine (e.g., Pneumovax). d. Avoid the use of acetaminophen (Tylenol) for at least 2 weeks prior to surgery.
ANS: C Asplenic patients are at high risk for infection with pneumococcal infections and immunization reduces this risk. There is no need to avoid acetaminophen use before surgery, but nonsteroidal antiinflammatory drugs (NSAIDs) may increase bleeding risk and should be avoided. The enlarged spleen may decrease respiratory depth, and the patient should be encouraged to take deep breaths. DIF: Cognitive Level: Apply (application) REF: 640 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
During a blood transfusion, the patient begins to have chills and back pain. What is the nurse's priority action?" a Observe for other symptoms. b Slow the infusion rate of the blood. c Discontinue the infusion immediately, and notify the prescriber. d Tell the patient that these symptoms are a normal reaction to the blood product.
ANS: C Because of the possibility of a transfusion reaction, the infusion should be discontinued immediately and the prescriber notified. The intravenous line should be kept patent with isotonic normal saline solution infusing at a slow rate, and the health care institution's protocol for transfusion reactions should always be followed. The other options are inappropriate actions.
A 52-yr-old patient has a new diagnosis of pernicious anemia. The nurse determines that the patient understands the teaching about the disorder when the patient states, a. "I need to start eating more red meat and liver." b. "I will stop having a glass of wine with dinner." c. "I could choose nasal spray rather than injections of vitamin B12." d. "I will need to take a proton pump inhibitor such as omeprazole (Prilosec)."
ANS: C Because pernicious anemia prevents the absorption of vitamin B12, this patient requires injections or intranasal administration of cobalamin. Alcohol use does not cause cobalamin deficiency. Proton pump inhibitors decrease the absorption of vitamin B12. Eating more foods rich in vitamin B12 is not helpful because the lack of intrinsic factor prevents absorption of the vitamin. DIF: Cognitive Level: Apply (application) REF: 612 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
During an infusion of albumin, the nurse monitors the patient closely for the development of which adverse effect? a Hypernatremia b Fluid volume deficit c Fluid volume overload d Transfusion reaction
ANS: C During the infusion of albumin, the development of fluid volume overload must be monitored by the nurse, especially in those at risk for heart failure. The other options are incorrect.
Which instruction will the nurse plan to include in discharge teaching for a patient admitted with a sickle cell crisis? a. Take a daily multivitamin with iron. b. Limit fluids to 2 to 3 quarts per day. c. Avoid exposure to crowds when possible. d. Drink only two caffeinated beverages daily.
ANS: C Exposure to crowds increases the patient's risk for infection, the most common cause of sickle cell crisis. There is no restriction on caffeine use. Iron supplementation is generally not recommended. A high-fluid intake is recommended. DIF: Cognitive Level: Apply (application) REF: 617 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
A patient is receiving an infusion of fresh frozen plasma. Based on this order, the nurse interprets that this patient has which condition?" a Hypovolemic shock b Anemia c Coagulation disorder d Previous transfusion reaction
ANS: C Fresh frozen plasma is used as an adjunct to massive blood transfusion in the treatment of patients with underlying coagulation disorders. The other options are not indications for fresh frozen plasma.
A patient who is severely anemic also has acute heart failure with severe edema due to fluid overload. The prescriber wants to raise the patient's hemoglobin and hematocrit levels. The nurse anticipates that the patient will receive which blood product?" a Fresh frozen plasma b Albumin c Packed red blood cells (PRBCs) d Whole blood
ANS: C PRBCs are given to increase the oxygen-carrying capacity in a patient with anemia, in a patient with substantial hemoglobin deficits, and in a patient who has lost up to 25% of total blood volume. A patient with a coagulation disorder or a clotting-factor deficiency would receive fresh frozen plasma; a patient who has lost a massive amount of blood would receive whole blood.
When reviewing the health history of a patient, the nurse will note that a potential contraindication to potassium supplements exists if the patient has which problem?" a Burns b Diarrhea c Renal disease d Cardiac tachydysrhythmias
ANS: C Potassium supplements are contraindicated in the presence of renal disease; the other conditions listed may be treated with potassium supplements.
Which finding about a patient with polycythemia vera is most important for the nurse to report to the health care provider? a. Hematocrit 55% c. Calf swelling and pain b. Presence of plethora d. Platelet count 450,000/L
ANS: C The calf swelling and pain suggest that the patient may have developed a deep vein thrombosis, which will require diagnosis and treatment to avoid complications such as pulmonary embolus. The other findings will also be reported to the health care provider but are expected in a patient with this diagnosis. DIF: Cognitive Level: Analyze (analysis) REF: 620 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment
Which action will the nurse include in the plan of care for a patient who has thalassemia major? a. Teach the patient to use iron supplements. b. Avoid the use of intramuscular injections. c. Administer iron chelation therapy as needed. d. Notify health care provider of hemoglobin 11 g/dL.
ANS: C The frequent transfusions used to treat thalassemia major lead to iron toxicity in patients unless iron chelation therapy is consistently used. Iron supplementation is avoided in patients with thalassemia. There is no need to avoid intramuscular injections. The goal for patients with thalassemia major is to maintain a hemoglobin of 10 g/dL or greater. DIF: Cognitive Level: Apply (application) REF: 611 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
A postoperative patient receiving a transfusion of packed red blood cells develops chills, fever, headache, and anxiety 35 minutes after the transfusion is started. After stopping the transfusion, what action should the nurse take? a. Give the PRN diphenhydramine . b. Send a urine specimen to the laboratory. c. Administer PRN acetaminophen (Tylenol). d. Draw blood for a new type and crossmatch.
ANS: C The patient's clinical manifestations are consistent with a febrile, nonhemolytic transfusion reaction. The transfusion should be stopped and antipyretics administered for the fever as ordered. A urine specimen is needed if an acute hemolytic reaction is suspected. Diphenhydramine is used for allergic reactions. This type of reaction does not indicate incorrect crossmatching. DIF: Cognitive Level: Apply (application) REF: 650 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
A patient with septicemia develops prolonged bleeding from venipuncture sites and blood in the stools. Which action is most important for the nurse to take? a. Avoid other venipunctures. b. Apply dressings to the sites. c. Notify the health care provider. d. Give prescribed proton-pump inhibitors.
ANS: C The patient's new onset of bleeding and diagnosis of sepsis suggest that disseminated intravascular coagulation (DIC) may have developed, which will require collaborative actions such as diagnostic testing, blood product administration, and heparin administration. The other actions are also appropriate, but the most important action should be to notify the health care provider so that DIC treatment can be initiated rapidly. DIF: Cognitive Level: Analyze (analysis) REF: 629 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
Which statement by a patient indicates good understanding of the nurse's teaching about prevention of sickle cell crisis? a. "Home oxygen therapy is frequently used to decrease sickling." b. "There are no effective medications that can help prevent sickling." c. "Routine continuous dosage narcotics are prescribed to prevent a crisis." d. "Risk for a crisis is decreased by having an annual influenza vaccination."
ANS: D Because infection is the most common cause of a sickle cell crisis, influenza, Haemophilus influenzae, pneumococcal pneumonia, and hepatitis immunizations should be administered. Although continuous dose opioids and oxygen may be administered during a crisis, patients do not receive these therapies to prevent crisis. Hydroxyurea (Hydrea) is a medication used to decrease the number of sickle cell crises. DIF: Cognitive Level: Apply (application) REF: 617 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
Which patient information is most important for the nurse to monitor when evaluating the effectiveness of deferoxamine (Desferal) for a patient with hemochromatosis? a. Skin color c. Liver function b. Hematocrit d. Serum iron level
ANS: D Because iron chelating agents are used to lower serum iron levels, the most useful information will be the patient's iron level. The other parameters will also be monitored, but are not the most important to monitor when determining the effectiveness of deferoxamine. DIF: Cognitive Level: Analyze (analysis) REF: 620 OBJ: Special Questions: Prioritization TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
Which laboratory test will the nurse use to determine whether filgrastim (Neupogen) is effective for a patient with acute lymphocytic leukemia who is receiving chemotherapy? a. Platelet count c. Total lymphocyte count b. Reticulocyte count d. Absolute neutrophil count
ANS: D Filgrastim increases the neutrophil count and function in neutropenic patients. Although total lymphocyte, platelet, and reticulocyte counts are also important to monitor in this patient, the absolute neutrophil count is used to evaluate the effects of filgrastim. DIF: Cognitive Level: Apply (application) REF: 634 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
A patient who has non-Hodgkin's lymphoma is receiving combination treatment with rituximab (Rituxan) and chemotherapy. Which patient assessment finding requires the most rapid action by the nurse? a. Anorexia c. Oral ulcers b. Vomiting d. Lip swelling
ANS: D Lip swelling in angioedema may indicate a hypersensitivity reaction to the rituximab. The nurse should stop the infusion and further assess for anaphylaxis. The other findings may occur with chemotherapy but are not immediately life threatening. DIF: Cognitive Level: Analyze (analysis) REF: 642 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
A patient is in an urgent care center and is receiving treatment for mild hyponatremia after spending several hours doing gardening work in the heat of the day. The nurse expects that which drug therapy will be used to treat this condition?" a Oral supplementation of fluids b Intravenous bolus of lactated Ringer's solution c Normal saline infusion, administered slowly d Oral administration of sodium chloride tablets
ANS: D Mild hyponatremia is usually treated by oral administration of sodium chloride tablets. Pronounced sodium depletion is treated by intravenous normal saline or lactated Ringer's solution.
An expected action by the nurse caring for a patient who has an acute exacerbation of polycythemia vera is to a. place the patient on bed rest. c. avoid use of aspirin products. b. administer iron supplements. d. monitor fluid intake and output.
ANS: D Monitoring hydration status is important during an acute exacerbation because the patient is at risk for fluid overload or underhydration. Aspirin therapy is used to decrease risk for thrombosis. The patient should be encouraged to ambulate to prevent deep vein thrombosis. Iron is contraindicated in patients with polycythemia vera. DIF: Cognitive Level: Apply (application) REF: 621 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
When monitoring a patient for signs of hypokalemia, the nurse looks for what early sign?" a Seizures b Cardiac dysrhythmias c Diarrhea d Muscle weakness
ANS: D Muscle weakness is an early symptom of hypokalemia, as are hypotension, lethargy, mental confusion, and nausea. Cardiac dysrhythmias are a late symptom of hypokalemia. The other options are incorrect.
Following successful treatment of Hodgkin's lymphoma for a 55-yr-old woman, which topic will the nurse include in patient teaching? a. Potential impact of chemotherapy treatment on fertility b. Application of soothing lotions to treat residual pruritus c. Use of maintenance chemotherapy to maintain remission d. Need for follow-up appointments to screen for malignancy
ANS: D The chemotherapy used in treating Hodgkin's lymphoma results in a high incidence of secondary malignancies; follow-up screening is needed. The fertility of a 55-yr-old woman will not be impacted by chemotherapy. Maintenance chemotherapy is not used for Hodgkin's lymphoma. Pruritus is a clinical manifestation of lymphoma but should not be a concern after treatment. DIF: Cognitive Level: Apply (application) REF: 640 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
A 62-year old man with chronic anemia is experiencing increased fatigue and occasional palpitations at rest. The nurse would expect the patient's laboratory test findings to include a. an RBC count of 4,500,000/L. b. a hematocrit (Hct) value of 38%. c. normal red blood cell (RBC) indices. d. a hemoglobin (Hgb) of 8.6 g/dL (86 g/L).
ANS: D The patient's clinical manifestations indicate moderate anemia, which is consistent with a Hgb of 6 to 10 g/dL. The other values are all within the range of normal. DIF: Cognitive Level: Understand (comprehension) REF: 607 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
A patient in the emergency department complains of back pain and difficulty breathing 15 minutes after a transfusion of packed red blood cells is started. The nurse's first action should be to a. administer oxygen therapy at a high flow rate. b. obtain a urine specimen to send to the laboratory. c. notify the health care provider about the symptoms. d. disconnect the transfusion and infuse normal saline.
ANS: D The patient's symptoms indicate a possible acute hemolytic reaction caused by the transfusion. The first action should be to disconnect the transfusion and infuse normal saline. The other actions also are needed but are not the highest priority. DIF: Cognitive Level: Analyze (analysis) REF: 650 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
The nurse is working with a graduate nurse to prepare an intravenous dose of potassium. Which statement by the graduate nurse reflects a need for further teaching?" a "We will need to monitor this infusion closely." b "The infusion rate should not go over 10 mEq/hr." c "The intravenous potassium will be diluted before we give it." d "The intravenous potassium dose will be given undiluted."
ANS: D When giving intravenous potassium, the medication must always be given in a diluted form and administered slowly. Intravenous bolus or undiluted forms may cause cardiac arrest. Intravenous rates are not to exceed 10 mEq/hr unless the patient is on a cardiac monitor. Oral forms should be mixed with juice or water or taken according to instructions.
The nurse finds that the patient with renal disease is irritable and has an irregular pulse. ECG changes suggest severe hyperkalemia. What should be the first nursing intervention? - Stop all sources of dietary potassium - Administer intravenous calcium gluconate - Administer ion-exchange resins - Administer intravenous insulin with glucose
Administer intravenous calcium gluconate Administer intravenous insulin with glucose In the case of severe hyperkalemia, manifested by irritation, irregular pulse, and changes in ECG findings, the nurse should act immediately to prevent cardiac arrest. The nurse should administer intravenous calcium gluconate to reverse the membrane potential effects of extracellular fluid (ECF) potassium. Administering ion-exchange resins (to increase elimination of potassium) and intravenous insulin with glucose (to force potassium from ECF to intracellular fluid [ICF]) can be done once the patient is stable. Stopping all sources of dietary potassium is an important measure when hyperkalemia is mild.
When assessing the patient with a multi-lumen central line, the nurse notices that the cap is off one of the lines. On assessment, the patient is in respiratory distress, and the vital signs show hypotension and tachycardia. What is the nurse's priority action? - Administer oxygen. - Notify the physician. - Rapidly administer more IV fluid. - Reposition the patient to the right side.
Administer oxygen. The cap off the central line could allow entry of air into the circulation. For an air emboli, oxygen is administered; the catheter is clamped; the patient is positioned on the left side with the head down. Then the physician is notified.
The nurse is caring for a patient diagnosed with heat stroke and with a urine output of 4000 mL per day. What is the most appropriate nursing action? - Transfusing blood - Applying moisturizer regularly - Administrating lactated Ringer's solution - Administrating supplementary water in enteric formula
Administrating lactated Ringer's solution Heat stroke and an increased amount of urine output of about 4000 mL leads to a deficit in extracellular fluid volume, causing dehydration. Administering lactated Ringer's solution to maintain fluid and electrolyte balance is beneficial. Blood transfusions are performed only when the fluid loss is due to blood loss. Moisturizers are applied to patients with dry skin to prevent the fluid loss.Tube feeding is preferred in the patient with severe extracellular fluid loss. The patient on tube feeding must be thereby supplemented with water added to the enteric formula.
The nurse determines the patient has a good understanding of the discharge instructions regarding warfarin (Coumadin) with which patient statement? a. "I should keep taking ibuprofen for my arthritis." b. "I should use a soft toothbrush for dental hygiene." c. "I should decrease the dose if I start bruising easily." d. "I will double my dose if I forget to take it the day before."
B
The nurse is caring for a patient admitted with gastrointestinal bleeding who is anticoagulated with warfarin (Coumadin). Which medication should the nurse anticipate administering? a. Vitamin E b. Vitamin K (Phytonadione) c. Protamine (Protamine sulfate) d. Calcium gluconate
B
The nurse is giving discharge instructions to a patient prescribed warfarin (Coumadin) for atrial fibrillation. Which statement by the patient indicates a need for further instruction from the nurse? a. "I will take my medication in the early evening each day." b. "I will increase the dark green leafy vegetables in my diet." c. "I will contact my health care provider if I develop excessive bruising." d. "I will avoid activities that have a risk for injury such as contact sports."
B
The nurse is preparing a patient with acute chest pain for an emergency angioplasty. The nurse would anticipate administering which medication to prevent platelet aggregation? a. Warfarin (Coumadin) b. Tirofiban (Aggrastat) c. Aminocaproic acid (Amicar) d. Protamine (Protamine sulfate)
B
While observing a patient self-administer enoxaparin (Lovenox), the nurse identifies the need for further teaching when the patient performs which self-injection action? a. Does not aspirate before injecting the medication b. Massages the site after administration of the medication c. Administers the medication into subcutaneous (fatty) tissue d. Injects the medication greater than 2 inches away from the umbilicus
B
A patient is prescribed oral anticoagulant therapy while still receiving IV heparin infusion. The patient is concerned about risk for bleeding. What is the nurse's best response? a. "Bleeding is a common adverse effect of taking warfarin. If bleeding occurs, your health care provider will prescribe an injection of medication to stop the bleeding." b. "Because you are now getting out of bed and walking around, you have a higher risk of blood clot formation and therefore need to be on both medications." c. "Because of your mechanical valve replacement, it is especially important for you to be fully anticoagulated, and the heparin and warfarin together are more effective than one alone." d. "It usually takes 4 to 5 days to achieve a full therapeutic effect for warfarin, so the heparin infusion is continued to help prevent blood clots until the warfarin reaches its therapeutic effect."
D
Before emergency surgery, the nurse would anticipate administering which medication to a patient receiving heparin? a. Vitamin K (Phytonadione) b. Vitamin E c. Phenytoin (Dilantin) d. Protamine (Protamine sulfate)
D
Enoxaparin sodium (Lovenox) is an anticoagulant used to prevent and treat deep vein thrombosis and pulmonary embolism. This medication is in which drug class? a. Thrombolytic drug b. Oral anticoagulant c. Glycoprotein IIb/IIIa inhibitor d. Low-molecular-weight heparin
D
The nurse would assess which laboratory value to determine the effectiveness of intravenous heparin (Hemochron)? a. Prothrombin time (PT) b. Blood urea nitrogen c. Complete blood count d. Activated partial thromboplastin time (aPTT)
D
The patient asks the nurse, "What is the difference between dalteparin (Fragmin) and heparin?" What is the nurse's best response? a. "There is really no difference, but dalteparin is preferred because it is less expensive." b. "I'm not really sure why some health care providers choose dalteparin and some heparin." c. "The only difference is that the heparin dosage calculation is based on the patient's weight." d. "Dalteparin is a low-molecular-weight heparin that has a more predictable anticoagulant effect."
D
A 46-year-old woman with a subclavian triple-lumen catheter is transferred from a critical care unit after an extended stay for respiratory failure. Which action is important for the nurse to take? - Change the injection cap after the administration of IV medications. - Use a 5-mL syringe to flush the catheter between medications and after use. - During removal of the catheter, have the patient perform the Valsalva maneuver. - If resistance is met when flushing, use the push-pause technique to dislodge the clot.
During removal of the catheter, have the patient perform the Valsalva maneuver. The nurse should withdraw the catheter while the patient performs the Valsalva maneuver to prevent an air embolism. Injection caps should be changed at regular intervals but not routinely after medications. Flushing should be performed with at least a 10-mL syringe to avoid excess pressure on the catheter. If resistance is encountered during flushing, force should not be applied. The push-pause method is preferred for flushing catheters but not used if resistance is encountered during flushing.
When planning care for a patient with dehydration related to nausea and vomiting, the nurse would anticipate which fluid shift to occur because of the fluid volume deficit? - Fluid movement from the blood vessels into the cells - Fluid movement from the interstitial spaces into the cells - Fluid movement from the blood vessels into interstitial spaces - Fluid movement from the interstitial space into the blood vessels
Fluid movement from the interstitial space into the blood vessels In dehydration, fluid is lost first from the blood vessels. To compensate, fluid moves out of the interstitial spaces into the blood vessels to restore circulating volume in that compartment. As the interstitial spaces then become volume depleted, fluid moves out of the cells into the interstitial spaces.
When assessing a patient admitted with nausea and vomiting, which finding supports the nursing diagnosis of deficient fluid volume? - Polyuria - Decreased pulse - Difficulty breathing - General restlessness
General restlessness Restlessness is an early cerebral sign that dehydration has progressed to the point where an intracellular fluid shift is occurring. If the dehydration is left untreated, cerebral signs could progress to confusion and later coma.
The patient is admitted with metabolic acidosis. Which system is not functioning normally? - Buffer system - Kidney system - Hormone system - Respiratory system
Kidney system When the patient has metabolic acidosis, the kidneys are not combining H+ with ammonia to form ammonium or eliminating acid with secretion of free hydrogen into the renal tubule. The buffer system neutralizes hydrochloric acid by forming a weak acid. The hormone system is not directly related to acid-base balance. The respiratory system releases CO2 that combines with water to form hydrogen ions and bicarbonate. The hydrogen is then buffered by the hemoglobin.
You are caring for an older patient who is receiving IV fluids postoperatively. During the 8:00 AM assessment of this patient, you note that the IV solution, which was ordered to infuse at 125 mL/hr, has infused 950 mL since it was hung at 4:00 AM. What is the priority nursing intervention? - Notify the physician and complete an incident report. - Slow the rate to keep vein open until next bag is due at noon. - Obtain a new bag of IV solution to maintain patency of the site. - Listen to the patient's lung sounds and assess respiratory status.
Listen to the patient's lung sounds and assess respiratory status. After 4 hours of infusion time, 500 mL of IV solution should have infused, not 950 mL. This patient is at risk for fluid volume excess, and you should assess the patient's respiratory status and lung sounds as the priority action and then notify the physician for further orders.
You are admitting a patient with complaints of abdominal pain, nausea, and vomiting. A bowel obstruction is suspected. You assess this patient for which anticipated primary acid-base imbalance if the obstruction is high in the intestine? - Metabolic acidosis - Metabolic alkalosis - Respiratory acidosis - Respiratory alkalosis
Metabolic alkalosis Because gastric secretions are rich in hydrochloric acid, the patient who is vomiting will lose a significant amount of gastric acid and be at an increased risk for metabolic alkalosis.
Which nursing intervention is most appropriate when caring for a patient with dehydration? - Auscultate lung sounds every 2 hours. - Monitor daily weight and intake and output. - Monitor diastolic blood pressure for increases. - Encourage the patient to reduce sodium intake.
Monitor daily weight and intake and output. Measuring weight is the most reliable means of detecting changes in fluid balance. Weight loss would indicate the dehydration is worsening, whereas weight gain would indicate restoration of fluid volume. Recall that a 1-kg weight gain indicates a gain of approximately 1000 mL of body water.
The nurse is caring for a 76-year-old woman admitted to the clinical unit with hypernatremia and dehydration after prolonged fever. Which beverage would be safest for the nurse to offer the patient? - Malted milk - Orange juice - Tomato juice - Hot chocolate
Orange juice Orange juice has the least amount of sodium (approximately 2 mg in 8 ounces). Hot chocolate has approximately 75 mg sodium in 8 ounces. Tomato juice has approximately 650 mg sodium in 8 ounces. Malted milk has approximately 625 mg sodium in 8 ounces.
You are caring for a patient admitted with a diagnosis of chronic obstructive pulmonary disease (COPD) who has the following arterial blood gas results: pH 7.33, PaO2 47 mm Hg, PaCO2 60 mm Hg, HCO3 32 mEq/L, and O2 saturation of 92%. What is the correct interpretation of these results? - Fully compensated respiratory alkalosis - Partially compensated respiratory acidosis - Normal acid-base balance with hypoxemia - Normal acid-base balance with hypercapnia
Partially compensated respiratory acidosis A low pH (normal 7.35-7.45) indicates acidosis. In the patient with respiratory disease such as COPD, the patient retains carbon dioxide (normal 35-45 mm Hg), which acts as an acid in the body. For this reason, the patient has respiratory acidosis. The elevated HCO3 indicates a partial compensation for the elevated CO2.
The patient has chronic kidney disease and ate a lot of nuts, bananas, peanut butter, and chocolate. The patient is admitted with loss of deep tendon reflexes, somnolence, and altered respiratory status. What treatment should the nurse expect for this patient? - Renal dialysis - IV potassium chloride - IV furosemide (Lasix) - IV normal saline at 250 mL per hour
Renal dialysis Renal dialysis will need to be administered to remove the excess magnesium that is in the blood from the increased intake of foods high in magnesium. If renal function was adequate, IV potassium chloride would oppose the effects of magnesium on the cardiac muscle. IV furosemide and increased fluid would increase urinary output which is the major route of excretion for magnesium.
You receive a physician's order to change a patient's IV from D5½ NS with 40 mEq KCl/L to D5NS with 20 mEq KCl/L. Which serum laboratory values on this same patient best support the rationale for this IV order change? - Sodium 136 mEq/L, potassium 4.5 mEq/L - Sodium 145 mEq/L, potassium 4.8 mEq/L - Sodium 135 mEq/L, potassium 3.6 mEq/L - Sodium 144 mEq/L, potassium 3.7 mEq/L
Sodium 136 mEq/L, potassium 4.5 mEq/L The normal range for serum sodium is 135 to 145 mEq/L, and the normal range for potassium is 3.5 to 5.0 mEq/L. The change in the IV order decreases the amount of potassium and increases the amount of sodium. Therefore for this order to be appropriate, the potassium level must be near the high end and the sodium level near the low end of their respective ranges.
A 50-year-old woman with hypertension has a serum potassium level that has acutely risen to 6.2 mEq/L. Which type of order, if written by the health care provider, should be questioned by the nurse? - Limit foods high in potassium - Spironolactone (Aldactone) daily - Calcium gluconate IV piggyback - Administer intravenous insulin and glucose
Spironolactone (Aldactone) daily Spironolactone (Aldactone) is a potassium-sparing diuretic that inhibits the exchange of sodium for potassium in the distal renal tubule and helps to prevent potassium loss. Spironolactone is contraindicated in a patient with hyperkalemia (serum potassium >5.0 mEq/L).
While caring for a patient with metastatic bone cancer, which clinical manifestations would alert the nurse to the possibility of hypercalcemia in this patient? - Weakness - Paresthesia - Facial spasms - Muscle tremors
Weakness Signs of hypercalcemia are lethargy, headache, weakness, muscle flaccidity, heart block, anorexia, nausea, and vomiting. Paresthesia, facial spasms, and muscle tremors are symptoms of hypocalcemia.
The nurse has obtained the health history, physical assessment data, and laboratory results shown in the accompanying figure for a patient admitted with aplastic anemia. Which information is most important to communicate to the health care provider? History Fatigue, which has increased over last month Frequent constipation Physical Assessment Conjunctiva pale pink, moist Multiple bruises Clear lung sounds Laboratory Results Hct 33% WBC 1500/μL Platelets 70,000/μL a. Neutropenia c. Increasing fatigue b. Constipation d. Thrombocytopenia
a. Neutropenia c. Increasing fatigue b. Constipation d. Thrombocytopenia ANS: A The low white blood cell count indicates that the patient is at high risk for infection and needs immediate actions to diagnose and treat the cause of the leukopenia. The other information may require further assessment or treatment but does not place the patient at immediate risk for complications. DIF: Cognitive Level: Analyze (analysis) REF: 632 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
