Set 2 of 3 - Midterm
The drug of choice during cardiopulmonary resuscitation to suppress ventricular dysrhythmias is:
lidocaine
A nurse in the CCU is caring for a patient with HF who has developed an intracardiac thrombus. This creates a high risk for what sequela? Stroke Myocardial infarction (MI) Hemorrhage Peripheral edema
Stroke*** Myocardial infarction (MI) Hemorrhage Peripheral edema Feedback: Intracardiac thrombi can become lodged in the cerebral vasculature, causing stroke. There is no direct risk of MI, hemorrhage, or peripheral edema.
6. A patient with renal failure has decreased erythropoietin production. Upon analysis of the patient's complete blood count, the nurse will expect which of the following results? A) An increased hemoglobin and decreased hematocrit B) A decreased hemoglobin and hematocrit C) A decreased mean corpuscular volume (MCV) and red cell distribution width (RDW) D) An increased MCV and RDW
Ans: B
The nurse is addressing exercise and physical activity during discharge education with a patient diagnosed with HF. What should the nurse teach this patient about exercise? "Do not exercise unsupervised." "Eventually aim to work up to 30 minutes of exercise each day." "Slow down if you get dizzy or short of breath." "Start your exercise program with highimpact activities."
"Do not exercise unsupervised." "Eventually aim to work up to 30 minutes of exercise each day."****** "Slow down if you get dizzy or short of breath." "Start your exercise program with highimpact activities." Feedback: Eventually, a total of 30 minutes of physical activity every day should be encouraged. Supervision is not necessarily required and the emergence of symptoms should prompt the patient to stop exercising, not simply to slow the pace. Lowimpact activities should be prioritized.
3. A critical care nurse is caring for a patient with autoimmune hemolytic anemia. The patient is not responding to conservative treatments, and his condition is now becoming life threatening. The nurse is aware that a treatment option in this case may include what? A) Hepatectomy B) Vitamin K administration C) Platelet transfusion D) Splenectomy
Ans: D
A patient with HF is placed on a lowsodium diet. Which statement by the patient indicates that the nurse's nutritional teaching plan has been effective? "I will have a ham and cheese sandwich for lunch." "I will have a baked potato with broiled chicken for dinner." "I will have a tossed salad with cheese and croutons for lunch." "I will have chicken noodle soup with crackers and an apple for lunch."
"I will have a ham and cheese sandwich for lunch." "I will have a baked potato with broiled chicken for dinner."**** "I will have a tossed salad with cheese and croutons for lunch." "I will have chicken noodle soup with crackers and an apple for lunch." Feedback: The patient's choice of a baked potato with broiled chicken indicates that the teaching plan has been effective. Potatoes and chicken are relatively low in sodium. Ham, cheese, and soup are often high in sodium.
Digitalis toxicity is a key concern in digitalis therapy. A therapeutic digitalis level should be:
0.5 - 2.0 mg/mL
On assessment, the nurse knows that the presence of pitting edema indicates fluid retention of at least:
10 lb.
Brain damage occurs with cessation of circulation after an approximate interval of:
4 minutes
3. An oncology nurse is caring for a patient with multiple myeloma who is experiencing bone destruction. When reviewing the patients most recent blood tests, the nurse should anticipate what imbalance? A) Hypercalcemia B) Hyperproteinemia C) Elevated serum viscosity D) Elevated RBC count
A Feedback: Hypercalcemia may result when bone destruction occurs due to the disease process. Elevated serum viscosity occurs because plasma cells excrete excess immunoglobulin. RBC count will be decreased. Hyperproteinemia would not be present.
9. A patient with leukemia has developed stomatitis and is experiencing a nutritional deficit. An oral anesthetic has consequently been prescribed. What health education should the nurse provide to the patient? A) Chew with care to avoid inadvertently biting the tongue. B) Use the oral anesthetic 1 hour prior to meal time. C) Brush teeth before and after eating. D) Swallow slowly and deliberately.
A Feedback: If oral anesthetics are used, the patient must be warned to chew with extreme care to avoid inadvertently biting the tongue or buccal mucosa. An oral anesthetic would be metabolized by the time the patient eats if it is used 1 hour prior to meals. There is no specific need to warn the patient about brushing teeth or swallowing slowly because an oral anesthetic has been used.
2. A nurse is caring for a patient who has a diagnosis of acute leukemia. What assessment most directly addresses the most common cause of death among patients with leukemia? A) Monitoring for infection B) Monitoring nutritional status C) Monitor electrolyte levels D) Monitoring liver function
A Feedback: In patients with acute leukemia, death typically occurs from infection or bleeding. Compromised nutrition, electrolyte imbalances, and impaired liver function are all plausible, but none is among the most common causes of death in this patient population.
22. A patient has been found to have an indolent neoplasm. The nurse should recognize what implication of this condition? A) The patient faces a significant risk of malignancy. B) The patient has a myeloid form of leukemia. C) The patient has a lymphocytic form of leukemia. D) The patient has a major risk factor for hemophilia.
A Feedback: Indolent neoplasms have the potential to develop into a neoplasm, but this is not always the case. The patient does not necessary have, or go on to develop, leukemia. Indolent neoplasms are unrelated to the pathophysiology of hemophilia.
18. A patient with a diagnosis of acute myeloid leukemia (AML) is being treated with induction therapy on the oncology unit. What nursing action should be prioritized in the patients care plan? A) Protective isolation and vigilant use of standard precautions B) Provision of a high-calorie, low-texture diet and appropriate oral hygiene C) Including the family in planning the patients activities of daily living D) Monitoring and treating the patients pain
A Feedback: Induction therapy causes neutropenia and a severe risk of infection. This risk must be addressed directly in order to ensure the patients survival. For this reason, infection control would be prioritized over nutritional interventions, family care, and pain, even though each of these are important aspects of nursing care.
1. An oncology nurse is providing health education for a patient who has recently been diagnosed with leukemia. What should the nurse explain about commonalities between all of the different subtypes of leukemia? A) The different leukemias all involve unregulated proliferation of white blood cells. B) The different leukemias all have unregulated proliferation of red blood cells and decreased bone marrow function. C) The different leukemias all result in a decrease in the production of white blood cells. D) The different leukemias all involve the development of cancer in the lymphatic system.
A Feedback: Leukemia commonly involves unregulated proliferation of white blood cells. Decreased production of red blood cells is associated with anemias. Decreased production of white blood cells is associated with leukopenia. The leukemias are not characterized by their involvement with the lymphatic system.
20. A 60-year-old patient with chronic myeloid leukemia will be treated in the home setting and the nurse is preparing appropriate health education. What topic should the nurse emphasize? A) The importance of adhering to the prescribed drug regimen B) The need to ensure that vaccinations are up to date C) The importance of daily physical activity D) The need to avoid shellfish and raw foods
A Feedback: Nurses need to understand that the effectiveness of the drugs used to treat CML is based on the ability of the patient to adhere to the medication regimen as prescribed. Adherence is often incomplete, thus this must be a focus of health education. Vaccinations normally would not be administered during treatment and daily physical activity may be impossible for the patient. Dietary restrictions are not normally necessary.
33. A nurse is planning the care of a patient who has been diagnosed with essential thrombocythemia (ET). What nursing diagnosis should the nurse prioritize when choosing interventions? A) Risk for Ineffective Tissue Perfusion B) Risk for Imbalanced Fluid Volume C) Risk for Ineffective Breathing Pattern D) Risk for Ineffective Thermoregulation
A Feedback: Patients with ET are at risk for hypercoagulation and consequent ineffective tissue perfusion. Fluid volume, breathing, and thermoregulation are not normally affected.
28. Following an extensive diagnostic workup, an older adult patient has been diagnosed with a secondary myelodysplastic syndrome (MDS). What assessment question most directly addresses the potential etiology of this patients health problem? A) Were you ever exposed to toxic chemicals in any of the jobs that you held? B) When you were younger, did you tend to have recurrent infections of any kind? C) Have your parents or siblings had any disease like this? D) Would you say that youve had a lot of sun exposure in your lifetime?
A Feedback: Secondary MDS can occur at any age and results from prior toxic exposure to chemicals, including chemotherapeutic medications. Family history, sun exposure, and previous infections are unrelated to the pathophysiology of secondary MDS.
13. A nurse is caring for a patient with Hodgkin lymphoma at the oncology clinic. The nurse should be aware of what main goal of care? A) Cure of the disease B) Enhancing quality of life C) Controlling symptoms D) Palliation
A Feedback: The goal in the treatment of Hodgkin lymphoma is cure. Palliation is thus not normally necessary. Quality of life and symptom control are vital, but the overarching goal is the cure the disease.
The nurse is reviewing the medication administration record of a patient diagnosed with systolic HF. What medication should the nurse anticipate administering to this patient? A betaadrenergic blocker An antiplatelet aggregator A calcium channel blocker A nonsteroidal antiinflammatory drug (NSAID)
A betaadrenergic blocker*** An antiplatelet aggregator A calcium channel blocker A nonsteroidal antiinflammatory drug (NSAID) Feedback: Several medications are routinely prescribed for systolic HF, including ACE inhibitors, betablockers, diuretics, and digitalis. Calcium channel blockers, antiplatelet aggregators, and NSAIDs are not commonly prescribed.
When assessing the patient with pericardial effusion, the nurse will assess for pulsus paradoxus. Pulsus paradoxus is characterized by what assessment finding? A diastolic blood pressure that is lower during exhalation A diastolic blood pressure that is higher during inhalation A systolic blood pressure that is higher during exhalation A systolic blood pressure that is lower during inhalation
A diastolic blood pressure that is lower during exhalation A diastolic blood pressure that is higher during inhalation A systolic blood pressure that is higher during exhalation A systolic blood pressure that is lower during inhalation**** Feedback: Systolic blood pressure that is markedly lower during inhalation is called pulsus paradoxus. The difference in systolic pressure between the point that is heard during exhalation and the point that is heard during inhalation is measured. Pulsus paradoxus exceeding 10 mm Hg is abnormal.
35. A nurse is writing the care plan of a patient who has been diagnosed with myelofibrosis. What nursing diagnoses should the nurse address? Select all that apply. A) Disturbed Body Image B) Impaired Mobility C) Imbalanced Nutrition: Less than Body Requirements D) Acute Confusion E) Risk for Infection
A, B, C, E Feedback: The profound splenomegaly that accompanies myelofibrosis can impact the patients body image and mobility. As well, nutritional deficits are common and the patient is at risk for infection. Cognitive effects are less common.
25. An oncology nurse recognizes a patients risk for fluid imbalance while the patient is undergoing treatment for leukemia. What relevant assessments should the nurse include in the patients plan of care? Select all that apply. A) Monitoring the patients electrolyte levels B) Monitoring the patients hepatic function C) Measuring the patients weight on a daily basis D) Measuring and recording the patients intake and output E) Auscultating the patients lungs frequently
A, C, D, E Feedback: Assessments that relate to fluid balance include monitoring the patients electrolytes, auscultating the patients chest for adventitious sounds, weighing the patient daily, and closely monitoring intake and output. Liver function is not directly relevant to the patients fluid status in most cases.
A cardiac patient's resistance to left ventricular filling has caused blood to back up into the patient's circulatory system. What health problem is likely to result? Acute pulmonary edema Rightsided HF Right ventricular hypertrophy Leftsided HF
Acute pulmonary edema**** Rightsided HF Right ventricular hypertrophy Leftsided HF Feedback: With increased resistance to left ventricular filling, blood backs up into the pulmonary circulation. The patient quickly develops pulmonary edema from the blood volume overload in the lungs. When the blood backs up into the pulmonary circulation, rightsided HF, leftsided HF, and right ventricular hypertrophy do not directly occur.
An example of a potassium-sparing diuretic that might be prescribed for a person with congestive heart failure is:
Aldactone
The nurse is performing a physical assessment on a patient suspected of having HF. The presence of what sound would signal the possibility of impending HF? An S3 heart sound Pleural friction rub Faint breath sounds A heart murmur
An S3 heart sound*** Pleural friction rub Faint breath sounds A heart murmur Feedback: The heart is auscultated for an S3 heart sound, a sign that the heart is beginning to fail and that increased blood volume fills the ventricle with each beat. HF does not normally cause a pleural friction rub or murmurs. Changes in breath sounds occur, such as the emergence of crackles or wheezes, but faint breath sounds are less characteristic of HF.
The clinic nurse is caring for a 57-year-old client who reports experiencing leg pain whenever she walks several blocks. The patient has type 1 diabetes and has smoked a pack of cigarettes every day for the past 40 years. The physician diagnoses intermittent claudication. The nurse should provide what instruction about long-term care to the client? A) "Be sure to practice meticulous foot care." B) "Consider cutting down on your smoking." C) "Reduce your activity level to accommodate your limitations." D) "Try to make sure you eat enough protein."
Ans: "Be sure to practice meticulous foot care." Feedback: The patient with peripheral vascular disease or diabetes should receive education or reinforcement about skin and foot care. Intermittent claudication and other chronic peripheral vascular diseases reduce oxygenation to the feet, making them susceptible to injury and poor healing; therefore, meticulous foot care is essential. The patient should stop smoking—not just cut down—because nicotine is a vasoconstrictor. Daily walking benefits the patient with intermittent claudication. Increased protein intake will not alleviate the patient's symptoms.
A patient has been scheduled for a bone marrow biopsy and admits to the nurse that she is worried about the pain involved with the procedure. What patient education is most accurate? A) "You'll be given painkillers before the test, so there won't likely be any pain?" B) "You'll feel some pain when the needle enters your skin, but none when the needle enters the bone because of the absence of nerves in bone." C) "Most people feel some brief, sharp pain when the needle enters the bone." D) "I'll be there with you, and I'll try to help you keep your mind off the pain."
Ans: "Most people feel some brief, sharp pain when the needle enters the bone." Feedback: Patients typically feel a pressure sensation as the needle is advanced into position. The actual aspiration always causes sharp, but brief pain, resulting from the suction exerted as the marrow is aspirated into the syringe; the patient should be warned about this. Stating, "I'll try to help you keep your mind off the pain" may increase the patient's fears of pain, because this does not help the patient know what to expect.
Two units of PRBCs have been ordered for a patient who has experienced a GI bleed. The patient is highly reluctant to receive a transfusion, stating, "I'm terrified of getting AIDS from a blood transfusion." How can the nurse best address the patient's concerns? A) "All the donated blood in the United States is treated with antiretroviral medications before it is used." B) "That did happen in some high-profile cases in the twentieth century, but it is no longer a possibility." C) "HIV was eradicated from the US blood supply in the early 2000s." D) "The chances of contracting AIDS from a blood transfusion in the United States are exceedingly low."
Ans: "The chances of contracting AIDS from a blood transfusion in the United States are exceedingly low." Feedback: The patient can be reassured about the very low possibility of contracting HIV from the transfusion. However, it is not an absolute impossibility. Antiretroviral medications are not introduced into donated blood. The blood supply is constantly dynamic, due to the brief life of donated blood.
A nurse in the rehabilitation unit is caring for an older adult patient who is in cardiac rehabilitation following an MI. The nurse's plan of care calls for the patient to walk for 10 minutes 3 times a day. The patient questions the relationship between walking and heart function. How should the nurse best reply? A) "The arteries in your legs constrict when you walk and allow the blood to move faster and with more pressure on the tissue." B) Walking increases your heart rate and blood pressure. Therefore your heart is under less stress." C) "Walking helps your heart adjust to your new arteries and helps build your self-esteem." D) "When you walk, the muscles in your legs contract and pump the blood in your veins back toward your heart, which allows more blood to return to your heart."
Ans: "When you walk, the muscles in your legs contract and pump the blood in your veins back toward your heart, which allows more blood to return to your heart." Feedback: Veins, unlike arteries, are equipped with valves that allow blood to move against the force of gravity. The legs have one-way bicuspid valves that prevent blood from seeping backward as it moves forward by the muscles in our legs pressing on the veins as we walk and increasing venous return. Leg arteries do constrict when walking, which allows the blood to move faster and with more pressure on the tissue, but the greater concern is increasing the flow of venous blood to the heart. Walking increases, not decreases, the heart' pumping ability, which increases heart rate and blood pressure and the hearts ability to manage stress. Walking does help the heart adjust to new arteries and may enhance self-esteem, but the patient had an MI—there are no "new arteries."
14. A patient with a history of cirrhosis is admitted to the ICU with a diagnosis of bleeding esophageal varices; an attempt to stop the bleeding has been only partially successful. What would the critical care nurse expect the care team to order for this patient? A) Packed red blood cells (PRBCs) B) Vitamin K C) Oral anticoagulants D) Heparin infusion
Ans: A
26. A patient's absolute neutrophil count (ANC) is 440/mm3. But the nurse's assessment reveals no apparent signs or symptoms of infection. What action should the nurse prioritize when providing care for this patient? A) Meticulous hand hygiene B) Timely administration of antibiotics C) Provision of a nutrient-dense diet D) Maintaining a sterile care environment
Ans: A
30. A patient with a recent diagnosis of ITP has asked the nurse why the care team has not chosen to administer platelets, stating, ìI have low platelets, so why not give me a transfusion of exactly what I'm missing?î How should the nurse best respond? A) "Transfused platelets usually aren't beneficial because they're rapidly destroyed in the body." B) "A platelet transfusion often blunts your body's own production of platelets even further." C) "Finding a matching donor for a platelet transfusion is exceedingly difficult." D) "A very small percentage of the platelets in a transfusion are actually functional."
Ans: A
36. A patient's low prothrombin time (PT) was attributed to a vitamin K deficiency and the patient's PT normalized after administration of vitamin K. When performing discharge education in an effort to prevent recurrence, what should the nurse emphasize? A) The need for adequate nutrition B) The need to avoid NSAIDs C) The need for constant access to factor concentrate D) The need for meticulous hygiene
Ans: A
7. A patient comes to the clinic complaining of fatigue and the health interview is suggestive of pica. Laboratory findings reveal a low serum iron level and a low ferritin level. With what would the nurse suspect that the patient will be diagnosed? A) Iron deficiency anemia B) Pernicious anemia C) Sickle cell anemia D) Hemolytic anemia
Ans: A
9. A nurse is caring for a patient with severe anemia. The patient is tachycardic and complains of dizziness and exertional dyspnea. The nurse knows that in an effort to deliver more blood to hypoxic tissue, the workload on the heart is increased. What signs and symptoms might develop if this patient goes into heart failure? A) Peripheral edema B) Nausea and vomiting C) Migraine D) Fever
Ans: A
2. A patient with primary hypertension comes to the clinic complaining of a gradual onset of blurry vision and decreased visual acuity over the past several weeks. The nurse is aware that these symptoms could be indicative of what? A) Retinal blood vessel damage B) Glaucoma C) Cranial nerve damage D) Hypertensive emergency
Ans: A Feedback: Blurred vision, spots in front of the eyes, and diminished visual acuity can mean retinal blood vessel damage indicative of damage elsewhere in the vascular system as a result of hypertension. Glaucoma and cranial nerve damage do not normally cause these symptoms. A hypertensive emergency would have a more rapid onset.
20. The nurse is developing a nursing care plan for a patient who is being treated for hypertension. What is a measurable patient outcome that the nurse should include? A) Patient will reduce Na+ intake to no more than 2.4 g daily. B) Patient will have a stable BUN and serum creatinine levels. C) Patient will abstain from fat intake and reduce calorie intake. D) Patient will maintain a normal body weight.
Ans: A Feedback: Dietary sodium intake of no more than 2.4 g sodium is recommended as a dietary lifestyle modification to prevent and manage hypertension. Giving a specific amount of allowable sodium intake makes this a measurable goal. None of the other listed goals is quantifiable and measurable.
14. A nurse is teaching an adult female patient about the risk factors for hypertension. What should the nurse explain as risk factors for primary hypertension? A) Obesity and high intake of sodium and saturated fat B) Diabetes and use of oral contraceptives C) Metabolic syndrome and smoking D) Renal disease and coarctation of the aorta
Ans: A Feedback: Obesity, stress, high intake of sodium or saturated fat, and family history are all risk factors for primary hypertension. Diabetes and oral contraceptives are risk factors for secondary hypertension. Metabolic syndrome, renal disease, and coarctation of the aorta are causes of secondary hypertension.
10. A patient with primary hypertension complains of dizziness with ambulation. The patient is currently on an alpha-adrenergic blocker and the nurse assesses characteristic signs and symptoms of postural hypotension. When teaching this patient about risks associated with postural hypotension, what should the nurse emphasize? A) Rising slowly from a lying or sitting position B) Increasing fluids to maintain BP C) Stopping medication if dizziness persists D) Taking medication first thing in the morning
Ans: A Feedback: Patients who experience postural hypotension should be taught to rise slowly from a lying or sitting position and use a cane or walker if necessary for safety. It is not necessary to teach these patients about increasing fluids or taking medication in the morning (this would increase the effects of dizziness). Patient should not be taught to stop the medication if dizziness persists because this is unsafe and beyond the nurse's scope of practice.
18. A patient has come to the clinic for a follow-up assessment that will include a BP reading. To ensure an accurate reading, the nurse should confirm that the patient has done which of the following? A) Tried to rest quietly for 5 minutes before the reading is taken B) Refrained from smoking for at least 8 hours C) Drunk adequate fluids during the day prior D) Avoided drinking coffee for 12 hours before the visit
Ans: A Feedback: Prior to the nurse assessing the patient's BP, the patient should try to rest quietly for 5 minutes. The forearm should be positioned at heart level. Caffeine products and cigarette smoking should be avoided for at least 30 minutes prior to the visit. Recent fluid intake is not normally relevant.
16. A patient with secondary hypertension has come into the clinic for a routine check-up. The nurse is aware that the difference between primary hypertension and secondary hypertension is which of the following? A) Secondary hypertension has a specific cause. B) Secondary hypertension has a more gradual onset than primary hypertension. C) Secondary hypertension does not cause target organ damage. D) Secondary hypertension does not normally respond to antihypertensive drug therapy.
Ans: A Feedback: Secondary hypertension has a specific identified cause. A cause could include narrowing of the renal arteries, renal parenchymal disease, hyperaldosteronism, certain medications, pregnancy, and coarctation of the aorta. Secondary hypertension does respond to antihypertensive drug therapy and can cause target organ damage if left untreated.
7. A patient has been prescribed antihypertensives. After assessment and analysis, the nurse has identified a nursing diagnosis of risk for ineffective health maintenance related to nonadherence to therapeutic regimen. When planning this patient's care, what desired outcome should the nurse identify? A) Patient takes medication as prescribed and reports any adverse effects. B) Patient's BP remains consistently below 140/90 mm Hg. C) Patient denies signs and symptoms of hypertensive urgency. D) Patient is able to describe modifiable risk factors for hypertension.
Ans: A Feedback: The most appropriate expected outcome for a patient who is given the nursing diagnosis of risk for ineffective health maintenance is that he or she takes the medication as prescribed. The other listed goals are valid aspects of care, but none directly relates to the patient's role in his or her treatment regimen.
9. A patient newly diagnosed with hypertension asks the nurse what happens when uncontrolled hypertension is prolonged. The nurse explains that a patient with prolonged, uncontrolled hypertension is at risk for developing what health problem? A) Renal failure B) Right ventricular hypertrophy C) Glaucoma D) Anemia
Ans: A Feedback: When uncontrolled hypertension is prolonged, it can result in renal failure, myocardial infarction, stroke, impaired vision, left ventricular hypertrophy, and cardiac failure. Glaucoma and anemia are not directly associated with hypertension.
An older adult patient has been treated for a venous ulcer and a plan is in place to prevent the occurrence of future ulcers. What should the nurse include in this plan? A) Use of supplementary oxygen to aid tissue oxygenation B) Daily use of normal saline compresses on the lower limbs C) Daily administration of prophylactic antibiotics D) A high-protein diet that is rich in vitamins
Ans: A high-protein diet that is rich in vitamins Feedback: A diet that is high in protein, vitamins C and A, iron, and zinc is encouraged to promote healing and prevent future ulcers. Prophylactic antibiotics and saline compresses are not used to prevent ulcers. Oxygen supplementation does not prevent ulcer formation.
33. A nurse is planning the care of a patient who has a diagnosis of hemophilia A. When addressing the nursing diagnosis of Acute Pain Related to Joint Hemorrhage, what principle should guide the nurse's choice of interventions? A) Gabapentin (Neurontin) is effective because of the neuropathic nature of the patient's pain. B) Opioids partially inhibit the patient's synthesis of clotting factors. C) Opioids may cause vasodilation and exacerbate bleeding. D) NSAIDs are contraindicated due to the risk for bleeding.
Ans: D
A medical nurse has admitted four patients over the course of a 12-hour shift. For which patient would assessment of ankle-brachial index (ABI) be most clearly warranted? A) A patient who has peripheral edema secondary to chronic heart failure B) An older adult patient who has a diagnosis of unstable angina C) A patient with poorly controlled type 1 diabetes who is a smoker D) A patient who has community-acquired pneumonia and a history of COPD
Ans: A patient with poorly controlled type 1 diabetes who is a smoker Feedback: Nurses should perform a baseline ABI on any patient with decreased pulses or any patient 50 years of age or older with a history of diabetes or smoking. The other answers do not apply.
A nurse has participated in organizing a blood donation drive at a local community center. Which of the following individuals would most likely be disallowed from donating blood? A) A man who is 81 years of age B) A woman whose blood pressure is 88/51 mm Hg C) A man who donated blood 4 months ago D) A woman who has type 1 diabetes
Ans: A woman whose blood pressure is 88/51 mm Hg Feedback: For potential blood donors, systolic arterial BP should be 90 to 180 mm Hg, and the diastolic pressure should be 50 to 100 mm Hg. There is no absolute upper age limit. Donation 4 months ago does not preclude safe repeat donation and diabetes is not a contraindication.
23. The nurse is teaching a patient about some of the health consequences of uncontrolled hypertension. What health problems should the nurse describe? Select all that apply. A) Transient ischemic attacks B) Cerebrovascular accident C) Retinal hemorrhage D) Venous insufficiency E) Right ventricular hypertrophy
Ans: A, B, C Feedback: Potential complications of hypertension include the following: left ventricular hypertrophy; MI; heart failure; transient ischemic attacks (TIAs); cerebrovascular accident; renal insufficiency and failure; and retinal hemorrhage. Venous insufficiency and right ventricular hypertrophy are not potential complications of uncontrolled hypertension.
29. The results of a patient's most recent blood work and physical assessment are suggestive of immune thrombocytopenic purpura (ITP). This patient should undergo testing for which of the following potential causes? Select all that apply. A) Hepatitis B) Acute renal failure C) HIV D) Malignant melanoma E) Cholecystitis
Ans: A, C
The nurse is planning the care of a patient with a nutritional deficit and a diagnosis of megaloblastic anemia. The nurse should recognize that this patient's health problem is due to what? A) Production of inadequate quantities of RBCs B) Premature release of immature RBCs C) Injury to the RBCs in circulation D) Abnormalities in the structure and function RBCs
Ans: Abnormalities in the structure and function RBCs Feedback: Vitamin B12 and folic acid deficiencies are characterized by the production of abnormally large erythrocytes called megaloblasts. Because these cells are abnormal, many are sequestered (trapped) while still in the bone marrow, and their rate of release is decreased. Some of these cells actually die in the marrow before they can be released into the circulation. This results in megaloblastic anemia. This pathologic process does not involve inadequate production, premature release, or injury to existing RBCs.
The nurse is caring for a 72-year-old patient who is in cardiac rehabilitation following heart surgery. The patient has been walking on a regular basis for about a week and walks for 15 minutes 3 times a day. The patient states that he is having a cramp-like pain in the legs every time he walks and that the pain gets "better when I rest." The patient's care plan should address what problem? A) Decreased mobility related to VTE B) Acute pain related to intermittent claudication C) Decreased mobility related to venous insufficiency D) Acute pain related to vasculitis
Ans: Acute pain related to intermittent claudication Feedback: Intermittent claudication presents as a muscular, cramp-type pain in the extremities consistently reproduced with the same degree of exercise or activity and relieved by rest. Patients with peripheral arterial insufficiency often complain of intermittent claudication due to a lack of oxygen to muscle tissue. Venous insufficiency presents as a disorder of venous blood reflux and does not present with cramp-type pain with exercise. Vasculitis is an inflammation of the blood vessels and presents with weakness, fever, and fatigue, but does not present with cramp-type pain with exercise. The pain associated with VTE does not have this clinical presentation.
The nurse is preparing to administer a unit of platelets to an adult patient. When administering this blood product, which of the following actions should the nurse perform? A) Administer the platelets as rapidly as the patient can tolerate. B) Establish IV access as soon as the platelets arrive from the blood bank. C) Ensure that the patient has a patent central venous catheter. D) Aspirate 10 to 15 mL of blood from the patient's IV immediately following the transfusion
Ans: Administer the platelets as rapidly as the patient can tolerate. Feedback: The nurse should infuse each unit of platelets as fast as patient can tolerate to diminish platelet clumping during administration. IV access should be established prior to obtaining the platelets from the blood bank. A central line is appropriate for administration, but peripheral IV access (22-gauge or larger) is sufficient. There is no need to aspirate after the transfusion.
The nurse is describing the role of plasminogen in the clotting cascade. Where in the body is plasminogen present? A) Myocardial muscle tissue B) All body fluids C) Cerebral tissue D) Venous and arterial vessel walls
Ans: All body fluids Feedback: Plasminogen, which is present in all body fluids, circulates with fibrinogen. Plasminogen is found in body fluids, not tissue.
A nurse on a medical unit is caring for a patient who has been diagnosed with lymphangitis. When reviewing this patient's medication administration record, the nurse should anticipate which of the following? A) Coumadin (warfarin) B) Lasix (furosemide) C) An antibiotic D) An antiplatelet aggregator
Ans: An antibiotic Feedback: Lymphangitis is an acute inflammation of the lymphatic channels caused by an infectious process. Antibiotics are always a component of treatment. Diuretics are of nominal use. Anticoagulants and antiplatelet aggregators are not indicated in this form of infection.
A client's health history reveals daily consumption of two to three bottles of wine. The nurse should plan assessments and interventions in light of the patient's increased risk for what hematologic disorder? A) Leukemia B) Anemia C) Thrombocytopenia D) Lymphoma
Ans: Anemia Feedback: Heavy alcohol use is associated with numerous health problems, including anemia. Leukemia and lymphoma are not associated with alcohol use; RBC levels are typically affected more than platelet levels.
The triage nurse in the ED is assessing a patient who has presented with complaint of pain and swelling in her right lower leg. The patient's pain became much worse last night and appeared along with fever, chills, and sweating. The patient states, "I hit my leg on the car door 4 or 5 days ago and it has been sore ever since." The patient has a history of chronic venous insufficiency. What intervention should the nurse anticipate for this patient? A) Platelet transfusion to treat thrombocytopenia B) Warfarin to treat arterial insufficiency C) Antibiotics to treat cellulitis D) Heparin IV to treat VTE
Ans: Antibiotics to treat cellulitis Feedback: Cellulitis is the most common infectious cause of limb swelling. The signs and symptoms include acute onset of swelling, localized redness, and pain; it is frequently associated with systemic signs of fever, chills, and sweating. The patient may be able to identify a trauma that accounts for the source of infection. Thrombocytopenia is a loss or decrease in platelets and increases a patient's risk of bleeding; this problem would not cause these symptoms. Arterial insufficiency would present with ongoing pain related to activity. This patient does not have signs and symptoms of VTE.
A nurse is educating a patient about the role of B lymphocytes. The nurse's description will include which of the following physiologic processes? A) Stem cell differentiation B) Cytokine production C) Phagocytosis D) Antibody production
Ans: Antibody production Feedback: B lymphocytes are capable of differentiating into plasma cells. Plasma cells, in turn, produce antibodies. Cytokines are produced by NK cells. Stem cell differentiation greatly precedes B lymphocyte production.
A 79-year-old man is admitted to the medical unit with digital gangrene. The man states that his problems first began when he stubbed his toe going to the bathroom in the dark. In addition to this trauma, the nurse should suspect that the patient has a history of what health problem? A) Raynaud's phenomenon B) CAD C) Arterial insufficiency D) Varicose veins
Ans: Arterial insufficiency Feedback: Arterial insufficiency may result in gangrene of the toe (digital gangrene), which usually is caused by trauma. The toe is stubbed and then turns black. Raynaud's, CAD and varicose veins are not the usual causes of digital gangrene in the elderly.
A patient who has undergone a femoral to popliteal bypass graft surgery returns to the surgical unit. Which assessments should the nurse perform during the first postoperative day? A) Assess pulse of affected extremity every 15 minutes at first. B) Palpate the affected leg for pain during every assessment. C) Assess the patient for signs and symptoms of compartment syndrome every 2 hours. D) Perform Doppler evaluation once daily.
Ans: Assess pulse of affected extremity every 15 minutes at first. Feedback: The primary objective in the postoperative period is to maintain adequate circulation through the arterial repair. Pulses, Doppler assessment, color and temperature, capillary refill, and sensory and motor function of the affected extremity are checked and compared with those of the other extremity; these values are recorded initially every 15 minutes and then at progressively longer intervals if the patient's status remains stable. Doppler evaluations should be performed every 2 hours. Pain is regularly assessed, but palpation is not the preferred method of performing this assessment. Compartment syndrome results from the placement of a cast, not from vascular surgery.
A patient's low hemoglobin level has necessitated transfusion of PRBCs. Prior to administration, what action should the nurse perform? A) Have the patient identify his or her blood type in writing. B) Ensure that the patient has granted verbal consent for transfusion. C) Assess the patient's vital signs to establish baselines. D) Facilitate insertion of a central venous catheter
Ans: Assess the patient's vital signs to establish baselines. Feedback: Prior to a transfusion, the nurse must take the patient's temperature, pulse, respiration, and BP to establish a baseline. Written consent is required and the patient's blood type is determined by type and cross match, not by the patient's self-declaration. Peripheral venous access is sufficient for blood transfusion.
28. A patient comes to the walk-in clinic complaining of frequent headaches. While assessing the patient's vital signs, the nurse notes the BP is 161/101 mm Hg. According to JNC 7, how would this patient's BP be defined if a similar reading were obtained at a subsequent office visit? A) High normal B) Normal C) Stage 1 hypertensive D) Stage 2 hypertensive
Ans: D Feedback: JNC 7 defines stage 2 hypertension as a reading 160/100 mm Hg.
A nurse is creating an education plan for a patient with venous insufficiency. What measure should the nurse include in the plan? A) Avoiding tight-fitting socks. B) Limit activity whenever possible. C) Sleep with legs in a dependent position. D) Avoid the use of pressure stockings.
Ans: Avoiding tight-fitting socks. Feedback: Measures taken to prevent complications include avoiding tight-fitting socks and panty girdles; maintaining activities, such as walking, sleeping with legs elevated, and using pressure stockings. Not included in the teaching plan for venous insufficiency would be reducing activity, sleeping with legs dependent, and avoiding pressure stockings. Each of these actions exacerbates venous insufficiency.
1. A nurse is caring for a patient who has sickle cell anemia and the nurse's assessment reveals the possibility of substance abuse. What is the nurse's most appropriate action? A) Encourage the patient to rely on complementary and alternative therapies. B) Encourage the patient to seek care from a single provider for pain relief. C) Teach the patient to accept chronic pain as an inevitable aspect of the disease. D) Limit the reporting of emergency department visits to the primary health care provider.
Ans: B
10. A patient is admitted to the hospital with pernicious anemia. The nurse should prepare to administer which of the following medications? A) Folic acid B) Vitamin B12 C) Lactulose D) Magnesium sulfate
Ans: B
11. A patient's blood work reveals a platelet level of 17,000/mm3. When inspecting the patient's integumentary system, what finding would be most consistent with this platelet level? A) Dermatitis B) Petechiae C) Urticaria D) Alopecia
Ans: B
16. A group of nurses are learning about the high incidence and prevalence of anemia among different populations. Which of the following individuals is most likely to have anemia? A) A 50-year-old African-American woman who is going through menopause B) An 81-year-old woman who has chronic heart failure C) A 48-year-old man who travels extensively and has a high-stress job D) A 13-year-old girl who has just experienced menarche
Ans: B
2. A patient newly diagnosed with thrombocytopenia is admitted to the medical unit. After the admission assessment, the patient asks the nurse to explain the disease. What should the nurse explain to this patient? A) There could be an attack on the platelets by antibodies. B) There could be decreased production of platelets. C) There could be impaired communication between platelets. D) There could be an autoimmune process causing platelet malfunction.
Ans: B
20. A patient with poorly controlled diabetes has developed end-stage renal failure and consequent anemia. When reviewing this patient's treatment plan, the nurse should anticipate the use of what drug? A) Magnesium sulfate B) Epoetin alfa C) Low-molecular weight heparin D) Vitamin K
Ans: B
24. A patient with a documented history of glucose-6-phosphate dehydrogenase deficiency has presented to the emergency department with signs and symptoms including pallor, jaundice, and malaise. Which of the nurse's assessment questions relates most directly to this patient's hematologic disorder? A) "When did you last have a blood transfusion?" B) "What medications have taken recently?" C) "Have you been under significant stress lately?" D) "Have you suffered any recent injuries?"
Ans: B
25. A patient's electronic health record notes that he has previously undergone treatment for secondary polycythemia. How should this aspect of the patient's history guide the nurse's subsequent assessment? A) The nurse should assess for recent blood donation. B) The nurse should assess for evidence of lung disease. C) The nurse should assess for a history of venous thromboembolism. D) The nurse should assess the patient for impaired renal function.
Ans: B
27. A nurse is providing discharge education to a patient who has recently been diagnosed with a bleeding disorder. What topic should the nurse prioritize when teaching this patient? A) Avoiding buses, subways, and other crowded, public sites B) Avoiding activities that carry a risk for injury C) Keeping immunizations current D) Avoiding foods high in vitamin K
Ans: B
34. A night nurse is reviewing the next day's medication administration record (MAR) of a patient who has hemophilia. The nurse notes that the MAR specifies both oral and subcutaneous options for the administration of a PRN antiemetic. What is the nurse's best action? A) Ensure that the day nurse knows not to give the antiemetic. B) Contact the prescriber to have the subcutaneous option discontinued. C) Reassess the patient's need for antiemetics. D) Remove the subcutaneous route from the patient's MAR.
Ans: B
8. The nurse is providing care for a patient with a new diagnosis of hypertension. How can the nurse best promote the patient's adherence to the prescribed therapeutic regimen? A) Screen the patient for visual disturbances regularly. B) Have the patient participate in monitoring his or her own BP. C) Emphasize the dire health outcomes associated with inadequate BP control. D) Encourage the patient to lose weight and exercise regularly.
Ans: B Feedback: Adherence to the therapeutic regimen increases when patients actively participate in self-care, including self-monitoring of BP and diet. Dire warnings may motivate some patients, but for many patients this is not an appropriate or effective strategy. Screening for vision changes and promoting healthy lifestyle are appropriate nursing actions, but do not necessarily promote adherence to a therapeutic regimen.
13. The nursing lab instructor is teaching student nurses how to take blood pressure. To ensure accurate measurement, the lab instructor would teach the students to avoid which of the following actions? A) Measuring the BP after the patient has been seated quietly for more than 5 minutes B) Taking the BP at least 10 minutes after nicotine or coffee ingestion C) Using a cuff with a bladder that encircles at least 80% of the limb D) Using a bare forearm supported at heart level on a firm surface
Ans: B Feedback: Blood pressures should be taken with the patient seated with arm bare, supported, and at heart level. The patient should not have smoked tobacco or taken caffeine in the 30 minutes preceding the measurement. The patient should rest quietly for 5 minutes before the reading is taken. The cuff bladder should encircle at least 80% of the limb being measured and have a width of at least 40% of limb circumference. Using a cuff that is too large results in a lower BP and a cuff that is too small will give a higher BP measurement.
22. The hospital nurse cares for many patients who have hypertension. What nursing diagnosis is most common among patients who are being treated for this health problem? A) Deficient knowledge regarding the lifestyle modifications for management of hypertension B) Noncompliance with therapeutic regimen related to adverse effects of prescribed therapy C) Deficient knowledge regarding BP monitoring D) Noncompliance with treatment regimen related to medication costs
Ans: B Feedback: Deviation from the therapeutic program is a significant problem for people with hypertension and other chronic conditions requiring lifetime management. For many patients, this is related to adverse effects of medications. Medication cost is relevant for many patients, but adverse effects are thought to be a more significant barrier. Many patients are aware of necessary lifestyle modification, but do not adhere to them. Most patients are aware of the need to monitor their BP.
15. The nurse is caring for an older adult with a diagnosis of hypertension who is being treated with a diuretic and beta-blocker. Which of the following should the nurse integrate into the management of this client's hypertension? A) Ensure that the patient receives a larger initial dose of antihypertensive medication due to impaired absorption. B) Pay close attention to hydration status because of increased sensitivity to extracellular volume depletion. C) Recognize that an older adult is less likely to adhere to his or her medication regimen than a younger patient. D) Carefully assess for weight loss because of impaired kidney function resulting from normal aging.
Ans: B Feedback: Elderly people have impaired cardiovascular reflexes and thus are more sensitive to extracellular volume depletion caused by diuretics. The nurse needs to assess hydration status, low BP, and postural hypotension carefully. Older adults may have impaired absorption, but they do not need a higher initial dose of an antihypertensive than a younger person. Adherence to treatment is not necessarily linked to age. Kidney function and absorption decline with age; less, rather than more antihypertensive medication is prescribed. Weight gain is not necessarily indicative of kidney function decline.
27. During an adult patient's last two office visits, the nurse obtained BP readings of 122/84 mm Hg and 130/88 mm Hg, respectively. How would this patient's BP be categorized? A) Normal B) Prehypertensive C) Stage 1 hypertensive D) Stage 2 hypertensive
Ans: B Feedback: Prehypertension is defined systolic BP of 120 to 139 mm Hg or diastolic BP of 80 to 89 mm Hg.
6. A 40-year-old male newly diagnosed with hypertension is discussing risk factors with the nurse. The nurse talks about lifestyle changes with the patient and advises that the patient should avoid tobacco use. What is the primary rationale behind that advice to the patient? A) Quitting smoking will cause the patient's hypertension to resolve. B) Tobacco use increases the patient's concurrent risk of heart disease. C) Tobacco use is associated with a sedentary lifestyle. D) Tobacco use causes ventricular hypertrophy.
Ans: B Feedback: Smoking increases the risk for heart disease, for which a patient with hypertension is already at an increased risk. Quitting will not necessarily cause hypertension to resolve and smoking does not directly cause ventricular hypertrophy. The association with a sedentary lifestyle is true, but this is not the main rationale for the nurse's advice; the association with heart disease is more salient.
11. The nurse is planning the care of a patient who has been diagnosed with hypertension, but who otherwise enjoys good health. When assessing the response to an antihypertensive drug regimen, what blood pressure would be the goal of treatment? A) 156/96 mm Hg or lower B) 140/90 mm Hg or lower C) Average of 2 BP readings of 150/80 mm Hg D) 120/80 mm Hg or lower
Ans: B Feedback: The goal of antihypertensive drug therapy is a BP of 140/90 mm Hg or lower. A pressure of 130/80 mm Hg is the goal for patients with diabetes or chronic kidney disease.
39. A patient's medication regimen for the treatment of hypertension includes hydrochlorothiazide. Following administration of this medication, the nurse should anticipate what effect? A) Drowsiness or lethargy B) Increased urine output C) Decreased heart rate D) Mild agitation
Ans: B Feedback: Thiazide diuretics lower BP by reducing circulating blood volume; this results in a short-term increase in urine output. These drugs do not cause bradycardia, agitation, or drowsiness.
29. A patient has been diagnosed as being prehypertensive. What should the nurse encourage this patient to do to aid in preventing a progression to a hypertensive state? A) Avoid excessive potassium intake. B) Exercise on a regular basis. C) Eat less protein and more vegetables. D) Limit morning activity.
Ans: B Feedback: To prevent or delay progression to hypertension and reduce risk, JNC 7 urged health care providers to encourage people with blood pressures in the prehypertension category to begin lifestyle modifications, such as nutritional changes and exercise. There is no need for patients to limit their activity in the morning or to avoid potassium and protein intake.
36. The nurse is reviewing the medication administration record of a patient who takes a variety of medications for the treatment of hypertension. What potential therapeutic benefits of antihypertensives should the nurse identify? Select all that apply. A) Increased venous return B) Decreased peripheral resistance C) Decreased blood volume D) Decreased strength and rate of myocardial contractions E) Decreased blood viscosity
Ans: B, C, D Feedback: The medications used for treating hypertension decrease peripheral resistance, blood volume, or the strength and rate of myocardial contraction. Antihypertensive medications do not increase venous return or decrease blood viscosity.
An interdisciplinary team has been commissioned to create policies and procedures aimed at preventing acute hemolytic transfusion reactions. What action has the greatest potential to reduce the risk of this transfusion reaction? A) Ensure that blood components are never infused at a rate greater than 125 mL/hr. B) Administer prophylactic antihistamines prior to all blood transfusions. C) Establish baseline vital signs for all patients receiving transfusions. D) Be vigilant in identifying the patient and the blood component.
Ans: Be vigilant in identifying the patient and the blood component. Feedback: The most common causes of acute hemolytic reaction are errors in blood component labeling and patient identification that result in the administration of an ABO-incompatible transfusion. Actions to address these causes are necessary in all health care settings. Prophylactic antihistamines are not normally administered, and would not prevent acute hemolytic reactions. Similarly, baseline vital signs and slow administration will not prevent this reaction.
15. The nurse on the pediatric unit is caring for a 10-year-old boy with a diagnosis of hemophilia. The nurse knows that a priority nursing diagnosis for a patient with hemophilia is what? A) Hypothermia B) Diarrhea C) Ineffective coping D) Imbalanced nutrition: Less than body requirements
Ans: C
19. A woman who is in her third trimester of pregnancy has been experiencing an exacerbation of iron-deficiency anemia in recent weeks. When providing the patient with nutritional guidelines and meal suggestions, what foods would be most likely to increase the woman's iron stores? A) Salmon accompanied by whole milk B) Mixed vegetables and brown rice C) Beef liver accompanied by orange juice D) Yogurt, almonds, and whole grain oats
Ans: C
21. A nurse is planning the care of a patient with a diagnosis of sickle cell disease who has been admitted for the treatment of an acute vaso-occlusive crisis. What nursing diagnosis should the nurse prioritize in the patient's plan of care? A) Risk for disuse syndrome related to ineffective peripheral circulation B) Functional urinary incontinence related to urethral occlusion C) Ineffective tissue perfusion related to thrombosis D) Ineffective thermoregulation related to hypothalamic dysfunction
Ans: C
28. A nurse is a long-term care facility is admitting a new resident who has a bleeding disorder. When planning this resident's care, the nurse should include which of the following? A) Housing the resident in a private room B) Implementing a passive ROM program to compensate for activity limitation C) Implementing of a plan for fall prevention D) Providing the patient with a high-fiber diet
Ans: C
31. A client with several chronic health problems has been newly diagnosed with a qualitative platelet defect. What component of the patient's previous medication regimen may have contributed to the development of this disorder? A) Calcium carbonate B) Vitamin B12 C) Aspirin D) Vitamin D
Ans: C
32. A young man with a diagnosis of hemophilia A has been brought to emergency department after suffering a workplace accident resulting in bleeding. Rapid assessment has revealed the source of the patient's bleeding and established that his vital signs are stable. What should be the nurse's next action? A) Position the patient in a prone position to minimize bleeding. B) Establish IV access for the administration of vitamin K. C) Prepare for the administration of factor VIII. D) Administer a normal saline bolus to increase circulatory volume.
Ans: C
37. A patient with a history of atrial fibrillation has contacted the clinic saying that she has accidentally overdosed on her prescribed warfarin (Coumadin). The nurse should recognize the possible need for what antidote? A) IVIG B) Factor X C) Vitamin K D) Factor VIII
Ans: C
4. A nurse is providing education to a patient with iron deficiency anemia who has been prescribed iron supplements. What should the nurse include in health education? A) Take the iron with dairy products to enhance absorption. B) Increase the intake of vitamin E to enhance absorption. C) Iron will cause the stools to darken in color. D) Limit foods high in fiber due to the risk for diarrhea.
Ans: C
5. The nurse is assessing a new patient with complaints of overwhelming fatigue and a sore tongue that is visibly smooth and beefy red. This patient is demonstrating signs and symptoms associated with what form of what hematologic disorder? A) Sickle cell anemia B) Hemophilia C) Megaloblastic anemia D) Thrombocytopenia
Ans: C
17. The nurse is assessing a patient new to the clinic. Records brought to the clinic with the patient show the patient has hypertension and that her current BP readings approximate the readings from when she was first diagnosed. What contributing factor should the nurse first explore in an effort to identify the cause of the client's inadequate BP control? A) Progressive target organ damage B) Possibility of medication interactions C) Lack of adherence to prescribed drug therapy D) Possible heavy alcohol use or use of recreational drugs
Ans: C Feedback: Deviation from the therapeutic program is a significant problem for people with hypertension and other chronic conditions requiring lifetime management. An estimated 50% of patients discontinue their medications within 1 year of beginning to take them. Consequently, this is a more likely problem than substance use, organ damage, or adverse drug interactions.
1. An older adult is newly diagnosed with primary hypertension and has just been started on a beta-blocker. The nurse's health education should include which of the following? A) Increasing fluids to avoid extracellular volume depletion from the diuretic effect of the beta-blocker B) Maintaining a diet high in dairy to increase protein necessary to prevent organ damage C) Use of strategies to prevent falls stemming from postural hypotension D) Limiting exercise to avoid injury that can be caused by increased intracranial pressure
Ans: C Feedback: Elderly people have impaired cardiovascular reflexes and are more sensitive to postural hypotension. The nurse teaches patients to change positions slowly when moving from lying or sitting positions to a standing position, and counsels elderly patients to use supportive devices as necessary to prevent falls that could result from dizziness. Lifestyle changes, such as regular physical activity/exercise, and a diet rich in fruits, vegetables, and low-fat dairy products, is strongly recommended. Increasing fluids in elderly patients may be contraindicated due to cardiovascular disease. Increased intracranial pressure is not a risk and activity should not normally be limited.
19. The nurse is providing care for a patient with a diagnosis of hypertension. The nurse should consequently assess the patient for signs and symptoms of which other health problem? A) Migraines B) Atrial-septal defect C) Atherosclerosis D) Thrombocytopenia
Ans: C Feedback: Hypertension is both a sign and a risk factor for atherosclerotic heart disease. It is not associated with structural cardiac defects, low platelet levels, or migraines.
5. A group of student nurses are practicing taking blood pressure. A 56-year-old male student has a blood pressure reading of 146/96 mm Hg. Upon hearing the reading, he exclaims, "My pressure has never been this high. Do you think my doctor will prescribe medication to reduce it?" Which of the following responses by the nursing instructor would be best? A) "Yes. Hypertension is prevalent among men; it is fortunate we caught this during your routine examination." B) "We will need to reevaluate your blood pressure because your age places you at high risk for hypertension." C) "A single elevated blood pressure does not confirm hypertension. You will need to have your blood pressure reassessed several times before a diagnosis can be made." D) "You have no need to worry. Your pressure is probably elevated because you are being tested."
Ans: C Feedback: Hypertension is confirmed by two or more readings with systolic pressure of at least 140 mm Hg and diastolic pressure of at least 90 mm Hg. An age of 56 does not constitute a risk factor in and of itself. The nurse should not tell the student that there is no need to worry.
12. A patient in a hypertensive emergency is admitted to the ICU. The nurse anticipates that the patient will be treated with IV vasodilators, and that the primary goal of treatment is what? A) Lower the BP to reduce onset of neurologic symptoms, such as headache and vision changes. B) Decrease the BP to a normal level based on the patient's age. C) Decrease the mean arterial pressure between 20% and 25% in the first hour of treatment. D) Reduce the BP to 120/75 mm Hg as quickly as possible.
Ans: C Feedback: Initially, the treatment goal in hypertensive emergencies is to reduce the mean arterial pressure by 25% in the first hour of treatment, with further reduction over the next 24 hours. Lowering the BP too fast may cause hypotension in a patient whose body has adjusted to hypertension and could cause a stroke, MI, or visual changes. Neurologic symptoms should be addressed, but this is not the primary focus of treatment planning.
24. The nurse is collaborating with the dietitian and a patient with hypertension to plan dietary modifications. These modifications should include which of the following? A) Reduced intake of protein and carbohydrates B) Increased intake of calcium and vitamin D C) Reduced intake of fat and sodium D) Increased intake of potassium, vitamin B12 and vitamin D
Ans: C Feedback: Lifestyle modifications usually include restricting sodium and fat intake, increasing intake of fruits and vegetables, and implementing regular physical activity. There is no need to increase calcium, potassium, and vitamin intake. Calorie restriction may be required for some patients, but a specific reduction in protein and carbohydrates is not normally indicated.
34. A student nurse is taking care of an elderly patient with hypertension during a clinical experience. The instructor asks the student about the relationships between BP and age. What would be the best answer by the student? A) "Because of reduced smooth muscle tone in blood vessels, blood pressure tends to go down with age, not up." B) "Decreases in the strength of arteries and the presence of venous insufficiency cause hypertension in the elderly." C) "Structural and functional changes in the cardiovascular system that occur with age contribute to increases in blood pressure." D) "The neurologic system of older adults is less efficient at monitoring and regulating blood pressure."
Ans: C Feedback: Structural and functional changes in the heart and blood vessels contribute to increases in BP that occur with aging. Venous insufficiency does not cause hypertension, however. Increased BP is not primarily a result of neurologic changes.
25. The critical care nurse is caring for a patient just admitted in a hypertensive emergency. The nurse should anticipate the administration of what medication? A) Warfarin (Coumadin) B) Furosemide (Lasix) C) Sodium nitroprusside (Nitropress) D) Ramipril (Altace)
Ans: C Feedback: The medications of choice in hypertensive emergencies are those that have an immediate effect. IV vasodilators, including sodium nitroprusside (Nitropress), nicardipine hydrochloride (Cardene), clevidipine (Cleviprex), fenoldopam mesylate (Corlopam), enalaprilat, and nitroglycerin, have immediate actions that are short lived (minutes to 4 hours), and they are therefore used for initial treatment. Ramipril is administered orally and would not meet the patient's immediate need for BP management. Diuretics, such as Lasix, are not used as initial treatments and there is no indication for anticoagulants such as Coumadin.
37. A newly diagnosed patient with hypertension is prescribed Diuril, a thiazide diuretic. What patient education should the nurse provide to this patient? A) "Eat a banana every day because Diuril causes moderate hyperkalemia." B) "Take over-the-counter potassium pills because Diuril causes your kidneys to lose potassium." C) "Diuril can cause low blood pressure and dizziness, especially when you get up suddenly." D) "Diuril increases sodium levels in your blood, so cut down on your salt."
Ans: C Feedback: Thiazide diuretics can cause postural hypotension, which may be potentiated by alcohol, barbiturates, opioids, or hot weather. Diuril does not cause either moderate hyperkalemia or severe hypokalemia and it does not result in hypernatremia.
3. A nurse is performing blood pressure screenings at a local health fair. While obtaining subjective assessment data from a patient with hypertension, the nurse learns that the patient has a family history of hypertension and she herself has high cholesterol and lipid levels. The patient says she smokes one pack of cigarettes daily and drinks "about a pack of beer" every day. The nurse notes what nonmodifiable risk factor for hypertension? A) Hyperlipidemia B) Excessive alcohol intake C) A family history of hypertension D) Closer adherence to medical regimen
Ans: C Feedback: Unlike cholesterol levels, alcohol intake and adherence to treatment, family history is not modifiable.
12. A nurse is admitting a patient with immune thrombocytopenic purpura to the unit. In completing the admission assessment, the nurse must be alert for what medications that potentially alter platelet function? Select all that apply. A) Antihypertensives B) Penicillins C) Sulfa-containing medications D) Aspirin-based drugs E) NSAIDs
Ans: C, D, E
A nurse is admitting a 45-year-old man to the medical unit who has a history of PAD. While providing his health history, the patient reveals that he smokes about two packs of cigarettes a day, has a history of alcohol abuse, and does not exercise. What would be the priority health education for this patient? A) The lack of exercise, which is the main cause of PAD. B) The likelihood that heavy alcohol intake is a significant risk factor for PAD. C) Cigarettes contain nicotine, which is a powerful vasoconstrictor and may cause or aggravate PAD. D) Alcohol suppresses the immune system, creates high glucose levels, and may cause PAD.
Ans: Cigarettes contain nicotine, which is a powerful vasoconstrictor and may cause or aggravate PAD. Feedback: Tobacco is powerful vasoconstrictor; its use with PAD is highly detrimental, and patients are strongly advised to stop using tobacco. Sedentary lifestyle is also a risk factor, but smoking is likely a more significant risk factor that the nurse should address. Alcohol use is less likely to cause PAD, although it carries numerous health risks.
13. A patient, 25 years of age, comes to the emergency department complaining of excessive bleeding from a cut sustained when cleaning a knife. Blood work shows a prolonged PT but a vitamin K deficiency is ruled out. When assessing the patient, areas of ecchymosis are noted on other areas of the body. Which of the following is the most plausible cause of the patient's signs and symptoms? A) Lymphoma B) Leukemia C) Hemophilia D) Hepatic dysfunction
Ans: D
17. An adult patient has been diagnosed with iron-deficiency anemia. What nursing diagnosis is most likely to apply to this patient's health status? A) Risk for deficient fluid volume related to impaired erythropoiesis B) Risk for infection related to tissue hypoxia C) Acute pain related to uncontrolled hemolysis D) Fatigue related to decreased oxygen-carrying capacity
Ans: D
18. A patient has been living with a diagnosis of anemia for several years and has experienced recent declines in her hemoglobin levels despite active treatment. What assessment finding would signal complications of anemia? A) Venous ulcers and visual disturbances B) Fever and signs of hyperkalemia C) Epistaxis and gastroesophageal reflux D) Ascites and peripheral edema
Ans: D
22. A patient is being treated on the medical unit for a sickle cell crisis. The nurse's most recent assessment reveals an oral temperature of 100.5∫F and a new onset of fine crackles on lung auscultation. What is the nurse's most appropriate action? A) Apply supplementary oxygen by nasal cannula. B) Administer bronchodilators by nebulizer. C) Liaise with the respiratory therapist and consider high-flow oxygen. D) Inform the primary care provider that the patient may have an infection.
Ans: D
23. The medical nurse is aware that patients with sickle cell anemia benefit from understanding what situations can precipitate a sickle cell crisis. When teaching a patient with sickle cell anemia about strategies to prevent crises, what measures should the nurse recommend? A) Using prophylactic antibiotics and performing meticulous hygiene B) Maximizing physical activity and taking OTC iron supplements C) Limiting psychosocial stress and eating a high-protein diet D) Avoiding cold temperatures and ensuring sufficient hydration
Ans: D
35. A patient with Von Willebrand disease (vWD) has experienced recent changes in bowel function that suggest the need for a screening colonoscopy. What intervention should be performed in anticipation of this procedure? A) The patient should not undergo the normal bowel cleansing protocol prior to the procedure. B) The patient should receive a unit of fresh-frozen plasma 48 hours before the procedure. C) The patient should be admitted to the surgical unit on the day before the procedure. D) The patient should be given necessary clotting factors before the procedure.
Ans: D
38. An intensive care nurse is aware of the need to identify patients who may be at risk of developing disseminated intravascular coagulation (DIC). Which of the following ICU patients most likely faces the highest risk of DIC? A) A patient with extensive burns B) A patient who has a diagnosis of acute respiratory distress syndrome C) A patient who suffered multiple trauma in a workplace accident D) A patient who is being treated for septic shock
Ans: D
39. A patient is being treated for DIC and the nurse has prioritized the nursing diagnosis of Risk for Deficient Fluid Volume Related to Bleeding. How can the nurse best determine if goals of care relating to this diagnosis are being met? A) Assess for edema. B) Assess skin integrity frequently. C) Assess the patient's level of consciousness frequently. D) Closely monitor intake and output.
Ans: D
40. A patient with a pulmonary embolism is being treated with a heparin infusion. What diagnostic finding suggests to the nurse that treatment is effective? A) The patient's PT is within reference ranges. B) Arterial blood sampling tests positive for the presence of factor XIII. C) The patient's platelet level is below 100,000/mm3. D) The patient's activated partial thromboplastin time (aPTT) is 1.5 to 2.5 times the control value.
Ans: D
8. A patient comes into the clinic complaining of fatigue. Blood work shows an increased bilirubin concentration and an increased reticulocyte count. What would the nurse suspect the patient has? A) A hypoproliferative anemia B) A leukemia C) Thrombocytopenia D) A hemolytic anemia
Ans: D
31. A community health nurse teaching a group of adults about preventing and treating hypertension. The nurse should encourage these participants to collaborate with their primary care providers and regularly monitor which of the following? A) Heart rate B) Sodium levels C) Potassium levels D) Blood lipid levels
Ans: D Feedback: Hypertension often accompanies other risk factors for atherosclerotic heart disease, such as dyslipidemia (abnormal blood fat levels), obesity, diabetes, metabolic syndrome, and a sedentary lifestyle. Individuals with hypertension need to monitor their sodium intake, but hypernatremia is not a risk factor for hypertension. In many patients, heart rate does not correlate closely with BP. Potassium levels do not normally relate to BP.
35. A 55-year-old patient comes to the clinic for a routine check-up. The patient's BP is 159/100 mm Hg and the physician diagnoses hypertension after referring to previous readings. The patient asks why it is important to treat hypertension. What would be the nurse's best response? A) "Hypertension can cause you to develop dangerous blood clots in your legs that can migrate to your lungs." B) "Hypertension puts you at increased risk of type 1 diabetes and cancer in your age group." C) "Hypertension is the leading cause of death in people your age." D) "Hypertension greatly increases your risk of stroke and heart disease."
Ans: D Feedback: Hypertension, particularly elevated systolic BP, increases the risk of death, stroke, and heart failure in people older than 50 years. Hypertension is not a direct precursor to pulmonary emboli, and it does not put older adults at increased risk of type 1 diabetes or cancer. It is not the leading cause of death in people 55 years of age.
4. The staff educator is teaching ED nurses about hypertensive crisis. The nurse educator should explain that hypertensive urgency differs from hypertensive emergency in what way? A) The BP is always higher in a hypertensive emergency. B) Vigilant hemodynamic monitoring is required during treatment of hypertensive emergencies. C) Hypertensive urgency is treated with rest and benzodiazepines to lower BP. D) Hypertensive emergencies are associated with evidence of target organ damage.
Ans: D Feedback: Hypertensive emergencies are acute, life-threatening BP elevations that require prompt treatment in an intensive care setting because of the serious target organ damage that may occur. Blood pressures are extremely elevated in both urgency and emergencies, but there is no evidence of target organ damage in hypertensive urgency. Extremely close hemodynamic monitoring of the patient's BP is required in both situations. The medications of choice in hypertensive emergencies are those with an immediate effect, such as IV vasodilators. Oral doses of fast-acting agents, such as beta-adrenergic blocking agents, angiotensin-converting enzyme inhibitors, or alpha-agonists, are recommended for the treatment of hypertensive urgencies.
26. A patient in hypertensive emergency is being cared for in the ICU. The patient has become hypovolemic secondary to natriuresis. What is the nurse's most appropriate action? A) Add sodium to the patient's IV fluid, as ordered. B) Administer a vasoconstrictor, as ordered. C) Promptly cease antihypertensive therapy. D) Administer normal saline IV, as ordered.
Ans: D Feedback: If there is volume depletion secondary to natriuresis caused by the elevated BP, then volume replacement with normal saline can prevent large, sudden drops in BP when antihypertensive medications are administered. Sodium administration, cessation of antihypertensive therapy, and administration of vasoconstrictors are not normally indicated.
38. A patient in hypertensive urgency is admitted to the hospital. The nurse should be aware of what goal of treatment for a patient in hypertensive urgency? A) Normalizing BP within 2 hours B) Obtaining a BP of less than 110/70 mm Hg within 36 hours C) Obtaining a BP of less than 120/80 mm Hg within 36 hours D) Normalizing BP within 24 to 48 hours
Ans: D Feedback: In cases of hypertensive urgency, oral agents can be administered with the goal of normalizing BP within 24 to 48 hours. For patients with this health problem, a BP of 120/80 mm Hg may be unrealistic.
30. The nurse is screening a number of adults for hypertension. What range of blood pressure is considered normal? A) Less than 140/90 mm Hg B) Less than 130/90 mm Hg C) Less than 129/89 mm Hg D) Less than 120/80 mm Hg
Ans: D Feedback: JNC 7 defines a blood pressure of less than 120/80 mm Hg as normal, 120 to 129/80 to 89 mm Hg as prehypertension, and 140/90 mm Hg or higher as hypertension.
40. A patient's recently elevated BP has prompted the primary care provider to prescribe furosemide (Lasix). The nurse should closely monitor which of the following? A) The client's oxygen saturation level B) The patient's red blood cells, hematocrit, and hemoglobin C) The patient's level of consciousness D) The patient's potassium level
Ans: D Feedback: Loop diuretics can cause potassium depletion. They do not normally affect level of consciousness, erythrocytes, or oxygen saturation.
32. A community health nurse is planning an educational campaign addressing hypertension. The nurse should anticipate that the incidence and prevalence of hypertension are likely to be highest among members of what ethnic group? A) Pacific Islanders B) African Americans C) Asian-Americans D) Hispanics
Ans: D Feedback: The prevalence of uncontrolled hypertension varies by ethnicity, with Hispanics and African Americans having the highest prevalence at approximately 63% and 57%, respectively.
33. The home health nurse is caring for a patient who has a comorbidity of hypertension. What assessment question most directly addresses the possibility of worsening hypertension? A) "Are you eating less salt in your diet?" B) "How is your energy level these days?" C) "Do you ever get chest pain when you exercise?" D) "Do you ever see spots in front of your eyes?"
Ans: D Feedback: To identify complications or worsening hypertension, the patient is questioned about blurred vision, spots in front of the eyes, and diminished visual acuity. The heart, nervous system, and kidneys are also carefully assessed, but angina pain and decreased energy are not normally suggestive of worsening hypertension. Sodium limitation is a beneficial lifestyle modification, but nonadherence to this is not necessarily a sign of worsening symptoms.
21. A patient with newly diagnosed hypertension has come to the clinic for a follow-up visit. The patient asks the nurse why she has to come in so often. What would be the nurse's best response? A) "We do this so you don't suffer a stroke." B) "We do this to determine how your blood pressure changes throughout the day." C) "We do this to see how often you should change your medication dose." D) "We do this to make sure your health is stable. We'll then monitor it at routinely scheduled intervals."
Ans: D Feedback: When hypertension is initially detected, nursing assessment involves carefully monitoring the BP at frequent intervals and then at routinely scheduled intervals. The reference to stroke is frightening and does not capture the overall rationale for the monitoring regimen. Changes throughout the day are not a clinical priority for most patients. The patient must not change his or her medication doses unilaterally.
A nurse in a long-term care facility is caring for an 83-year-old woman who has a history of HF and peripheral arterial disease (PAD). At present the patient is unable to stand or ambulate. The nurse should implement measures to prevent what complication? A) Aoritis B) Deep vein thrombosis C) Thoracic aortic aneurysm D) Raynaud's disease
Ans: Deep vein thrombosis Feedback: Although the exact cause of venous thrombosis remains unclear, three factors, known as Virchow's triad, are believed to play a significant role in its development: stasis of blood (venous stasis), vessel wall injury, and altered blood coagulation. In this woman's case, she has venous stasis from immobility, vessel wall injury from PAD, and altered blood coagulation from HF. The cause of aoritis is unknown, but it has no direct connection to HF, PAD, or mobility issues. The greatest risk factors for thoracic aortic aneurysm are atherosclerosis and hypertension; there is no direct connection to HF, PAD, or mobility issues. Raynaud's disease is a disorder that involves spasms of blood vessels and, again, no direct connection to HF, PAD, or mobility issues.
A patient on the medical unit is receiving a unit of PRBCs. Difficult IV access has necessitated a slow infusion rate and the nurse notes that the infusion began 4 hours ago. What is the nurse's most appropriate action? A) Apply an icepack to the blood that remains to be infused. B) Discontinue the remainder of the PRBC transfusion and inform the physician. C) Disconnect the bag of PRBCs, cool for 30 minutes and then administer. D) Administer the remaining PRBCs by the IV direct (IV push) route.
Ans: Discontinue the remainder of the PRBC transfusion and inform the physician. Feedback: Because of the risk of infection, a PRBC transfusion should not exceed 4 hours. Remaining blood should not be transfused, even if it is cooled. Blood is not administered by the IV direct route.
A patient is receiving the first of two ordered units of PRBCs. Shortly after the initiation of the transfusion, the patient complains of chills and experiences a sharp increase in temperature. What is the nurse's priority action? A) Position the patient in high Fowler's. B) Discontinue the transfusion. C) Auscultate the patient's lungs. D) Obtain a blood specimen from the patient
Ans: Discontinue the transfusion. Feedback: Stopping the transfusion is the first step in any suspected transfusion reaction. This must precede other assessments and interventions, including repositioning, chest auscultation, and collecting specimens.
When assessing venous disease in a patient's lower extremities, the nurse knows that what test will most likely be ordered? A) Duplex ultrasonography B) Echocardiography C) Positron emission tomography (PET) D) Radiography
Ans: Duplex ultrasonography Feedback: Duplex ultrasound may be used to determine the level and extent of venous disease as well as its chronicity. Radiographs (x-rays), PET scanning, and echocardiography are never used for this purpose as they do not allow visualization of blood flow.
The nurse is admitting a 32-year-old woman to the presurgical unit. The nurse learns during the admission assessment that the patient takes oral contraceptives. Consequently, the nurse's postoperative plan of care should include what intervention? A) Early ambulation and leg exercises B) Cessation of the oral contraceptives until 3 weeks postoperative C) Doppler ultrasound of peripheral circulation twice daily D) Dependent positioning of the patient's extremities when at rest
Ans: Early ambulation and leg exercises Feedback: Oral contraceptive use increases blood coagulability; with bed rest, the patient may be at increased risk of developing deep vein thrombosis. Leg exercises and early ambulation are among the interventions that address this risk. Assessment of peripheral circulation is important, but Doppler ultrasound may not be necessary to obtain these data. Dependent positioning increases the risk of venous thromboembolism (VTE). Contraceptives are not normally discontinued to address the risk of VTE in the short term.
The nurse is evaluating a patient's diagnosis of arterial insufficiency with reference to the adequacy of the patient's blood flow. On what physiological variables does adequate blood flow depend? Select all that apply. A) Efficiency of heart as a pump B) Adequacy of circulating blood volume C) Ratio of platelets to red blood cells D) Size of red blood cells E) Patency and responsiveness of the blood vessels
Ans: Efficiency of heart as a pump, Adequacy of circulating blood volume, Patency and responsiveness of the blood vessels Feedback: Adequate blood flow depends on the efficiency of the heart as a pump, the patency and responsiveness of the blood vessels, and the adequacy of circulating blood volume. Adequacy of blood flow does not primarily depend on the size of red cells or their ratio to the number of platelets.
How should the nurse best position a patient who has leg ulcers that are venous in origin? A) Keep the patient's legs flat and straight. B) Keep the patient's knees bent to 45-degree angle and supported with pillows. C) Elevate the patient's lower extremities. D) Dangle the patient's legs over the side of the bed.
Ans: Elevate the patient's lower extremities. Feedback: Positioning of the legs depends on whether the ulcer is of arterial or venous origin. With venous insufficiency, dependent edema can be avoided by elevating the lower extremities. Dangling the patient's legs and applying pillows may further compromise venous return.
A nurse has written a plan of care for a man diagnosed with peripheral arterial insufficiency. One of the nursing diagnoses in the care plan is altered peripheral tissue perfusion related to compromised circulation. What is the most appropriate intervention for this diagnosis? A) Elevate his legs and arms above his heart when resting. B) Encourage the patient to engage in a moderate amount of exercise. C) Encourage extended periods of sitting or standing. D) Discourage walking in order to limit pain.
Ans: Encourage the patient to engage in a moderate amount of exercise. Feedback: The nursing diagnosis of altered peripheral tissue perfusion related to compromised circulation requires interventions that focus on improving circulation. Encouraging the patient to engage in a moderate amount of exercise serves to improve circulation. Elevating his legs and arms above his heart when resting would be passive and fails to promote circulation. Encouraging long periods of sitting or standing would further compromise circulation. The nurse should encourage, not discourage, walking to increase circulation and decrease pain.
A patient with advanced venous insufficiency is confined following orthopedic surgery. How can the nurse best prevent skin breakdown in the patient's lower extremities? A) Ensure that the patient's heels are protected and supported. B) Closely monitor the patient's serum albumin and prealbumin levels. C) Perform gentle massage of the patient's lower legs, as tolerated. D) Perform passive range-of-motion exercises once per shift.
Ans: Ensure that the patient's heels are protected and supported. Feedback: If the patient is on bed rest, it is important to relieve pressure on the heels to prevent pressure ulcerations, since the heels are among the most vulnerable body regions. Monitoring blood work does not directly prevent skin breakdown, even though albumin is related to wound healing. Massage is not normally indicated and may exacerbate skin breakdown. Passive range- of-motion exercises do not directly reduce the risk of skin breakdown.
The nurse is caring for a patient who is admitted to the medical unit for the treatment of a venous ulcer in the area of her lateral malleolus that has been unresponsive to treatment. What is the nurse most likely to find during an assessment of this patient's wound? A) Hemorrhage B) Heavy exudate C) Deep wound bed D) Pale-colored wound bed
Ans: Heavy exudate Feedback: Venous ulcerations in the area of the medial or lateral malleolus (gaiter area) are typically large, superficial, and highly exudative. Venous hypertension causes extravasation of blood, which discolors the area of the wound bed. Bleeding is not normally present.
A nurse at a blood donation clinic has completed the collection of blood from a woman. The woman states that she feels "lightheaded" and she appears visibly pale. What is the nurse's most appropriate action? A) Help her into a sitting position with her head lowered below her knees. B) Administer supplementary oxygen by nasal prongs. C) Obtain a full set of vital signs.
Ans: Help her into a sitting position with her head lowered below her knees. Feedback: A donor who appears pale or complains of faintness should immediately lie down or sit with the head lowered below the knees. He or she should be observed for another 30 minutes. There is no immediate need for a physician's care. Supplementary oxygen may be beneficial, but may take too much time to facilitate before a syncopal episode. Repositioning must precede assessment of vital signs.
The nurse is describing normal RBC physiology to a patient who has a diagnosis of anemia. The nurse should explain that the RBCs consist primarily of which of the following? A) Plasminogen B) Hemoglobin C) Hematocrit D) Fibrin
Ans: Hemoglobin Feedback: Mature erythrocytes consist primarily of hemoglobin, which contains iron and makes up 95% of the cell mass. RBCs are not made of fibrin or plasminogen. Hematocrit is a measure of RBC volume in whole blood.
A patient's electronic health record states that the patient receives regular transfusions of factor IX. The nurse would be justified in suspecting that this patient has what diagnosis? A) Leukemia B) Hemophilia C) Hypoproliferative anemia D) Hodgkin's lymphoma
Ans: Hemophilia Feedback: Administration of clotting factors is used to treat diseases where these factors are absent or insufficient; hemophilia is among the most common of these diseases. Factor IX is not used in the treatment of leukemia, lymphoma, or anemia.
The nurse caring for a patient with a leg ulcer has finished assessing the patient and is developing a problem list prior to writing a plan of care. What major nursing diagnosis might the care plan include? A) Risk for disuse syndrome B) Ineffective health maintenance C) Sedentary lifestyle D) Imbalanced nutrition: less than body requirements
Ans: Imbalanced nutrition: less than body requirements Feedback: Major nursing diagnoses for the patient with leg ulcers may include imbalanced nutrition: less than body requirements, related to increased need for nutrients that promote wound healing. Risk for disuse syndrome is a state in which an individual is at risk for deterioration of body systems owing to prescribed or unavoidable musculoskeletal inactivity. A leg ulcer will affect activity, but rarely to this degree. Leg ulcers are not necessarily a consequence of ineffective health maintenance or sedentary lifestyle.
While assessing a patient the nurse notes that the patient's ankle-brachial index (ABI) of the right leg is 0.40. How should the nurse best respond to this assessment finding? A) Assess the patient's use of over-the-counter dietary supplements. B) Implement interventions relevant to arterial narrowing. C) Encourage the patient to increase intake of foods high in vitamin K. D) Adjust the patient's activity level to accommodate decreased coronary output.
Ans: Implement interventions relevant to arterial narrowing. Feedback: ABI is used to assess the degree of stenosis of peripheral arteries. An ABI of less than 1.0 indicates possible claudication of the peripheral arteries. It does not indicate inadequate coronary output. There is no direct indication for changes in vitamin K intake and OTC medications are not likely causative.
A patient with a hematologic disorder asks the nurse how the body forms blood cells. The nurse should describe a process that takes place where? A) In the spleen B) In the kidneys C) In the bone marrow D) In the liver
Ans: In the bone marrow Feedback: Bone marrow is the primary site for hematopoiesis. The liver and spleen may be involved during embryonic development or when marrow is destroyed. The kidneys release erythropoietin, which stimulates the marrow to increase production of red blood cells (RBCs). However, blood cells are not primarily formed in the spleen, kidneys, or liver.
The nurse educating a patient with anemia is describing the process of RBC production. When the patient's kidneys sense a low level of oxygen in circulating blood, what physiologic response is initiated? A) Increased stem cell synthesis B) Decreased respiratory rate C) Arterial vasoconstriction D) Increased production of erythropoietin
Ans: Increased production of erythropoietin Feedback: If the kidney detects low levels of oxygen, as occurs when fewer red cells are available to bind oxygen (i.e., anemia), erythropoietin levels increase. The body does not compensate with vasoconstriction, decreased respiration, or increased stem cell activity.
You are caring for a patient who is diagnosed with Raynaud's phenomenon. The nurse should plan interventions to address what nursing diagnosis? A) Chronic pain B) Ineffective tissue perfusion C) Impaired skin integrity D) Risk for injury
Ans: Ineffective tissue perfusion Feedback: Raynaud's phenomenon is a form of intermittent arteriolar vasoconstriction resulting in inadequate tissue perfusion. This results in coldness, pain, and pallor of the fingertips or toes. Pain is typically intermittent and acute, not chronic, and skin integrity is rarely at risk. In most cases, the patient is not at a high risk for injury.
A postsurgical patient has illuminated her call light to inform the nurse of a sudden onset of lower leg pain. On inspection, the nurse observes that the patient's left leg is visibly swollen and reddened. What is the nurse's most appropriate action? A) Administer a PRN dose of subcutaneous heparin. B) Inform the physician that the patient has signs and symptoms of VTE. C) Mobilize the patient promptly to dislodge any thrombi in the patient's lower leg. D) Massage the patient's lower leg to temporarily restore venous return.
Ans: Inform the physician that the patient has signs and symptoms of VTE. Feedback: VTE requires prompt medical follow-up. Heparin will not dissolve an established clot. Massaging the patient's leg and mobilizing the patient would be contraindicated because they would dislodge the clot, possibly resulting in a pulmonary embolism.
The nurse is taking a health history of a new patient. The patient reports experiencing pain in his left lower leg and foot when walking. This pain is relieved with rest. The nurse notes that the left lower leg is slightly edematous and is hairless. When planning this patient's subsequent care, the nurse should most likely address what health problem? A) Coronary artery disease (CAD) B) Intermittent claudication C) Arterial embolus D) Raynaud's disease
Ans: Intermittent claudication Feedback: A muscular, cramp-type pain in the extremities consistently reproduced with the same degree of exercise or activity and relieved by rest is experienced by patients with peripheral arterial insufficiency. Referred to as intermittent claudication, this pain is caused by the inability of the arterial system to provide adequate blood flow to the tissues in the face of increased demands for nutrients and oxygen during exercise. The nurse would not suspect the patient has CAD, arterial embolus, or Raynaud's disease; none of these health problems produce this cluster of signs and symptoms.
The nurse is preparing to administer warfarin (Coumadin) to a client with deep vein thrombophlebitis (DVT). Which laboratory value would most clearly indicate that the patient's warfarin is at therapeutic levels? A) Partial thromboplastin time (PTT) within normal reference range B) Prothrombin time (PT) eight to ten times the control C) International normalized ratio (INR) between 2 and 3 D) Hematocrit of 32%
Ans: International normalized ratio (INR) between 2 and 3 Feedback: The INR is most often used to determine if warfarin is at a therapeutic level; an INR of 2 to 3 is considered therapeutic. Warfarin is also considered to be at therapeutic levels when the client's PT is 1.5 to 2 times the control. Higher values indicate increased risk of bleeding and hemorrhage, whereas lower values indicate increased risk of blood clot formation. Heparin, not warfarin, prolongs PTT. Hematocrit does not provide information on the effectiveness of warfarin; however, a falling hematocrit in a client taking warfarin may be a sign of hemorrhage.
A patient has come to the OB/GYN clinic due to recent heavy menstrual flow. Because of the patient's consequent increase in RBC production, the nurse knows that the patient may need to increase her daily intake of what substance? A) Vitamin E B) Vitamin D C) Iron D) Magnesium
Ans: Iron Feedback: To replace blood loss, the rate of red cell production increases. Iron is incorporated into hemoglobin. Vitamins E and D and magnesium do not need to be increased when RBC production is increased.
A patient lives with a diagnosis of sickle cell anemia and receives frequent blood transfusions. The nurse should recognize the patient's consequent risk of what complication of treatment? A) Hypovolemia B) Vitamin B 12 deficiency C) Thrombocytopenia D) Iron overload
Ans: Iron overload Feedback: Patients with chronic transfusion requirements can quickly acquire more iron than they can use, leading to iron overload. These individuals are not at risk for hypovolemia and there is no consequent risk for low platelet or vitamin B12 levels.
Through the process of hematopoiesis, stem cells differentiate into either myeloid or lymphoid stem cells. Into what do myeloid stem cells further differentiate? Select all that apply. A) Leukocytes B) Natural killer cells C) Cytokines D) Platelets E) Erythrocytes
Ans: Leukocytes, Platelets, Erythrocytes Feedback: Myeloid stem cells differentiate into three broad cell types: erythrocytes, leukocytes, and platelets. Natural killer cells and cytokines do not originate as myeloid stem cells.
The nurse is caring for a patient who has developed scar tissue in many of the areas that normally produce blood cells. What organs can become active in blood cell production by the process of extramedullary hematopoiesis? A) Spleen and kidneys B) Kidneys and pancreas C) Pancreas and liver D) Liver and spleen
Ans: Liver and spleen Feedback: In adults with disease that causes marrow destruction, fibrosis, or scarring, the liver and spleen can also resume production of blood cells by a process known as extramedullary hematopoiesis. The kidneys and pancreas do not produce blood cells for the body.
The nurse has performed a thorough nursing assessment of the care of a patient with chronic leg ulcers. The nurse's assessment should include which of the following components? Select all that apply. A) Location and type of pain B) Apical heart rate C) Bilateral comparison of peripheral pulses D) Comparison of temperature in the patient's legs E) Identification of mobility limitations
Ans: Location and type of pain, Bilateral comparison of peripheral pulses, Comparison of temperature in the patient's legs, Identification of mobility limitations Feedback: A careful nursing history and assessment are important. The extent and type of pain are carefully assessed, as are the appearance and temperature of the skin of both legs. The quality of all peripheral pulses is assessed, and the pulses in both legs are compared. Any limitation of mobility and activity that results from vascular insufficiency is identified. Not likely is there any direct indication for assessment of apical heart rate, although peripheral pulses must be assessed.
The nurse is caring for an acutely ill patient who is on anticoagulant therapy. The patient has a comorbidity of renal insufficiency. How will this patient's renal status affect heparin therapy? A) Heparin is contraindicated in the treatment of this patient. B) Heparin may be administered subcutaneously, but not IV. C) Lower doses of heparin are required for this patient. D) Coumadin will be substituted for heparin.
Ans: Lower doses of heparin are required for this patient. Feedback: If renal insufficiency exists, lower doses of heparin are required. Coumadin cannot be safely and effectively used as a substitute and there is no contraindication for IV administration.
A patient comes to the walk-in clinic with complaints of pain in his foot following stepping on a roofing nail 4 days ago. The patient has a visible red streak running up his foot and ankle. What health problem should the nurse suspect? A) Cellulitis B) Local inflammation C) Elephantiasis D) Lymphangitis
Ans: Lymphangitis Feedback: Lymphangitis is an acute inflammation of the lymphatic channels. It arises most commonly from a focus of infection in an extremity. Usually, the infectious organism is hemolytic streptococcus. The characteristic red streaks that extend up the arm or the leg from an infected wound outline the course of the lymphatic vessels as they drain. Cellulitis is caused by bacteria, which cause a generalized edema in the subcutaneous tissues surrounding the affected area. Local inflammation would not present with red streaks in the lymphatic channels. Elephantiasis is transmitted by mosquitoes that carry parasitic worm larvae; the parasites obstruct the lymphatic channels and results in gross enlargement of the limbs.
The nurse is providing care for an older adult who has a hematologic disorder. What age-related change in hematologic function should the nurse integrate into care planning? A) Bone marrow in older adults produces a smaller proportion of healthy, functional blood cells. B) Older adults are less able to increase blood cell production when demand suddenly increases. C) Stem cells in older adults eventually lose their ability to differentiate. D) The ratio of plasma to erythrocytes and lymphocytes increases with age.
Ans: Older adults are less able to increase blood cell production when demand suddenly increases. Feedback: Due to a variety of factors, when an older person needs more blood cells, the bone marrow may not be able to increase production of these cells adequately. Stem cell activity continues throughout the lifespan, although at a somewhat decreased rate. The proportion of functional cells does not greatly decrease and the relative volume of plasma does not change significantly.
A nurse working in a long-term care facility is performing the admission assessment of a newly admitted, 85-year-old resident. During inspection of the resident's feet, the nurse notes that she appears to have early evidence of gangrene on one of her great toes. The nurse knows that gangrene in the elderly is often the first sign of what? A) Chronic venous insufficiency B) Raynaud's phenomenon C) VTE D) PAD
Ans: PAD Feedback: In elderly people, symptoms of PAD may be more pronounced than in younger people. In elderly patients who are inactive, gangrene may be the first sign of disease. Venous insufficiency does not normally manifest with gangrene. Similarly, VTE and Raynaud's phenomenon do not cause the ischemia that underlies gangrene.
A patient has been diagnosed with a lymphoid stem cell defect. This patient has the potential for a problem involving which of the following? A) Plasma cells B) Neutrophils C) Red blood cells D) Platelets
Ans: Plasma cells Feedback: A defect in a myeloid stem cell can cause problems with erythrocyte, leukocyte, and platelet production. In contrast, a defect in the lymphoid stem cell can cause problems with T or B lymphocytes, plasma cells (a more differentiated form of B lymphocyte), or natural killer (NK) cells.
A patient's wound has begun to heal and the blood clot which formed is no longer necessary. When a blood clot is no longer needed, the fibrinogen and fibrin will be digested by which of the following? A) Plasminogen B) Thrombin C) Prothrombin D) Plasmin
Ans: Plasmin Feedback: The substance plasminogen is required to lyse (break down) the fibrin. Plasminogen, which is present in all body fluids, circulates with fibrinogen and is therefore incorporated into the fibrin clot as it forms. When the clot is no longer needed (e.g., after an injured blood vessel has healed), the plasminogen is activated to form plasmin. Plasmin digests the fibrinogen and fibrin. Prothrombin is converted to thrombin, which in turn catalyzes the conversion of fibrinogen to fibrin so a clot can form.
An individual has accidentally cut his hand, immediately initiating the process of hemostasis. Following vasoconstriction, what event in the process of hemostasis will take place? A) Fibrin will be activated at the bleeding site. B) Platelets will aggregate at the injury site. C) Thromboplastin will form a clot. D) Prothrombin will be converted to thrombin.
Ans: Platelets will aggregate at the injury site. Feedback: Following vasoconstriction, circulating platelets aggregate at the site and adhere to the vessel and to one another, forming an unstable hemostatic plug. Events involved in the clotting cascade take place subsequent to this initial platelet action.
A patient undergoing a hip replacement has autologous blood on standby if a transfusion is needed. What is the primary advantage of autologous transfusions? A) Safe transfusion for patients with a history of transfusion reactions B) Prevention of viral infections from another person's blood C) Avoidance of complications in patients with alloantibodies D) Prevention of alloimmunization
Ans: Prevention of viral infections from another person's blood Feedback: The primary advantage of autologous transfusions is the prevention of viral infections from another person's blood. Other secondary advantages include safe transfusion for patients with a history of transfusion reactions, prevention of alloimmunization, and avoidance of complications in patients with alloantibodies.
The nurse is caring for a patient with a large venous leg ulcer. What intervention should the nurse implement to promote healing and prevent infection? A) Provide a high-calorie, high-protein diet. B) Apply a clean occlusive dressing once daily and whenever soiled. C) Irrigate the wound with hydrogen peroxide once daily. D) Apply an antibiotic ointment on the surrounding skin with each dressing change.
Ans: Provide a high-calorie, high-protein diet. Feedback: Wound healing is highly dependent on adequate nutrition. The diet should be sufficiently high in calories and protein. Antibiotic ointments are not normally used on the skin surrounding a leg ulcer and occlusive dressings can exacerbate impaired blood flow. Hydrogen peroxide is not normally used because it can damage granulation tissue.
A patient's diagnosis of atrial fibrillation has prompted the primary care provider to prescribe warfarin (Coumadin), an anticoagulant. When assessing the therapeutic response to this medication, what is the nurse's most appropriate action? A) Assess for signs of myelosuppression. B) Review the patient's platelet level. C) Assess the patient's capillary refill time. D) Review the patient's international normalized ratio (INR).
Ans: Review the patient's international normalized ratio (INR). Feedback: The INR and aPTT serve as useful screening tools for evaluating a patient's clotting ability and to monitor the therapeutic effectiveness of anticoagulant medications. The patient's platelet level is not normally used as a short-term indicator of anticoagulation effectiveness. Assessing the patient for signs of myelosuppression and capillary refill time does not address the effectiveness of anticoagulants.
A patient's most recent blood work reveals low levels of albumin. This assessment finding should suggest the possibility of what nursing diagnosis? A) Risk for imbalanced fluid volume related to low albumin B) Risk for infection related to low albumin C) Ineffective tissue perfusion related to low albumin D) Impaired skin integrity related to low albumin
Ans: Risk for imbalanced fluid volume related to low albumin Feedback: Albumin is particularly important for the maintenance of fluid balance within the vascular system. Deficiencies nearly always manifest as fluid imbalances. Tissue oxygenation and skin integrity are not normally affected. Low albumin does not constitute a risk for infection.
The nurse is caring for a patient who returned from the tropics a few weeks ago and who sought care with signs and symptoms of lymphedema. The nurse's plan of care should prioritize what nursing diagnosis? A) Risk for infection related to lymphedema B) Disturbed body image related to lymphedema C) Ineffective health maintenance related to lymphedema D) Risk for deficient fluid volume related to lymphedema
Ans: Risk for infection related to lymphedema Feedback: Lymphedema, which is caused by accumulation of lymph in the tissues, constitutes a significant risk for infection. The patient's body image is likely to be disturbed, and the nurse should address this, but infection is a more significant threat to the patient's physiological well-being. Lymphedema is unrelated to ineffective health maintenance and deficient fluid volume is not a significant risk.
A nurse is caring for a patient who undergoing preliminary testing for a hematologic disorder. What sign or symptom most likely suggests a potential hematologic disorder? A) Sudden change in level of consciousness (LOC) B) Recurrent infections C) Anaphylaxis D) Severe fatigue
Ans: Severe fatigue Feedback: The most common indicator of hematologic disease is extreme fatigue. This is more common than changes in LOC, infections, or analphylaxis.
A man suffers a leg wound which causes minor blood loss. As a result of bleeding, the process of primary hemostasis is activated. What occurs in primary hemostasis? A) Severed blood vessels constrict. B) Thromboplastin is released. C) Prothrombin is converted to thrombin. D) Fibrin is lysed
Ans: Severed blood vessels constrict. Feedback: Primary hemostasis involves the severed vessel constricting and platelets collecting at the injury site. Secondary hemostasis occurs when thromboplastin is released, prothrombin converts to thrombin, and fibrin is lysed.
Fresh-frozen plasma (FFP) has been ordered for a hospital patient. Prior to administration of this blood product, the nurse should prioritize what patient education? A) Infection risks associated with FFP administration B) Physiologic functions of plasma C) Signs and symptoms of a transfusion reaction D) Strategies for managing transfusion-associated anxiety
Ans: Signs and symptoms of a transfusion reaction Feedback: Patients should be educated about signs and symptoms of transfusion reactions prior to administration of any blood product. In most cases, this is priority over education relating to infection. Anxiety may be an issue for some patients, but transfusion reactions are a possibility for all patients. Teaching about the functions of plasma is not likely a high priority.
The nurse's review of a patient's most recent blood work reveals a significant increase in the number of band cells. The nurse's subsequent assessment should focus on which of the following? A) Respiratory function B) Evidence of decreased tissue perfusion C) Signs and symptoms of infection D) Recent changes in activity tolerance
Ans: Signs and symptoms of infection Feedback: Ordinarily, band cells account for only a small percentage of circulating granulocytes, although their percentage can increase greatly under conditions in which neutrophil production increases, such as infection. This finding is not suggestive of problems with oxygenation and subsequent activity intolerance.
A patient is receiving a blood transfusion and complains of a new onset of slight dyspnea. The nurse's rapid assessment reveals bilateral lung crackles and elevated BP. What is the nurse's most appropriate action? A) Slow the infusion rate and monitor the patient closely. B) Discontinue the transfusion and begin resuscitation. C) Pause the transfusion and administer a 250 mL bolus of normal saline. D) Discontinue the transfusion and administer a beta-blocker, as ordered.
Ans: Slow the infusion rate and monitor the patient closely. Feedback: The patient is showing early signs of hypervolemia; the nurse should slow the infusion rate and assess the patient closely for any signs of exacerbation. At this stage, discontinuing the transfusion is not necessary. A bolus would worsen the patient's fluid overload.
An older adult client is exhibiting many of the characteristic signs and symptoms of iron deficiency. In addition to a complete blood count, what diagnostic assessment should the nurse anticipate? A) Stool for occult blood B) Bone marrow biopsy C) Lumbar puncture D) Urinalysis
Ans: Stool for occult blood Feedback: Iron deficiency in the adult generally indicates blood loss (e.g., from bleeding in the GI tract or heavy menstrual flow). Bleeding in the GI tract can be preliminarily identified by testing stool for the presence of blood. A bone marrow biopsy would not be undertaken for the sole purpose of investigating an iron deficiency. Lumbar puncture and urinalysis would not be clinically relevant.
The nurse caring for a patient receiving a transfusion notes that 15 minutes after the infusion of packed red blood cells (PRBCs) has begun, the patient is having difficulty breathing and complains of severe chest tightness. What is the most appropriate initial action for the nurse to take? A) Notify the patient's physician. B) Stop the transfusion immediately. C) Remove the patient's IV access. D) Assess the patient's chest sounds and vital signs
Ans: Stop the transfusion immediately. Feedback: Vascular collapse, bronchospasm, laryngeal edema, shock, fever, chills, and jugular vein distension are severe reactions. The nurse should discontinue the transfusion immediately, monitor the patient's vital signs, and notify the physician. The blood container and tubing should be sent to the blood bank. A blood and urine specimen may be needed if a transfusion reaction or a bacterial infection is suspected. The patient's IV access should not be removed.
A nurse is closely monitoring a patient who has recently been diagnosed with an abdominal aortic aneurysm. What assessment finding would signal an impending rupture of the patient's aneurysm? A) Sudden increase in blood pressure and a decrease in heart rate B) Cessation of pulsating in an aneurysm that has previously been pulsating visibly C) Sudden onset of severe back or abdominal pain D) New onset of hemoptysis
Ans: Sudden onset of severe back or abdominal pain Feedback: Signs of impending rupture include severe back or abdominal pain, which may be persistent or intermittent. Impending rupture is not typically signaled by increased blood pressure, bradycardia, cessation of pulsing, or hemoptysis.
The nurse is assessing a woman who is pregnant at 27 weeks' gestation. The patient is concerned about the recent emergence of varicose veins on the backs of her calves. What is the nurse's best response? A) Facilitate a referral to a vascular surgeon. B) Assess the patient's ankle-brachial index (ABI) and perform Doppler ultrasound testing. C) Encourage the patient to increase her activity level. D) Teach the patient that circulatory changes during pregnancy frequently cause varicose veins.
Ans: Teach the patient that circulatory changes during pregnancy frequently cause varicose veins. Feedback: Pregnancy may cause varicosities because of hormonal effects related to decreased venous outflow, increased pressure by the gravid uterus, and increased blood volume. In most cases, no intervention or referral is necessary. This finding is not an indication for ABI assessment and increased activity will not likely resolve the problem.
A nurse is reviewing the physiological factors that affect a patient's cardiovascular health and tissue oxygenation. What is the systemic arteriovenous oxygen difference? A) The average amount of oxygen removed by each organ in the body B) The amount of oxygen removed from the blood by the heart C) The amount of oxygen returning to the lungs via the pulmonary artery D) The amount of oxygen in aortic blood minus the amount of oxygen in the vena caval blood
Ans: The amount of oxygen in aortic blood minus the amount of oxygen in the vena caval blood Feedback: The average amount of oxygen removed collectively by all of the body tissues is about 25%. This means that the blood in the vena cava contains about 25% less oxygen than aortic blood. This is known as the systemic arteriovenous oxygen difference. The other answers do not apply.
A patient is being treated in the ICU after a medical error resulted in an acute hemolytic transfusion reaction. What was the etiology of this patient's adverse reaction? A) Antibodies to donor leukocytes remained in the blood. B) The donor blood was incompatible with that of the patient. C) The patient had a sensitivity reaction to a plasma protein in the blood. D) The blood was infused too quickly and overwhelmed the patient's circulatory system
Ans: The donor blood was incompatible with that of the patient. Feedback: An acute hemolytic reaction occurs when the donor blood is incompatible with that of the recipient. In the case of a febrile nonhemolytic reaction, antibodies to donor leukocytes remain in the unit of blood or blood component. An allergic reaction is a sensitivity reaction to a plasma protein within the blood component. Hypervolemia does not cause an acute hemolytic reaction.
Graduated compression stockings have been prescribed to treat a patient's venous insufficiency. What education should the nurse prioritize when introducing this intervention to the patient? A) The need to take anticoagulants concurrent with using compression stockings B) The need to wear the stockings on a "one day on, one day off" schedule C) The importance of wearing the stockings around the clock to ensure maximum benefit D) The importance of ensuring the stockings are applied evenly with no pressure points
Ans: The importance of ensuring the stockings are applied evenly with no pressure points Feedback: Any type of stocking can inadvertently become a tourniquet if applied incorrectly (i.e., rolled tightly at the top). In such instances, the stockings produce rather than prevent stasis. For ambulatory patients, graduated compression stockings are removed at night and reapplied before the legs are lowered from the bed to the floor in the morning. They are used daily, not on alternating days. Anticoagulants are not always indicated in patients who are using compression stockings.
A patient is scheduled for a splenectomy. During discharge education, what teaching point should the nurse prioritize? A) The importance of adhering to prescribed immunosuppressant therapy B) The need to report any signs or symptoms of infection promptly C) The need to ensure adequate folic acid, iron, and vitamin B 12 intake D) The importance of limiting activity postoperatively to prevent hemorrhage
Ans: The need to report any signs or symptoms of infection promptly Feedback: After splenectomy, the patient is instructed to seek prompt medical attention if even relatively minor symptoms of infection occur. Often, patients with high platelet counts have even higher counts after splenectomy, which can predispose them to serious thrombotic or hemorrhagic problems. However, this increase is usually transient and therefore often does not warrant additional treatment. Dietary modifications are not normally necessary and immunosuppressants would be strongly contraindicated.
Which of the following circumstances would most clearly warrant autologous blood donation? A) The patient has type-O blood. B) The patient has sickle cell disease or a thalassemia. C) The patient has elective surgery pending. D) The patient has hepatitis C
Ans: The patient has elective surgery pending. Feedback: Autologous blood donation is useful for many elective surgeries where the potential need for transfusion is high. Type-O blood, hepatitis, sickle cell disease, and thalassemia are not clear indications for autologous donation.
A patient is being treated for the effects of a longstanding vitamin B12 deficiency. What aspect of the patient's health history would most likely predispose her to this deficiency? A) The patient has irregular menstrual periods. B) The patient is a vegan. C) The patient donated blood 60 days ago. D) The patient frequently smokes marijuana
Ans: The patient is a vegan. Feedback: Because vitamin B12 is found only in foods of animal origin, strict vegetarians may ingest little vitamin B12. Irregular menstrual periods, marijuana use, and blood donation would not precipitate a vitamin B12 deficiency.
The nurse's brief review of a patient's electronic health record indicates that the patient regularly undergoes therapeutic phlebotomy. Which of the following rationales for this procedure is most plausible? A) The patient may chronically produce excess red blood cells. B) The patient may frequently experience a low relative plasma volume. C) The patient may have impaired stem cell function. D) The patient may previously have undergone bone marrow biopsy
Ans: The patient may chronically produce excess red blood cells. Feedback: Persistently elevated hematocrit is an indication for therapeutic phlebotomy. It is not used to address excess or deficient plasma volume and is not related to stem cell function. Bone marrow biopsy is not an indication for therapeutic phlebotomy.
The nurse is providing care for a patient who has just been diagnosed with peripheral arterial occlusive disease (PAD). What assessment finding is most consistent with this diagnosis? A) Numbness and tingling in the distal extremities B) Unequal peripheral pulses between extremities C) Visible clubbing of the fingers and toes D) Reddened extremities with muscle atrophy
Ans: Unequal peripheral pulses between extremities Feedback: PAD assessment may manifest as unequal pulses between extremities, with the affected leg cooler and paler than the unaffected leg. Intermittent claudication is far more common than sensations of numbness and tingling. Clubbing and muscle atrophy are not associated with PAD.
A patient presents to the clinic complaining of the inability to grasp objects with her right hand. The patient's right arm is cool and has a difference in blood pressure of more than 20 mm Hg compared with her left arm. The nurse should expect that the primary care provider may diagnose the woman with what health problem? A) Lymphedema B) Raynaud's phenomenon C) Upper extremity arterial occlusive disease D) Upper extremity VTE
Ans: Upper extremity arterial occlusive disease Feedback: The patient with upper extremity arterial occlusive disease typically complains of arm fatigue and pain with exercise (forearm claudication) and inability to hold or grasp objects (e.g., combing hair, placing objects on shelves above the head) and, occasionally, difficulty driving. Assessment findings include coolness and pallor of the affected extremity, decreased capillary refill, and a difference in arm blood pressures of more than 20 mm Hg. These symptoms are not closely associated with Raynaud's or lymphedema. The upper extremities are rare sites for VTE.
A nurse is assessing a new patient who is diagnosed with PAD. The nurse cannot feel the pulse in the patient's left foot. How should the nurse proceed with assessment? A) Have the primary care provider order a CT. B) Apply a tourniquet for 3 to 5 minutes and then reassess. C) Elevate the extremity and attempt to palpate the pulses. D) Use Doppler ultrasound to identify the pulses.
Ans: Use Doppler ultrasound to identify the pulses. Feedback: When pulses cannot be reliably palpated, a hand-held continuous wave (CW) Doppler ultrasound device may be used to hear (insonate) the blood flow in vessels. CT is not normally warranted and the application of a tourniquet poses health risks and will not aid assessment. Elevating the extremity would make palpation more difficult.
An occupational health nurse is providing an educational event and has been asked by an administrative worker about the risk of varicose veins. What should the nurse suggest as a proactive preventative measure for varicose veins? A) Sit with crossed legs for a few minutes each hour to promote relaxation. B) Walk for several minutes every hour to promote circulation. C) Elevate the legs when tired. D) Wear snug-fitting ankle socks to decrease edema.
Ans: Walk for several minutes every hour to promote circulation. Feedback: A proactive approach to preventing varicose veins would be to walk for several minutes every hour to promote circulation. Sitting with crossed legs may promote relaxation, but it is contraindicated for patients with, or at risk for, varicose veins. Elevating the legs only helps blood passively return to the heart and does not help maintain the competency of the valves in the veins. Wearing tight ankle socks is contraindicated for patients with, or at risk for, varicose veins; socks that are below the muscles of the calf do not promote venous return, the socks simply capture the blood and promote venous stasis.
The prevention of VTE is an important part of the nursing care of high-risk patients. When providing patient teaching for these high-risk patients, the nurse should advise lifestyle changes, including which of the following? Select all that apply. A) High-protein diet B) Weight loss C) Regular exercise D) Smoking cessation E) Calcium and vitamin D supplementation
Ans: Weight loss, Regular exercise, Smoking cessation Feedback: Patients at risk for VTE should be advised to make lifestyle changes, as appropriate, which may include weight loss, smoking cessation, and regular exercise. Increased protein intake and supplementation with vitamin D and calcium do not address the main risk factors for VTE.
A patient who is at high risk for developing intracardiac thrombi has been placed on longterm anticoagulation. What aspect of the patient's health history creates a heightened risk of intracardiac thrombi? Atrial fibrillation Infective endocarditis Recurrent pneumonia Recent surgery
Atrial fibrillation*** Infective endocarditis Recurrent pneumonia Recent surgery Feedback: Intracardiac thrombi are especially common in patients with atrial fibrillation, because the atria do not contract forcefully and blood flows slowly and turbulently, increasing the likelihood of thrombus formation. Endocarditis, pneumonia, and recent surgery do not normally cause an increased risk for intracardiac thrombi formation.
The nurse is educating an 80yearold patient diagnosed with HF about his medication regimen. What should the nurse to teach this patient about the use of oral diuretics? Avoid drinking fluids for 2 hours after taking the diuretic. Take the diuretic in the morning to avoid interfering with sleep. Avoid taking the medication within 2 hours consuming dairy products. Take the diuretic only on days when experiencing shortness of breath.
Avoid drinking fluids for 2 hours after taking the diuretic . Take the diuretic in the morning to avoid interfering with sleep.**** Avoid taking the medication within 2 hours consuming dairy products. Take the diuretic only on days when experiencing shortness of breath. Feedback: Oral diuretics should be administered early in the morning so that diuresis does not interfere with the patient's nighttime rest. Discussing the timing of medication administration is especially important for elderly patients who may have urinary urgency or incontinence. The nurse would not teach the patient about the timing of fluid intake. Fluid intake does not need to be adjusted and dairy products are not contraindicated.
21. An older adult patient is undergoing diagnostic testing for chronic lymphocytic leukemia (CLL). What assessment finding is certain to be present if the patient has CLL? A) Increased numbers of blast cells B) Increased lymphocyte levels C) Intractable bone pain D) Thrombocytopenia with no evidence of bleeding
B Feedback: An increased lymphocyte count (lymphocytosis) is always present in patients with CLL. Each of the other listed symptoms may or may not be present, and none is definitive for CLL.
30. A nurse is preparing health education for a patient who has received a diagnosis of myelodysplastic syndrome (MDS). Which of the following topics should the nurse prioritize? A) Techniques for energy conservation and activity management B) Emergency management of bleeding episodes C) Technique for the administration of bronchodilators by metered-dose inhaler D) Techniques for self-palpation of the lymph nodes
B Feedback: Because of patients risks of hemorrhage, patients with MDS should be taught techniques for managing emergent bleeding episodes. Bronchodilators are not indicated for the treatment of MDS and lymphedema is not normally associated with the disease. Energy conservation techniques are likely to be useful, but management of hemorrhage is a priority because of the potential consequences.
15. An adult patient has presented to the health clinic with a complaint of a firm, painless cervical lymph node. The patient denies any recent infectious diseases. What is the nurses most appropriate response to the patients complaint? A) Call 911. B) Promptly refer the patient for medical assessment. C) Facilitate a radiograph of the patients neck and have the results forwarded to the patients primary care provider. D) Encourage the patient to track the size of the lymph node and seek care in 1 week.
B Feedback: Hodgkin lymphoma usually begins as an enlargement of one or more lymph nodes on one side of the neck. The individual nodes are painless and firm but not hard. Prompt medical assessment is necessary if a patient has this presentation. However, there is no acute need to call 911.
6. A nursing student is caring for a patient with acute myeloid leukemia who is preparing to undergo induction therapy. In preparing a plan of care for this patient, the student should assign the highest priority to which nursing diagnoses? A) Activity Intolerance B) Risk for Infection C) Acute Confusion D) Risk for Spiritual Distress
B Feedback: Induction therapy places the patient at risk for infection, thus this is the priority nursing diagnosis. During the time of induction therapy, the patient is very ill, with bacterial, fungal, and occasional viral infections; bleeding and severe mucositis, which causes diarrhea; and marked decline in the ability to maintain adequate nutrition. Supportive care consists of administering blood products and promptly treating infections. Immobility, confusion, and spiritual distress are possible, but infection is the patients most acute physiologic threat.
16. A nurse practitioner is assessing a patient who has a fever, malaise, and a white blood cell count that is elevated. Which of the following principles should guide the nurses management of the patients care? A) There is a need for the patient to be assessed for lymphoma. B) Infection is the most likely cause of the patients change in health status. C) The patient is exhibiting signs and symptoms of leukemia. D) The patient should undergo diagnostic testing for multiple myeloma
B Feedback: Leukocytosis is most often the result of infection. It is only considered pathologic (and suggestive of leukemia) if it is persistent and extreme. Multiple myeloma and lymphoma are not likely causes of this constellation of symptoms.
10. A patient diagnosed with acute myelogenous leukemia has just been admitted to the oncology unit. When writing this patients care plan, what potential complication should the nurse address? A) Pancreatitis B) Hemorrhage C) Arteritis D) Liver dysfunction
B Feedback: Pancreatitis, arteritis, and liver dysfunction are generally not complications of leukemia. However, the patient faces a high risk of hemorrhage.
39. A patient has a diagnosis of multiple myeloma and the nurse is preparing health education in preparation for discharge from the hospital. What action should the nurse promote? A) Daily performance of weight-bearing exercise to prevent muscle atrophy B) Close monitoring of urine output and kidney function C) Daily administration of warfarin (Coumadin) as ordered D) Safe use of supplementary oxygen in the home setting
B Feedback: Renal function must be monitored closely in the patient with multiple myeloma. Excessive weight-bearing can cause pathologic fractures. There is no direct indication for anticoagulation or supplementary oxygen
24. A patient who is undergoing consolidation therapy for the treatment of leukemia has been experiencing debilitating fatigue. How can the nurse best meet this patients needs for physical activity? A) Teach the patient about the risks of immobility and the benefits of exercise. B) Assist the patient to a chair during awake times, as tolerated. C) Collaborate with the physical therapist to arrange for stair exercises. D) Teach the patient to perform deep breathing and coughing exercises
B Feedback: Sitting is a chair is preferable to bed rest, even if a patient is experiencing severe fatigue. A patient who has debilitating fatigue would not likely be able to perform stair exercises. Teaching about mobility may be necessary, but education must be followed by interventions that actually involve mobility. Deep breathing and coughing reduce the risk of respiratory complications but are not substitutes for physical mobility in preventing deconditioning.
36. An adult patients abnormal complete blood count (CBC) and physical assessment have prompted the primary care provider to order a diagnostic workup for Hodgkin lymphoma. The presence of what assessment finding is considered diagnostic of the disease? A) Schwann cells B) Reed-Sternberg cells C) Lewy bodies D) Loops of Henle
B Feedback: The malignant cell of Hodgkin lymphoma is the Reed-Sternberg cell, a gigantic tumor cell that is morphologically unique and thought to be of immature lymphoid origin. It is the pathologic hallmark and essential diagnostic criterion. Schwann cells exist in the peripheral nervous system and Lewy bodies are markers of Parkinson disease. Loops of Henle exist in nephrons.
19. A nurse is caring for a patient who has been diagnosed with leukemia. The nurses most recent assessment reveals the presence of ecchymoseson the patients sacral area and petechiae in her forearms. In addition to informing the patients primary care provider, the nurse should perform what action? A) Initiate measures to prevent venous thromboembolism (VTE). B) Check the patients most recent platelet level. C) Place the patient on protective isolation. D) Ambulate the patient to promote circulatory function.
B Feedback: The patients signs are suggestive of thrombocytopenia, thus the nurse should check the patients most recent platelet level. VTE is not a risk and this does not constitute a need for isolation. Ambulation and activity may be contraindicated due to the risk of bleeding.
A key diagnostic laboratory test for heart failure is the
B-type natriuretic peptide.
A patient with HF has met with his primary care provider and begun treatment with an angiotensinconverting enzyme (ACE) inhibitor. When the patient begins treatment, the nurse should prioritize what assessment? Blood pressure Level of consciousness (LOC) Assessment for nausea Oxygen saturation
Blood pressure**** Level of consciousness (LOC) Assessment for nausea Oxygen saturation Feedback: Patients receiving ACE inhibitors are monitored for hypotension, hyperkalemia (increased potassium in the blood), and alterations in renal function. ACE inhibitors do not typically cause alterations in LOC. Oxygen saturation must be monitored in patients with HF, but this is not particular to ACE inhibitor therapy. ACE inhibitors do not normally cause nausea.
11. An emergency department nurse is triaging a 77-year-old man who presents with uncharacteristic fatigue as well as back and rib pain. The patient denies any recent injuries. The nurse should recognize the need for this patient to be assessed for what health problem? A) Hodgkin disease B) Non-Hodgkin lymphoma C) Multiple myeloma D) Acute thrombocythemia
C Feedback: Back pain, which is often a presenting symptom in multiple myeloma, should be closely investigated in older patients. The lymphomas and bleeding disorders do not typically present with the primary symptom of back pain or rib pain.
29. A patient with a myelodysplastic syndrome is being treated on the medical unit. What assessment finding should prompt the nurse to contact the patients primary care provider? A) The patient is experiencing a frontal lobe headache. B) The patient has an episode of urinary incontinence. C) The patient has an oral temperature of 37.5C (99.5F). D) The patients SpO2 is 91% on room air.
C Feedback: Because the patient with MDS is at a high risk for infection, any early signs of infection must be reported promptly. The nurse should address each of the listed assessment findings, but none is as direct a threat to the patients immediate health as an infection.
4. A nurse is planning the care of a patient who has been admitted to the medical unit with a diagnosis of multiple myeloma. In the patients care plan, the nurse has identified a diagnosis of Risk for Injury. What pathophysiologic effect of multiple myeloma most contributes to this risk? A) Labyrinthitis B) Left ventricular hypertrophy C) Decreased bone density D) Hypercoagulation
C Feedback: Clients with multiple myeloma are at risk for pathologic bone fractures secondary to diffuse osteoporosis and osteolytic lesions. Labyrinthitis is uncharacteristic, and patients do not normally experience hypercoagulation or cardiac hypertrophy.
23. A nurse is caring for a patient who is being treated for leukemia in the hospital. The patient was able to maintain her nutritional status for the first few weeks following her diagnosis but is now exhibiting early signs and symptoms of malnutrition. In collaboration with the dietitian, the nurse should implement what intervention? A) Arrange for total parenteral nutrition (TPN). B) Facilitate placement of a percutaneous endoscopic gastrostomy (PEG) tube. C) Provide the patient with several small, soft-textured meals each day. D) Assign responsibility for the patients nutrition to the patients friends and family.
C Feedback: For patients experiencing difficulties with oral intake, the provision of small, easily chewed meals may be beneficial. This option would be trialed before resorting to tube feeding or TPN. The family should be encouraged to participate in care, but should not be assigned full responsibility.
34. A nurse at a long-term care facility is amending the care plan of a resident who has just been diagnosed with essential thrombocythemia (ET). The nurse should anticipate the administration of what medication? A) Dalteparin B) Allopurinol C) Hydroxyurea D) Hydrochlorothiazide
C Feedback: Hydroxyurea is effective in lowering the platelet count for patients with ET. Dalteparin, allopurinol, and HCTZ do not have this therapeutic effect.
26. After receiving a diagnosis of acute lymphocytic leukemia, a patient is visibly distraught, stating, I have no idea where to go from here. How should the nurse prepare to meet this patients psychosocial needs? A) Assess the patients previous experience with the health care system. B) Reassure the patient that treatment will be challenging but successful. C) Assess the patients specific needs for education and support. D) Identify the patients plan of medical care.
C Feedback: In order to meets the patients needs, the nurse must first identify the specific nature of these needs. According to the nursing process, assessment must precede interventions. The plan of medical care is important, but not central to the provision of support. The patients previous health care is not a primary consideration, and the nurse cannot assure the patient of successful treatment.
5. A patient with advanced leukemia is responding poorly to treatment. The nurse finds the patient tearful and trying to express his feelings, but he is clearly having difficulty. What is the nurses most appropriate action? A) Tell him that you will give him privacy and leave the room. B) Offer to call pastoral care. C) Ask if he would like you to sit with him while he collects his thoughts. D) Tell him that you can understand how hes feeling.
C Feedback: Providing emotional support and discussing the uncertain future are crucial. Leaving is incorrect because leaving the patient doesnt show acceptance of his feelings. Offering to call pastoral care may be helpful for some patients but should be done after the nurse has spent time with the patient. Telling the patient that you understand how hes feeling is inappropriate because it doesnt help him express his feelings.
37. A young adult patient has received the news that her treatment for Hodgkin lymphoma has been deemed successful and that no further treatment is necessary at this time. The care team should ensure that the patient receives regular health assessments in the future due to the risk of what complication? A) Iron-deficiency anemia B) Hemophilia C) Hematologic cancers D) Genitourinary cancers
C Feedback: Survivors of Hodgkin lymphoma have a high risk of second cancers, with hematologic cancers being the most common. There is no consequent risk of anemia or hemophilia, and hematologic cancers are much more common than GU cancers.
7. A 77-year-old male is admitted to a unit with a suspected diagnosis of acute myeloid leukemia (AML). When planning this patients care, the nurse should be aware of what epidemiologic fact? A) Early diagnosis is associated with good outcomes. B) Five-year survival for older adults is approximately 50%. C) Five-year survival for patients over 75 years old is less than 2%. D) Survival rates are wholly dependent on the patients pre-illness level of health.
C Feedback: The 5-year survival rate for patients with AML who are 50 years of age or younger is 43%; it drops to 19% for those between 50 and 64 years, and drops to1.6% for those older than 75 years. Early diagnosis is beneficial, but is nonetheless not associated with good outcomes or high survival rates. Preillness health is significant, but not the most important variable.
38. The clinical nurse educator is presenting health promotion education to a patient who will be treated for non-Hodgkin lymphoma on an outpatient basis. The nurse should recommend which of the following actions? A) Avoiding direct sun exposure in excess of 15 minutes daily B) Avoiding grapefruit juice and fresh grapefruit C) Avoiding highly crowded public places D) Using an electric shaver rather than a razor
C Feedback: The risk of infection is significant for these patients, not only from treatment-related myelosuppression but also from the defective immune response that results from the disease itself. Limiting infection exposure is thus necessary. The need to avoid grapefruit is dependent on the patients medication regimen. Sun exposure and the use of razors are not necessarily contraindicated.
The nurse knows that this angiotensin-converting enzyme inhibitor ordered by the physician has a rapid onset of action within 15 minutes.
Capoten
The triage nurse in the ED is performing a rapid assessment of a man with complaints of severe chest pain and shortness of breath. The patient is diaphoretic, pale, and weak. When the patient collapses, what should the nurse do first? Check for a carotid pulse. Apply supplemental oxygen. Give two full breaths. Gently shake and shout, "Are you OK?"
Check for a carotid pulse. Apply supplemental oxygen. Give two full breaths. Gently shake and shout, "Are you OK?"*** Feedback: Assessing responsiveness is the first step in basic life support. Opening the airway and checking for respirations should occur next. If breathing is absent, two breaths should be given, usually accompanied by supplementary oxygen. Circulation is checked by palpating the carotid artery.
The nurse is caring for an adult patient with HF who is prescribed digoxin. When assessing the patient for adverse effects, the nurse should assess for which of the following signs and symptoms? Confusion and bradycardia Uncontrolled diuresis and tachycardia Numbness and tingling in the extremities Chest pain and shortness of breath
Confusion and bradycardia**** Uncontrolled diuresis and tachycardia Numbness and tingling in the extremities Chest pain and shortness of breath Feedback: A key concern associated with digitalis therapy is digitalis toxicity. Symptoms include anorexia, nausea, visual disturbances, confusion, and bradycardia. The other listed signs and symptoms are not characteristic of digitalis toxicity.
40. A nurse is caring for patient whose diagnosis of multiple myeloma is being treated with bortezomib. The nurse should assess for what adverse effect of this treatment? A) Stomatitis B) Nephropathy C) Cognitive changes D) Peripheral neuropathy
D Feedback: A significant toxicity associated with the use of bortezomib for multiple myeloma is peripheral neuropathy. Stomatitis, cognitive changes, and nephropathy are not noted to be adverse effects of this medication.
17. Diagnostic testing has resulted in a diagnosis of acute myeloid leukemia (AML) in an adult patient who is otherwise healthy. The patient and the care team have collaborated and the patient will soon begin induction therapy. The nurse should prepare the patient for which of the following? A) Daily treatment with targeted therapy medications B) Radiation therapy on a daily basis C) Hematopoietic stem cell transplantation D) An aggressive course of chemotherapy
D Feedback: Attempts are made to achieve remission of AML by the aggressive administration of chemotherapy, called induction therapy, which usually requires hospitalization for several weeks. Induction therapy is not synonymous with radiation, stem cell transplantation, or targeted therapies.
31. A clinic patient is being treated for polycythemia vera and the nurse is providing health education. What practice should the nurse recommend in order to prevent the complications of this health problem? A) Avoiding natural sources of vitamin K B) Avoiding altitudes of 1500 feet (457 meters) C) Performing active range of motion exercises daily D) Avoiding tight and restrictive clothing on the legs
D Feedback: Because of the risk of DVT, patients with polycythemia vera should avoid tight and restrictive clothing. There is no need to avoid foods with vitamin K or to avoid higher altitudes. Activity levels should be maintained, but there is no specific need for ROM exercises.
12. A home health nurse is caring for a patient with multiple myeloma. Which of the following interventions should the nurse prioritize when addressing the patients severe bone pain? A) Implementing distraction techniques B) Educating the patient about the effective use of hot and cold packs C) Teaching the patient to use NSAIDs effectively D) Helping the patient manage the opioid analgesic regimen
D Feedback: For severe pain resulting from multiple myeloma, opioids are likely necessary. NSAIDs would likely be ineffective and are associated with significant adverse effects. Hot and cold packs as well as distraction would be insufficient for severe pain.
8. A 35-year-old male is admitted to the hospital complaining of severe headaches, vomiting, and testicular pain. His blood work shows reduced numbers of platelets, leukocytes, and erythrocytes, with a high proportion of immature cells. The nurse caring for this patient suspects a diagnosis of what? A) AML B) CML C) MDS D) ALL
D Feedback: In acute lymphocytic leukemia (ALL), manifestations of leukemic cell infiltration into other organs are more common than with other forms of leukemia, and include pain from an enlarged liver or spleen, as well as bone pain. The central nervous system is frequently a site for leukemic cells; thus, patients may exhibit headache and vomiting because of meningeal involvement. Other extranodal sites include the testes and breasts. This particular presentation is not closely associated with acute myeloid leukemia (AML), chronic myeloid leukemia (CML), or myelodysplastic syndromes (MDS).
27. A patient has completed the full course of treatment for acute lymphocytic leukemia and has failed to respond appreciably. When preparing for the patients subsequent care, the nurse should perform what action? A) Arrange a meeting between the patients family and the hospital chaplain. B) Assess the factors underlying the patients failure to adhere to the treatment regimen. C) Encourage the patient to vigorously pursue complementary and alternative medicine (CAM). D) Identify the patients specific wishes around end-of-life care.
D Feedback: Should the patient not respond to therapy, it is important to identify and respect the patients choices about treatment, including measures to prolong life and other end-of-life measures. The patient may or may not be open to pursuing CAM. Unsuccessful treatment is not necessarily the result of failure to adhere to the treatment plan. Assessment should precede meetings with a chaplain, which may or may not be beneficial to the patient and congruent with the familys belief system.
32. A clinic nurse is working with a patient who has a long-standing diagnosis of polycythemia vera. How can the nurse best gauge the course of the patients disease? A) Document the color of the patients palms and face during each visit. B) Follow the patients erythrocyte sedimentation rate over time. C) Document the patients response to erythropoietin injections. D) Follow the trends of the patients hematocrit.
D Feedback: The course of polycythemia vera can be best ascertained by monitoring the patients hematocrit, which should remain below 45%. Erythropoietin injections would exacerbate the condition. Skin tone should be observed, but is a subjective assessment finding. The patients ESR is not relevant to the course of the disease.
14. A patient with non-Hodgkins lymphoma is receiving information from the oncology nurse. The patient asks the nurse why she should stop drinking and smoking and stay out of the sun. What would be the nurses best response? A) Everyone should do these things because theyre health promotion activities that apply to everyone. B) You dont want to develop a second cancer, do you? C) You need to do this just to be on the safe side. D) Its important to reduce other factors that increase the risk of second cancers.
D Feedback: The nurse should encourage patients to reduce other factors that increase the risk of developing second cancers, such as use of tobacco and alcohol and exposure to environmental carcinogens and excessive sunlight. The other options do not answer the patients question, and also make light of the patients question.
A patient with a diagnosis of HF is started on a betablocker. What is the nurse's priority role during gradual increases in the patient's dose? Educating the patient that symptom relief may not occur for several weeks Stressing that symptom relief may take up to 4 months to occur Making adjustments to each day's dose based on the blood pressure trends Educating the patient about the potential changes in LOC that may result from the drug
Educating the patient that symptom relief may not occur for several weeks*** Stressing that symptom relief may take up to 4 months to occur Making adjustments to each day's dose based on the blood pressure trends Educating the patient about the potential changes in LOC that may result from the drug Feedback: An important nursing role during titration is educating the patient about the potential worsening of symptoms during the early phase of treatment and stressing that improvement may take several weeks. Relief does not take 4 months, however. The nurse monitors blood pressure, but changes are not made based on shortterm assessment results. Betablockers rarely affect LOC.
The nurse's comprehensive assessment of a patient who has HF includes evaluation of the patient's hepatojugular reflux. What action should the nurse perform during this assessment? Elevate the patient's head to 90 degrees. Press the right upper abdomen. Press above the patient's symphysis pubis. Lay the patient flat in bed.
Elevate the patient's head to 90 degrees. Press the right upper abdomen.***** Press above the patient's symphysis pubis. Lay the patient flat in bed. Feedback: Hepatojugular reflux, a sign of rightsided heart failure, is assessed with the head of the bed at a 45degree angle. As the right upper abdomen (the area over the liver) is compressed for 30 to 40 seconds, the nurse observes the internal jugular vein. If the internal jugular vein becomes distended, a patient has positive hepatojugular reflux.
The triage nurse in the ED is assessing a patient with chronic HF who has presented with worsening symptoms. In reviewing the patient's medical history, what is a potential primary cause of the patient's heart failure? Endocarditis Pleural effusion Atherosclerosis Atrialseptal defect
Endocarditis Pleural effusion Atherosclerosis*** Atrialseptal defect Feedback: Atherosclerosis of the coronary arteries is the primary cause of HF. Pleural effusion, endocarditis, and an atrialseptal defect are not health problems that contribute to the etiology of HF.
The nurse is creating a care plan for a patient diagnosed with HF. When addressing the problem of anxiety, what interventions should the nurse include in the care plan? Select all that apply. Facilitate the presence of friends and family whenever possible. Teach the patient about the harmful effects of anxiety on cardiac function. Provide supplemental oxygen, as needed. Provide validation of the patient's expressions of anxiety. Administer benzodiazepines two to three times daily.
Facilitate the presence of friends and family whenever possible.***** Teach the patient about the harmful effects of anxiety on cardiac function. Provide supplemental oxygen, as needed.*** Provide validation of the patient's expressions of anxiety.***** Administer benzodiazepines two to three times daily. Feedback: The nurse should empathically validate the patient's sensations of anxiety. The presence of friends and family are frequently beneficial and oxygen supplementation promotes comfort. Antianxiety medications may be necessary for some patients, but alternative methods of relief should be prioritized. As well, medications are administered on a PRN basis. Teaching the patient about the potential harms of anxiety is likely to exacerbate, not relieve, the problem.
The nurse is performing an initial assessment of a client diagnosed with HF. The nurse also assesses the patient's sensorium and LOC. Why is the assessment of the patient's sensorium and LOC important in patients with HF? HF ultimately affects oxygen transportation to the brain. Patients with HF are susceptible to overstimulation of the sympathetic nervous system. Decreased LOC causes an exacerbation of the signs and symptoms of HF. The most significant adverse effect of medications used for HF treatment is altered LOC.
HF ultimately affects oxygen transportation to the brain.**** Patients with HF are susceptible to overstimulation of the sympathetic nervous system. Decreased LOC causes an exacerbation of the signs and symptoms of HF. The most significant adverse effect of medications used for HF treatment is altered LOC. Feedback: As the volume of blood ejected by the heart decreases, so does the amount of oxygen transported to the brain. Sympathetic stimulation is not a primary concern in patients with HF, although it is a possibility. HF affects LOC but the reverse is not usually true. Medications used to treat HF carry many adverse effects, but the most common and significant effects are cardiovascular.
On assessment, the nurse knows that a patient who reports no symptoms of heart failure at rest but is symptomatic with increased physical activity would have a heart failure classification of:
II (2)
The nurse is planning the care of a patient with HF. The nurse should identify what overall goals of this patient's care? Improve functional status Prevent endocarditis. Extend survival. Limit physical activity. Relieve patient symptoms.
Improve functional status**** Prevent endocarditis. Extend survival.**** Limit physical activity. Relieve patient symptoms.*** Feedback: The overall goals of management of HF are to relieve the patient's symptoms, to improve functional status and quality of life, and to extend survival. Activity limitations should be accommodated, but reducing activity is not a goal. Endocarditis is not a common complication of HF and preventing it is not a major goal of care.
A patient admitted to the medical unit with HF is exhibiting signs and symptoms of pulmonary edema. The nurse is aware that positioning will promote circulation. How should the nurse best position the patient? In a high Fowler's position On the left sidelying position In a flat, supine position In the Trendelenburg position
In a high Fowler's position**** On the left sidelying position In a flat, supine position In the Trendelenburg position Feedback: Proper positioning can help reduce venous return to the heart. The patient is positioned upright. If the patient is unable to sit with the lower extremities dependent, the patient may be placed in an upright position in bed. The supine position and Trendelenburg positions will not reduce venous return, lower the output of the right ventricle, or decrease lung congestion. Similarly, sidelying does not promote circulation.
The nurse is caring for a patient with severe left ventricular dysfunction who has been identified as being at risk for sudden cardiac death. What medical intervention can be performed that may extend the survival of the patient? Insertion of an implantable cardioverter defibrillator Insertion of an implantable pacemaker Administration of a calcium channel blocker Administration of a betablocker
Insertion of an implantable cardioverter defibrillator** Insertion of an implantable pacemaker Administration of a calcium channel blocker Administration of a betablocker Feedback: In patients with severe left ventricular dysfunction and the possibility of lifethreatening dysrhythmias, placement of an implantable cardioverter defibrillator (ICD) can prevent sudden cardiac death and extend survival. A pacemaker, a calcium channel blocker, and a betablocker are not medical interventions that may extend the survival of the patient with left ventricular dysfunction.
The nurse is caring for an 84yearold man who has just returned from the OR after inguinal hernia repair. The OR report indicates that the patient received large volumes of IV fluids during surgery and the nurse recognizes that the patient is at risk for leftsided heart failure. What signs and symptoms would indicate leftsided heart failure? Jugular vein distention Right upper quadrant pain Bibasilar fine crackles Dependent edema
Jugular vein distention Right upper quadrant pain Bibasilar fine crackles**** Dependent edema Feedback: Bibasilar fine crackles are a sign of alveolar fluid, a sequela of left ventricular fluid, or pressure overload. Jugular vein distention, right upper quadrant pain (hepatomegaly), and dependent edema are caused by rightsided heart failure, usually a chronic condition.
The nurse is providing patient education prior to a patient's discharge home after treatment for HF. The nurse gives the patient a home care checklist as part of the discharge teaching. What should be included on this checklist? Know how to recognize and prevent orthostatic hypotension. Weigh yourself weekly at a consistent time of day. Measure everything you eat and drink until otherwise instructed. Limit physical activity to only those tasks that are absolutely necessary.
Know how to recognize and prevent orthostatic hypotension.**** Weigh yourself weekly at a consistent time of day. Measure everything you eat and drink until otherwise instructed. Limit physical activity to only those tasks that are absolutely necessary. Feedback: Patients with HF should be aware of the risks of orthostatic hypotension. Weight should be measured daily; detailed documentation of all forms of intake is not usually required. Activity should be gradually increased within the parameters of safety and comfort.
A commonly prescribed diuretic that is given intravenously to produce a rapid diuretic effect is
Lasix.
The nurse is caring for a patient who has developed obvious signs of pulmonary edema. What is the priority nursing action? Lay the patient flat. Notify the family of the patient's critical state. Stay with the patient. Update the physician.
Lay the patient flat. Notify the family of the patient's critical state. Stay with the patient.**** Update the physician. Feedback: Because the patient has an unstable condition, the nurse must remain with the patient. The physician must be updated promptly, but the patient should not be left alone in order for this to happen. Supine positioning is unlikely to relieve dyspnea. The family should be informed, but this is not the priority action.
The nurse expects that positive inotropic medications would be administered to treat cardiogenic shock, with the exception of:
Levophed
The nurse is caring for a patient with systolic HF whose previous adverse reactions preclude the safe use of ACE inhibitors. The nurse should anticipate that the prescriber may choose what combination of drugs? Loop diuretic and antiplatelet aggregator Loop diuretic and calcium channel blocker Combination of hydralazine and isosorbide dinitrate Combination of digoxin and normal saline
Loop diuretic and antiplatelet aggregator Loop diuretic and calcium channel blocker Combination of hydralazine and isosorbide dinitrate*** Combination of digoxin and normal saline Feedback: A combination of hydralazine and isosorbide dinitrate may be an alternative for patients who cannot take ACE inhibitors. Antiplatelet aggregators, calcium channel blockers, and normal saline are not typically prescribed.
The nurse is providing discharge education to a patient diagnosed with HF. What should the nurse teach this patient to do to assess her fluid balance in the home setting? Monitor her blood pressure daily Assess her radial pulses daily Monitor her weight daily Monitor her bowel movements
Monitor her blood pressure daily Assess her radial pulses daily Monitor her weight daily*** Monitor her bowel movements Feedback: To assess fluid balance at home, the patient should monitor daily weights at the same time every day. Assessing radial pulses and monitoring the blood pressure may be done, but these measurements do not provide information about fluid balance. Bowel function is not indicative of fluid balance.
Which assessment would be most appropriate for a patient who is receiving a loop diuretic for HF? Monitor liver function studies Monitor for hypotension Assess the patient's vitamin D intake Assess the patient for hyperkalemia
Monitor liver function studies Monitor for hypotension*** Assess the patient's vitamin D intake Assess the patient for hyperkalemia Feedback: Diuretic therapy increases urine output and decreases blood volume, which places the patient at risk of hypotension. Patients are at risk of losing potassium with loop diuretic therapy and need to continue with potassium in their diet; hypokalemia is a consequent risk. Liver function is rarely compromised by diuretic therapy and vitamin D intake is not relevant.
The nurse has entered a patient's room and found the patient unresponsive and not breathing. What is the nurse's next appropriate action? Palpate the patient's carotid pulse. Illuminate the patient's call light. Begin performing chest compressions.
Palpate the patient's carotid pulse. Illuminate the patient's call light. Begin performing chest compressions. Activate the Emergency Response System (ERS).*** Feedback: After checking for responsiveness and breathing, the nurse should activate the ERS. Assessment of carotid pulse should follow and chest compressions may be indicated. Illuminating the call light is an insufficient response.
Cardiopulmonary resuscitation has been initiated on a patient who was found unresponsive. When performing chest compressions, the nurse should do which of the following? Perform at least 100 chest compressions per minute. Pause to allow a colleague to provide a breath every 10 compressions. Pause chest compressions to allow for vital signs monitoring every 4 to 5 minutes. Perform highquality chest compressions as rapidly as possible.
Perform at least 100 chest compressions per minute.*** Pause to allow a colleague to provide a breath every 10 compressions. Pause chest compressions to allow for vital signs monitoring every 4 to 5 minutes. Perform highquality chest compressions as rapidly as possible. Feedback: During CPR, the chest is compressed 2 inches at a rate of at least 100 compressions per minute. This rate is the resuscitator's goal; the aim is not to give compressions as rapidly as possible. Compressions are not stopped after 10 compressions to allow for a breath or for full vital signs monitoring.
The nurse notes that a patient has developed a cough productive for mucoid sputum, is short of breath, has cyanotic hands, and has noisy, moistsounding, rapid breathing. These symptoms and signs are suggestive of what health problem? Pericarditis Cardiomyopathy Pulmonary edema Right ventricular hypertrophy
Pericarditis Cardiomyopathy Pulmonary edema*** Right ventricular hypertrophy Feedback: As a result of decreased cerebral oxygenation, the patient with pulmonary edema becomes increasingly restless and anxious. Along with a sudden onset of breathlessness and a sense of suffocation, the patient's hands become cold and moist, the nail beds become cyanotic (bluish), and the skin turns ashen (gray). The pulse is weak and rapid, and the neck veins are distended. Incessant coughing may occur, producing increasing quantities of foamy sputum. Pericarditis, ventricular hypertrophy, and cardiomyopathy do not involve wet breath sounds or mucus production.
The nurse is caring for a 68yearold patient the nurse suspects has digoxin toxicity. In addition to physical assessment, the nurse should collect what assessment datum? Skin turgor Potassium level White blood cell count Peripheral pulses
Skin turgor Potassium level*** White blood cell count Peripheral pulses Feedback: The serum potassium level is monitored because the effect of digoxin is enhanced in the presence of hypokalemia and digoxin toxicity may occur. Skin turgor, white cell levels, and peripheral pulses are not normally affected in cases of digitalis toxicity.
The critical care nurse is caring for a patient who is in cardiogenic shock. What assessments must the nurse perform on this patient? Select all that apply. Platelet level Fluid status Cardiac rhythm Action of medications Sputum volume
Platelet level Fluid status*** Cardiac rhythm**** Action of medications*** Sputum volume Feedback: The critical care nurse must carefully assess the patient in cardiogenic shock, observe the cardiac rhythm, monitor hemodynamic parameters, monitor fluid status, and adjust medications and therapies based on the assessment data. Platelet levels and sputum production are not major assessment parameters in a patient who is experiencing cardiogenic shock.
The nurse is assessing a patient who is known to have rightsided HF. What assessment finding is most consistent with this patient's diagnosis? Pulmonary edema Distended neck veins Dry cough Orthopnea
Pulmonary edema Distended neck veins*** Dry cough Orthopnea Feedback: Rightsided HF may manifest by distended neck veins, dependent edema, hepatomegaly, weight gain, ascites, anorexia, nausea, nocturia, and weakness. The other answers do not apply.
Diagnostic imaging reveals that the quantity of fluid in a client's pericardial sac is dangerously increased. The nurse should collaborate with the other members of the care team to prevent the development of what complication? Pulmonary edema Pericardiocentesis Cardiac tamponade Pericarditis
Pulmonary edema Pericardiocentesis Cardiac tamponade*** Pericarditis Feedback: An increase in pericardial fluid raises the pressure within the pericardial sac and compresses the heart, eventually causing cardiac tamponade. Pericardiocentesis is the treatment for this complication. Pericarditis and pulmonary edema do not result from this pathophysiological process.
The cardiac monitor alarm alerts the critical care nurse that the patient is showing no cardiac rhythm on the monitor. The nurse's rapid assessment suggests cardiac arrest. In providing cardiac resuscitation documentation, how will the nurse describe this initial absence of cardiac rhythm? Pulseless electrical activity (PEA) Ventricular fibrillation Ventricular tachycardia Asystole
Pulseless electrical activity (PEA) Ventricular fibrillation Ventricular tachycardia Asystole*** Feedback: Cardiac arrest occurs when the heart ceases to produce an effective pulse and circulate blood. It may be caused by a cardiac electrical event such as ventricular fibrillation, ventricular tachycardia, profound bradycardia, or when there is no heart rhythm at all (asystole). Cardiac arrest may also occur when electrical activity is present, but there is ineffective cardiac contraction or circulating volume, which is PEA. Asystole is the only condition that involves the absolute absence of a heart rhythm.
A cardiovascular patient with a previous history of pulmonary embolism (PE) is experiencing a sudden onset of dyspnea, rapid breathing, and chest pain. The nurse recognizes the characteristic signs and symptoms of a PE. What is the nurse's best action? Rapidly assess the patient's cardiopulmonary status. Arrange for an ECG. Increase the height of the patient's bed. Manage the patient's anxiety.
Rapidly assess the patient's cardiopulmonary status.**** Arrange for an ECG. Increase the height of the patient's bed. Manage the patient's anxiety. Feedback: Patient management in the event of a PE begins with cardiopulmonary assessment and intervention. This is a priority over ECG monitoring, management of anxiety, or repositioning of the patient, even though each of these actions may be appropriate and necessary.
A patient presents to the ED complaining of increasing shortness of breath. The nurse assessing the patient notes a history of leftsided HF. The patient is agitated and occasionally coughing up pinktinged, foamy sputum. The nurse should recognize the signs and symptoms of what health problem? Rightsided heart failure Acute pulmonary edema Pneumonia Cardiogenic shock
Rightsided heart failure Acute pulmonary edema**** Pneumonia Cardiogenic shock Feedback: Because of decreased contractility and increased fluid volume and pressure in patients with HF, fluid may be driven from the pulmonary capillary beds into the alveoli, causing pulmonary edema and signs and symptoms described. In rightsided heart failure, the patient exhibits hepatomegaly, jugular vein distention, and peripheral edema. In pneumonia, the patient would have a temperature spike, and sputum that varies in color. Cardiogenic shock would show signs of hypotension and tachycardia.
An older adult patient with HF is being discharged home on an ACE inhibitor and a loop diuretic. The patient's most recent vital signs prior to discharge include oxygen saturation of 93% on room air, heart rate of 81 beats per minute, and blood pressure of 94/59 mm Hg. When planning this patient's subsequent care, what nursing diagnosis should be identified? Risk for ineffective tissue perfusion related to dysrhythmia Risk for fluid volume excess related to medication regimen Risk for ineffective breathing pattern related to hypoxia Risk for falls related to hypotension
Risk for ineffective tissue perfusion related to dysrhythmia Risk for fluid volume excess related to medication regimen Risk for ineffective breathing pattern related to hypoxia Risk for falls related to hypotension***** Feedback: The combination of low BP, diuretic use, and ACE inhibitor use constitute a risk for falls. There is no evidence, or heightened risk, of dysrhythmia. The patient's medications create a risk for fluid deficit, not fluid excess. Hypoxia is a risk for all patients with HF, but this is not in evidence for this patient at this time.
The nurse is reviewing a newly admitted patient's electronic health record, which notes a history of orthopnea? What nursing action is most clearly indicated? Teach the patient deep breathing and coughing exercises. Administer supplemental oxygen at all times. Limit the patient's activity level. Avoid positioning the patient supine.
Teach the patient deep breathing and coughing exercises. Administer supplemental oxygen at all times. Limit the patient's activity level. Avoid positioning the patient supine.**** Feedback: Orthopnea is defined as difficulty breathing while lying flat. This is a possible complication of HF and, consequently, the nurse should avoid positioning the patient supine. Oxygen supplementation may or may not be necessary and activity does not always need to be curtailed. Deep breathing and coughing exercises do not directly address this symptom.
The nurse overseeing care in the ICU reviews the shift report on four patients. The nurse recognizes which patient to be at greatest risk for the development of cardiogenic shock? The patient admitted with acute renal failure The patient admitted following an MI The patient admitted with malignant hypertension The patient admitted following a stroke
The patient admitted with acute renal failure The patient admitted following an MI*** The patient admitted with malignant hypertension The patient admitted following a stroke Feedback: Cardiogenic shock may occur following an MI when a large area of the myocardium becomes ischemic, necrotic, and hypokinetic. It also can occur as a result of endstage heart failure, cardiac tamponade, pulmonary embolism, cardiomyopathy, and dysrhythmias. While patients with acute renal failure are at risk for dysrhythmias and patients experiencing a stroke are at risk for thrombus formation, the patient admitted following an MI is at the greatest risk for development of cardiogenic shock when compared with the other listed diagnoses.
The nurse is assessing an older adult patient with numerous health problems. What assessment datum indicates an increase in the patient's risk for heart failure (HF)? The patient takes Lasix (furosemide) 20 mg/day. The patient's potassium level is 4.7 mEq/L. The patient is an African American man. The patient's age is greater than 65.
The patient takes Lasix (furosemide) 20 mg/day. The patient's potassium level is 4.7 mEq/L. The patient is an African American man. The patient's age is greater than 65.***** Feedback: HF is the most common reason for hospitalization of people older than 65 years of age and is the second most common reason for visits to a physician's office. A potassium level of 4.7 mEq/L is within reference range and does not indicate an increased risk for HF. The fact that the patient takes Lasix 20 mg/day does not indicate an increased risk for HF, although this drug is often used in the treatment of HF. The patient being an African American man does not indicate an increased risk for HF.
The most reliable sign of cardiac arrest is:
absence of a pulse
With pulmonary edema, there is usually an alteration in:
afterload. b. contractility. c. preload.
he diagnosis of heart failure is usually confirmed by:
an echocardiogram
A primary classification of medications used in the treatment of systolic heart failure is:
angiotensin-converting enzyme inhibitors.
Hemodynamic monitoring by means of a multilumen pulmonary artery catheter can provide detailed information about:
assess the involved extremity for color temperature
Nursing measures in hemodynamic monitoring include assessing for localized ischemia caused by inadequate arterial flow. The nurse should:
assess the involved extremity for color temperature. b. check for capillary filling,. evaluate pulse rate.
Classic signs of cardiogenic shock include all of the following except:
bradycardia
The multilumen pulmonary artery catheter allows the nurse to measure hemodynamic pressures at various points in the heart. When the tip enters the small branches of the pulmonary artery, the nurse can assess all of the following measurements except:
central venous pressure (CVP)
The primary cause of heart failure is:
coronary atherosclerosis
The primary underlying disorder of pulmonary edema is:
decreased left ventricular pumping
The treatment for cardiac failure is directed at:
decreasing oxygen needs of the heart. b. increasing the cardiac output by strengthening muscle contraction or decreasing peripheral resistance. c. reducing the amount of circulating blood volume.
Pulmonary edema is characterized by:
elevated left ventricular end-diastolic pressure. b. a rise in pulmonary venous pressure. c. increased hydrostatic pressure.
The most frequent cause for hospitalization for people older than 75 years of age is:
heart failure
The dominant function in cardiac failure is:
inadequate tissue perfusion.
Cardiogenic shock is pump failure that occurs primarily as the result of:
left ventricular damage.
Morphine is given in acute pulmonary edema to redistribute the pulmonary circulation to the periphery by decreasing:
peripheral resistance. b. pulmonary capillary pressure. c. transudation of fluid.
A clinical manifestation of pericardial effusion is:
shortness of breath
ccording to the American College of Cardiology and the American Heart Association, a patient presenting with left ventricular dysfunction without symptoms of heart failure would be classified as:
stage B
A recommended position for a patient in acute pulmonary edema is:
upright with the legs down, to decrease venous return.
