Chapter 27 My Nursing Test Banks

Wagner, High Acuity Nursing, 6e
Chapter 27

Question 1

Type: MCSA

A patient was admitted through the emergency department with fractures of the skull, ribs, and both femurs sustained from a motor vehicle accident. The nurse provides care based upon changes in which pathophysiological process?

1. Formation of red blood cells

2. Cellular and humoral immune responses

3. Formation of plasma

4. Antigenantibody formation

Correct Answer: 1

Rationale 1: Blood cells are formed in the bone marrow which exists within all bones. Because the patient sustained fractures to the skull, ribs, and both femurs, red blood cell formation will be impacted.

Rationale 2: Cellular and humoral immune responses occur in secondary lymphoid organs such as the tonsils, adenoids, lymph nodes, and spleen. This patients injuries are not focused in these areas.

Rationale 3: Plasma is a clear fluid that remains once all of the blood cells are removed. Formation of plasma should not be affected by these injuries.

Rationale 4: Antigenantibody response is what occurs when an infectious organism is introduced into the body. The ability to mount this response will continue despite these injuries.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 27-1

Question 2

Type: MCSA

A patient diagnosed with leukemia has minimal white blood cells. The nurse realizes which intervention may be indicated for this patient?

1. Infusion of fresh frozen plasma

2. Infusion of red blood cells

3. Bone marrow transplant

4. Immunizations

Correct Answer: 3

Rationale 1: Infusion of fresh frozen plasma would expand intravascular volume but would not add white blood cells.

Rationale 2: There is no indication that this patient needs additional red blood cells.

Rationale 3: Blood cells include red cells, white cells, and platelets. All three of these elements of blood are created in the bone marrow. The patient with low white blood cells would benefit from a bone marrow transplant since each of these types of cells originates from a stem cell.

Rationale 4: Individuals with low white blood cell counts usually do not receive immunizations.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 27-1

Question 3

Type: MCSA

A patient is admitted with left lower thoracic rib injuries. The nurse realizes this injury could result in which problem for this patient?

1. Decrease in platelet maturation

2. Decreased availability of B cells

3. Reduction in T cell formation

4. Reduction in filtering of foreign matter in the blood

Correct Answer: 2

Rationale 1: Platelet maturation does not occur in this area.

Rationale 2: The spleen sits behind the 9th, 10th, and 11th left ribs and serves three functions: destroy injured or worn out red blood cells, store extra blood for use by the body, and store B cells. With an injury to the left lower thoracic rib area, the patient could have an injury to the spleen.

Rationale 3: There is a possibility of splenic injury. Splenic injuries do not cause a reduction in T cell formation.

Rationale 4: Lymph tissue is where the blood is filtered of foreign matter.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 27-1

Question 4

Type: MCSA

A patient is diagnosed with a low red blood cell count. The nurse should assess this patient for which finding?

1. History of fractures

2. Carbohydrate intake

3. Location of joint replacements

4. Renal functioning

Correct Answer: 4

Rationale 1: A history of fractures will not impact the patients current red blood cell formation.

Rationale 2: Production of red blood cells requires certain levels of adequate nutrients which include protein, multivitamins, and nutrients. The patients carbohydrate intake will not affect red blood cell production.

Rationale 3: Even though red blood cells do originate in the marrow of the ribs, sternum, and femur, joint replacements will most likely not impact red blood cell formation.

Rationale 4: Red blood cells arise from the myeloid cell line in the red bone marrow and mature in the blood or spleen. Erythrocyte production is tightly regulated by erythropoietin, a circulating hormone that is primarily produced by the kidneys. It is believed that erythropoietin may be produced in the renal tubular cells, which are major consumers of oxygen that are particularly sensitive to lowering oxygen levels. In a patient with a low red blood cell count, the patients renal function should be further assessed.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 27-2

Question 5

Type: MCSA

A patient is admitted with iron deficiency anemia. The nurse assesses this patient for the presence of which most likely finding?

1. Hypoxia

2. Reduced urine output

3. Bleeding

4. Dehydration

Correct Answer: 1

Rationale 1: Each red blood cell contains hemoglobin. Hemoglobin has two parts: the heme portion that contains oxygen and iron and the globin part which is a protein. The oxygen will adhere to the portion of the hemoglobin with the iron molecule. In the event of iron deficiency anemia, the patient has reduced iron molecules which means less oxygen molecules will be available for body use. Because of this, the patient will most likely demonstrate signs of hypoxia.

Rationale 2: Iron deficiency anemia is not related to reduced urine output.

Rationale 3: Iron deficiency anemia will not result in bleeding.

Rationale 4: Iron deficiency anemia has not been linked to dehydration.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 27-2

Question 6

Type: MCSA

A patient is prescribed vitamin B12 injections. What information should the nurse provide when starting this medication?

1. Vitamin B12 will strengthen the red blood cells membranes and prevent them from being damaged so easily.

2. Vitamin B12 is needed for normal manufacture of red blood cells.

3. Vitamin B12 will increase the ability of your blood to carry oxygen.

4. Vitamin B12 helps build the components of white blood cells.

Correct Answer: 2

Rationale 1: Iron and copper strengthen the plasma membrane.

Rationale 2: Vitamin B12 is one vitamin needed for normal red blood cell synthesis, development of DNA and RNA, and cell maturation.

Rationale 3: Iron increases the oxygen-carrying capacity of the blood.

Rationale 4: Vitamin B12 does not impact white blood cell synthesis.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 27-2

Question 7

Type: MCSA

A patient is concerned that the disease that has affected his horses will cause him to become ill. What information should the nurse provide?

1. You will probably contract the same illness but in a milder form.

2. Many illnesses are species specific and it is not likely that you will contract the same illness as your horses.

3. All illnesses can be transmitted between animals and humans, so I am glad you came in to be checked.

4. There are vaccinations against diseases caused by horses. I would talk with the veterinarian.

Correct Answer: 2

Rationale 1: There is no way of knowing if the patient will contract the same illness as the horses or if the illness will be in a milder form.

Rationale 2: Innate immunity is species specific which means that human beings are immune to a variety of diseases to which certain animals are susceptible, and vice versa. The nurse should explain this concept to the patient.

Rationale 3: All illnesses cannot be transmitted between animals and humans.

Rationale 4: It is unknown if there is a vaccine to provide immunity against diseases caused by horses.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 27-3

Question 8

Type: MCSA

A patient is admitted with a leg wound with a large amount of pus exudate. The nurse assesses that which part of the immune process is functioning?

1. The complement system causing cellular destruction

2. The natural killer lymphocytes circulating through the lymph

3. The neutrophils arriving at the wound as the first line of defense

4. The macrophages circulating in the blood

Correct Answer: 3

Rationale 1: The complement system is an immune mechanism that resembles the blood coagulation cascade by progressing through several sequential stages, each contributing to the immune response and resulting in cellular destruction or cytolysis. Activation of the complement system does not result in pus formation.

Rationale 2: Natural killer lymphocytes protect the body from pathologic cells such as microbes and cancer cells through cytolytic activities and secretion of cytokines. They do not produce pus.

Rationale 3: Neutrophils are responsible for the formation of pus. As they die, the neutrophil-degrading enzymes are released, causing breakdown and liquefaction of local cells as well as foreign substances. This forms pus, a thin liquid residue that is an important indicator of inflammation.

Rationale 4: Mobile macrophages circulate in the blood supply and migrate out of the vessels into the tissues when required through the process of chemotaxis. They do not produce pus.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 27-3

Question 9

Type: MCSA

The nurse caring for a patient with an infected leg wound realizes that neutrophils and macrophages will arrive to the wound as a part of the natural body response. How would the nurse explain this process to the patient?

1. Your white blood cells will travel through your lymph system to the wound.

2. Chemical signals from the injured tissue help guide the white blood cells to where they are needed.

3. Only the white blood cells already in your system will be able to fight this infection.

4. The white blood cells attach to red blood cells for transport to the wound.

Correct Answer: 2

Rationale 1: The white blood cells do not travel through the lymph system.

Rationale 2: Circulating neutrophils and monocytes have to arrive where they are needed and then they must be able to transfer from the blood vessels to the site of injury. After the leukocyte is outside the capillary, it requires guidance to move to the correct location. This is accomplished through chemotaxis, which refers to movement as a result of some type of chemical stimulus.

Rationale 3: Infection stimulates the production of additional white blood cells.

Rationale 4: White blood cells are independent of red blood cells.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 27-3

Question 10

Type: MCMA

A patient tells the nurse that he thought he had a varicella vaccine as a child. His daughter has just developed varicella. What information should the nurse provide?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Since you were vaccinated you wont contract varicella from your daughter.

2. Your innate immunity will protect you from contracting this disease.

3. It is dangerous to give a second injection of vaccines.

4. You may need an injection to boost your immunity.

5. We can check your blood titer to check your immunity.

Correct Answer: 4,5

Rationale 1: Vaccinations do not always provide life-long immunity.

Rationale 2: The immunity that this patient may have against varicella is not innate immunity.

Rationale 3: There is no indication that a second injection of vaccines is dangerous if it is needed.

Rationale 4: In some cases, there is need for a second injection.

Rationale 5: Antibody titers can be compared to pre-established norms to see if repeated immunizations are necessary.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 27-4

Question 11

Type: MCSA

The mother of a young child tells the nurse that when she was breastfeeding her baby, he never had any colds or infections but now that he is weaned, he seems to be sick all of the time. What should the nurse explain to the mother?

1. The breast milk provided passive immunity to the baby that he no longer is receiving.

2. The child should be immunized to prevent these common illnesses.

3. Some children are just prone to getting more infections than others.

4. Most babies wont get sick until they are past the age of 12 months.

Correct Answer: 1

Rationale 1: Passive immunity is a temporary immunity involving the transfer of antibodies from one individual to another or from some other source to an individual. An infant receives passive immunity both in utero and from breast milk.

Rationale 2: There are no immunizations against many of these common illnesses.

Rationale 3: This information is not accurate and should not be provided to the mother

Rationale 4: This information is not accurate and should not be provided to the mother.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 24-4

Question 12

Type: MCSA

A patient is scheduled to have his tonsils removed. The nurse realizes that this procedure could result in deficiency of which immunoglobulin?

1. Immunoglobulin D

2. Immunoglobulin A

3. Immunoglobulin E

4. Immunoglobulin G

Correct Answer: 2

Rationale 1: Immunoglobulin D is a trace antibody found primarily in the blood.

Rationale 2: Immunoglobulin A protects mucous membranes from invading organisms and is found in the tonsils.

Rationale 3: Immunoglobulin E plays a role in the allergic response and is extremely powerful even though it is present in the body in very small quantities.

Rationale 4: Immunoglobulin G is the chief immunoglobulin and is produced on a secondary exposure to an antigen.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 27-4

Question 13

Type: MCSA

A patient is being evaluated for a kidney transplant. Which individual is most likely the best candidate to donate this organ?

1. A live donor from a donor bank

2. Live kidney transplant from the patients spouse

3. Cadaver kidney transplant

4. Live kidney transplant from a brother

Correct Answer: 4

Rationale 1: A person willing to donate a kidney, but who is unrelated to the recipient, is not likely to be a match.

Rationale 2: A spouse may or may not be a match for this donation.

Rationale 3: Cadaver kidneys may or may not match the donor.

Rationale 4: Because full siblings share the same biological parents, they often have some degree of human leukocyte antigen matching. The closer the human leukocyte antigen combination matches between two people, the more the fingerprint is recognized as self.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 27-5

Question 14

Type: MCMA

A man with assessment findings associated with prostate cancer is having the tumor-associated antigen PSA drawn. The nurse anticipates this level will be used for which purposes?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. To confirm the diagnosis of prostate cancer

2. To rule out the presence of prostate cancer

3. To screen for the probability of prostate cancer

4. To assess efficacy of treatment

5. To determine presence of metastasis

Correct Answer: 3,4

Rationale 1: PSA levels are not diagnostic of prostate cancer.

Rationale 2: Even if the level of PSA is low, it does not rule out prostate cancer.

Rationale 3: PSA is best used as a screening tool. If levels are high, additional assessment should be done. If levels are low, but other findings indicate strong suspicion of prostate cancer, additional assessment should be done.

Rationale 4: Monitoring PSA levels after treatment for prostate cancer has begun can help to monitor the effects of treatment.

Rationale 5: PSA does not help to identify metastasis.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 27-5

Question 15

Type: MCSA

A patient being admitted for knee surgery says, Everyone in my office is sick all of the time, but I never get sick. How would the nurse evaluate this statement?

1. The patient may have a strong antigenantibody response.

2. This patients poorly differentiated histocompatibility antigens may be a problem during postoperative recovery.

3. The patients coworkers must have immune system compromise.

4. The patient must have strong passive immunity.

Correct Answer: 1

Rationale 1: Normally, an antibody circulates in the bloodstream until it encounters an appropriate antigen to bind. This binding results in antigenantibody complexes, or immune complexes. The process of binding is such that the antibody binds to specifically conformed antigenic determinant sites on the antigen, which prevents the antigen from binding to receptors on host cells. The outcome is the host is protected from an infection.

Rationale 2: Histocompatibility antigens are surface antigens which are genetically determined and are proteins found on the surface of a cell. These antigens would not impact the patients inability to get colds or other illnesses, nor would they cause complications postoperatively.

Rationale 3: Immune system compromise does result in frequent illnesses, but there is not enough information for the nurse to make this determination.

Rationale 4: Passive immunity is a temporary immunity involving the transfer of antibodies from one individual to another or from some other source to an individual. Passive immunity can be transferred also through vaccination either of antiserum, an antitoxin, or as gamma globulin.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 27-5

Question 16

Type: MCMA

A patients admission laboratory work reveals a platelet count of 90,000/mcL. Which interventions should the nurse implement?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Implement bleeding precautions.

2. Monitor urine output.

3. Limit the ingestion of green leafy vegetables.

4. Restrict fluids.

5. Review the patients medication history.

Correct Answer: 1,5

Rationale 1: Platelets play a crucial role in hemostasis or blood clotting. Since the normal platelet count in an adult is 150,000 to 400,000/mcL, a count of 90,000/mcL means the patient is prone to bleeding. Bleeding precautions should be implemented for this patient.

Rationale 2: There is no evidence that monitoring urine output is an essential part of this patients care.

Rationale 3: Green leafy vegetables contain vitamin K which is needed by the liver to form coagulation factors. Since these factors are needed for the coagulation cascade, vitamin K should not be limited in this patient.

Rationale 4: There is no evidence to suggest that fluids should be restricted for this patient.

Rationale 5: Medications can be implicated in low platelet counts, so reviewing medication history is indicated.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 27-6

Question 17

Type: MCSA

A wound on a patients leg has stopped bleeding. The nurse would attribute this to which physiologic occurrence?

1. Tumor necrosis factor has sealed the wound.

2. Neutrophils have invaded the wound.

3. Macrophages have been released into the general circulation.

4. Platelets retracted the clot, reducing leakage.

Correct Answer: 4

Rationale 1: Tumor necrosis factor will not seal a wound.

Rationale 2: Neutrophils do not impact the amount of bleeding from a wound.

Rationale 3: Macrophages in the general circulation do not impact the amount of bleeding from a wound.

Rationale 4: Shortly after bleeding has stopped and the clot has formed, it retracts, drawing the torn vessel walls into closer proximity, reducing leakage. Clot retraction is largely a function of platelets.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 27-6

Question 18

Type: MCMA

A patient suffered severe trunk and lower extremity injury in a motor vehicle accident. Which injuries would indicate to the nurse that this patient may have dysfunction of normal hemostasis?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Contusion of the spleen

2. Laceration of the liver

3. Femur fractures

4. Bruising of the heart

5. Pneumothorax

Correct Answer: 1,2,3

Rationale 1: The spleen provides storage for platelets. If the spleen is damaged and unable to hold or release platelets, normal hemostasis will be disrupted.

Rationale 2: The liver produces most of the clotting factors so injury would affect normal hemostasis.

Rationale 3: The marrow of long bones support blood cell development. This patient may have disruption of all three cell lines.

Rationale 4: Bruising of the heart should not affect hemostasis.

Rationale 5: Pneumothorax should not affect hemostasis.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 27-6

Question 19

Type: MCMA

A patient is being treated for anemia after a postpartum hemorrhage. The nurse would expect that this patients erythrocytes would have which appearance?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Microcytic

2. Normochromic

3. Macrocytic

4. Hypochromic

5. Normocytic

Correct Answer: 2,5

Rationale 1: Blood loss would not result in change in the size of the RBCs.

Rationale 2: Since the RBCs are lost, not changed due to a physiological problem, they will have a normal color.

Rationale 3: There is no reason for these RBCs to be bigger than normal.

Rationale 4: The cells should not appear hypochromic.

Rationale 5: The RBCs should be of normal size.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 27-7

Question 20

Type: MCSA

The patient has developed a shift to the left. The nurse would expect which value on the complete blood count?

1. Increased bands

2. Increased eosinophils

3. Decreased lymphocytes

4. Increased monocytes

Correct Answer: 1

Rationale 1: When an infection exists and the body needs neutrophils, the production is increased, but many immature cells or bands are released. This release results in a shift to the left.

Rationale 2: Eosinophils are not involved in the shift to the left.

Rationale 3: A decrease in lymphocytes is not reported as a shift.

Rationale 4: An increase in monocytes is not reported as a shift.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 27-7

Wagner, High Acuity Nursing, 6/E Test Bank

Copyright 2014 by Pearson Education, Inc.

Leave a Reply