Chapter 28 My Nursing Test Banks

Wagner, High Acuity Nursing, 6e
Chapter 28

Question 1

Type: MCSA

A patient diagnosed with chronic renal insufficiency has a hemoglobin level of 8.6 mg/dL. The nurse plans care for a patient with which level of anemia?

1. Grade 1 or mild

2. Grade 3 or severe

3. Grade 4 or life threatening

4. Grade 2 or moderate

Correct Answer: 4

Rationale 1: Anemia is considered grade 1 or mild if the hemoglobin level is 10.0 g/dL or higher to normal.

Rationale 2: Anemia is considered grade 3 or severe if the hemoglobin level is between 6.5 and 7.0 g/dL.

Rationale 3: Anemia is considered grade 4 or life threatening if the hemoglobin is less than 6.5 g/dL.

Rationale 4: Anemia is considered grade 2 or moderate if the hemoglobin level is 8.0 to 9.9 g/dL.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 28-1

Question 2

Type: MCMA

A patient with rheumatoid arthritis has a hemoglobin level of 10.0 g/dL. The nurse would consider this anemia to be related to inflammation if which other findings are present?

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

Standard Text: Select all that apply.

1. The patient has low vitamin B12 levels.

2. Laboratory testing shows low hepcidin level.

3. Increased destruction of erythrocytes is occurring.

4. Serum iron levels are low.

5. The patients stools are guaiac positive.

Correct Answer: 2,4

Rationale 1: Low vitamin B12 levels are associated with anemia of decreased red blood cell production.

Rationale 2: Hepcidin is an iron-regulating hormone produced in the liver. Some of the cytokines due to inflammation regulate hepciden, resulting in low levels.

Rationale 3: Anemia caused by increased red blood cell destruction can occur from congenital or acquired problems and is not typically associated with rheumatoid arthritis.

Rationale 4: Anemia of inflammation is associated with low serum iron levels.

Rationale 5: Stools that are positive for blood may indicate blood loss anemia is present.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 28-1

Question 3

Type: MCSA

A patient receiving chemotherapy for cancer is diagnosed with anemia secondary to bone marrow depression. The nurse would expect which intervention?

1. Recombinant erythropoietin therapy

2. Iron supplements

3. Fresh frozen plasma

4. Hematopoietic stem-cell transplantation

Correct Answer: 1

Rationale 1: Recombinant erythropoietin therapy, such as Procrit or Epogen, has been used for some time for treatment of blood loss anemia seen in some cancers.

Rationale 2: Iron supplementation is not likely to be effective in reversing this anemia.

Rationale 3: Fresh frozen plasma may help to expand volume, but will not improve oxygen carrying capacity.

Rationale 4: Hematopoietic stem-cell transplantation is the definitive treatment for aplastic anemia, but is not indicated during chemotherapy.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 28-1

Question 4

Type: MCSA

A patient with sickle cell disease tells the nurse that she knows when the disease is going to flare because she has pain in her arms and legs. Which explanation would the nurse provide?

1. The shape of your blood cells blocks the small capillaries in your arms and legs.

2. The pain is really due to your history of malaria along with having sickle cell anemia.

3. Your spleen is destroying all the malformed red blood cells which makes you anemic and causes arm and leg pain.

4. The chronic blood loss associated with sickle cell anemia causes pain in the arms and legs.

Correct Answer: 1

Rationale 1: In sickle cell disease, the red blood cell membrane is stiffer and cells are misshapen which slows down or obstructs blood flow in the small capillaries. This can lead to microvascular occlusion leading to pain in the arms and legs as well as other body areas.

Rationale 2: Having a history of malaria is related to disease development as a genetic adaptation.

Rationale 3: The spleen does destroy the malformed red blood cells but this does not cause pain in the arms and legs.

Rationale 4: Blood loss is not typically seen in sickle cell disease.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 28-2

Question 5

Type: MCMA

The nurse is planning to instruct a patient with sickle cell disease on ways to avoid a painful crisis. What should the nurse include in this instruction?

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

Standard Text: Select all that apply.

1. Do not drink alcohol.

2. Eat a diet low in protein.

3. Avoid tiring exercise.

4. Avoid carbohydrates.

5. Do not smoke.

Correct Answer: 3,5

Rationale 1: Alcohol ingestion is not implicated in development of a painful crisis.

Rationale 2: Dietary changes do not impact the onset of a painful crisis.

Rationale 3: Excessive exercise can result in painful crisis.

Rationale 4: Dietary changes do not impact the onset of a painful crisis.

Rationale 5: Smoking is associated with vessel constriction and development of painful crisis.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 28-2

Question 6

Type: MCSA

A 25-year-old patient with sickle cell disease says, My sister is having a baby. I cant wait until I have kids of my own. Which nursing response is indicated?

1. You should use barrier protection until you are ready to have a child.

2. Have you thought about adopting children?

3. Genetic counseling will be important for you and your partner.

4. I hope that infertility does not cause problems for you.

Correct Answer: 3

Rationale 1: This is not the best information to provide in this situation.

Rationale 2: This is not the best topic for the nurse to introduce.

Rationale 3: A patient with sickle cell disease has inherited the trait from both parents which means that it can be genetically transmitted to any children. The patient should receive information about genetic counseling.

Rationale 4: There is no evidence to suggest the patient needs information about infertility.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 28-2

Question 7

Type: MCMA

A patient is admitted with the tentative diagnosis of polycythemia vera. Which assessment findings would the nurse evaluate as supporting that diagnosis?

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

Standard Text: Select all that apply.

1. Plethora

2. Fingers that are dark and cool to touch

3. Report of night sweats

4. Complaint of shortness of breath

5. Hypotension

Correct Answer: 1,2,3

Rationale 1: Plethora, or a ruddy coloration, is caused by the presence of red blood cells in superficial tissues.

Rationale 2: Dark coloration and coolness to touch is a manifestation of the chronic tissue hypoxia seen in polycythemia.

Rationale 3: Night sweats are a finding associated with polycythemia.

Rationale 4: Shortness of breath is not a common complaint in polycythemia.

Rationale 5: Hypertension is more commonly seen in polycythemia.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 28-3

Question 8

Type: MCSA

A patient with a 40-pack-year smoking history has increased hemoglobin and hematocrit. The nurse expects that which test will be done to assess for erythrocytosis?

1. Serum electrolytes

2. Sedimentation rate

3. Platelet count

4. Carboxyhemoglobin level

Correct Answer: 4

Rationale 1: Serum electrolytes will not aid in the diagnosis of erythrocytosis.

Rationale 2: Results of sedimentation rate testing will not help to diagnose erythrocytosis.

Rationale 3: Platelet count will not aid in the diagnosis of erythrocytosis.

Rationale 4: A carboxyhemoglobin level may be drawn if smoking-related polycythemia or erythrocytosis is suspected.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 28-3

Question 9

Type: MCSA

The nurse is providing care for a patient diagnosed with secondary polycythemia. Which finding is most significant for the nurse to discuss with the primary health care provider immediately?

1. The patient becomes short of breath on exertion.

2. The patient has had no appetite for the last two days.

3. The patient is confused.

4. The patients fingers are red and warm to touch.

Correct Answer: 3

Rationale 1: Shortness of breath on exertion is not associated with major complications of polycythemia. If the patient was experiencing a pulmonary embolism, the shortness of breath would be constant.

Rationale 2: Loss of appetite is not associated with polycythemia.

Rationale 3: Confusion could be caused by transient ischemic attack which is a complication of polycythemia.

Rationale 4: Polycythemia results in a reddened color and warm skin.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 28-3

Question 10

Type: MCSA

The nurse is providing care for a young woman diagnosed with idiopathic thrombocytopenia. Which information should the nurse provide?

1. Take a low-dose aspirin daily.

2. Use pads during menstrual cycle instead of tampons.

3. Brush and floss teeth carefully.

4. Use glycerin suppositories to prevent constipation.

Correct Answer: 2

Rationale 1: Aspirin is contraindicated when idiopathic thrombocytopenia is diagnosed.

Rationale 2: Tampon use is contraindicated when the patient is at risk for bleeding.

Rationale 3: Patients diagnosed with idiopathic thrombocytopenia should use toothettes for oral care.

Rationale 4: Suppository use is contraindicated in this patient.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 28-4

Question 11

Type: MCSA

A patient being treated for thrombocytopenia is not responding to therapy. The nurse would begin to prepare the patient for which medical intervention?

1. Intravenous fluids

2. Bone marrow transplant

3. Splenectomy

4. Blood transfusion

Correct Answer: 3

Rationale 1: The patient will most likely already be receiving intravenous fluids as a part of cardiovascular fluid volume support.

Rationale 2: Bone marrow transplant is not included as a course of treatment for a patient with thrombocytopenia.

Rationale 3: Treatment for thrombocytopenia includes steroids, immune anti-D antibody infusion, and intravenous immune globulin. If unresponsive to therapy, a splenectomy is indicated.

Rationale 4: Blood transfusions are not included as a course of treatment for a patient with thrombocytopenia.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 28-4

Question 12

Type: MCSA

A critically ill patient who is being mechanically ventilated was started on an antibiotic, a steroid, and intravenous heparin one week ago. This morning the nurse notes the patient has red rashlike eruptions across his abdomen and chest. What nursing action is indicated?

1. Notify the primary care provider immediately.

2. Monitor the rash to see if it spreads.

3. Apply a nonpetroleumbased lotion over the affected area.

4. Hold the antibiotic.

Correct Answer: 1

Rationale 1: This rash may indicate the development of heparin-induced thrombocytopenia. The nurse should collaborate with the primary care provider immediately.

Rationale 2: The rash may spread, but monitoring is not the best intervention.

Rationale 3: It is not likely that lotion will be effective in treating this rash.

Rationale 4: It is not likely that this rash is related to an antibiotic that was started a week ago.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 28-4

Question 13

Type: MCSA

A critically ill patient is diagnosed with disseminated intravascular coagulation. Which history would the nurse evaluate as indicating increased risk for this development?

1. The patient had a transfusion reaction yesterday.

2. The patient was intubated and placed on mechanical ventilation 2 days ago.

3. The patient has a long history of hypertension.

4. The patient passed a kidney stone this morning.

Correct Answer: 1

Rationale 1: Transfusion reaction is a risk factor for development of DIC.

Rationale 2: Intubation and mechanical ventilation are not risk factors for DIC.

Rationale 3: Hypertension is not associated with development of DIC.

Rationale 4: Renal calculi are not a risk factor for development of DIC.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 28-5

Question 14

Type: MCSA

A patient has developed disseminated intravascular coagulation. Which assessment would the nurse evaluate as reflecting the microthrombosis results of this disorder?

1. Oozing from older intravenous access sites

2. Jaundice

3. Petechiae

4. Ecchymoses

Correct Answer: 2

Rationale 1: Oozing from old puncture sites is a bleeding-related finding of DIC.

Rationale 2: Clinical manifestations of disseminated intravascular coagulation related to microthrombosis include oliguria, anuria, hematuria, and jaundice.

Rationale 3: Petechiae result from bleeding in the skin.

Rationale 4: Ecchymoses results from bleeding into the skin.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 28-5

Question 15

Type: MCSA

The nurse is caring for a patient with disseminated intravascular coagulation who is bleeding from the gastrointestinal tract with a platelet count of 45,000. The nurse would anticipate which intervention for this patient?

1. Heparin

2. Intravenous platelets

3. Warfarin

4. Aspirin

Correct Answer: 2

Rationale 1: Heparin is beneficial when disseminated intravascular coagulation is secondary to metastatic carcinoma, dead fetus syndrome, and aortic aneurysm.

Rationale 2: Thrombocytopenia may be treated with the administration of concentrated platelets if the patient is actively bleeding or has a platelet count of less than 50,000.

Rationale 3: Warfarin is not indicated for use in DIC.

Rationale 4: Aspirin is not indicated in the treatment of this disorder.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 28-5

Question 16

Type: MCMA

A patient arrives at the emergency department following a gunshot wound to the abdomen. He is unresponsive and has cool, clammy skin. Paramedics were unable to initiate a peripheral IV and the patients abdominal wound is bleeding briskly. The nurse bases emergency interventions on which priority nursing diagnoses?

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

Standard Text: Select all that apply.

1. Decreased Cardiac Output

2. Fluid Volume Deficit

3. Risk for Shock

4. Ineffective Breathing Pattern

5. Altered Tissue Perfusion: Cerebral

Correct Answer: 1,2,3,5

Rationale 1: Blood loss has decreased this patients cardiac output as evidenced by cool and clammy skin.

Rationale 2: Due to the loss of blood through a briskly bleeding abdominal wound, the patient has fluid volume deficit. Decreased consciousness and cool, clammy skin are evidence of this diagnosis.

Rationale 3: The patient is at risk for hypovolemic shock due to the nature of this wound.

Rationale 4: There is no evidence presented that supports this nursing diagnosis. The patient may still be breathing at an acceptable rate and depth.

Rationale 5: Lack of responsiveness may indicate poor perfusion to the brain. Since the patient is losing blood rapidly the nurse would act to support cerebral perfusion.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 28-6

Question 17

Type: MCSA

A patient with thrombocytopenia has developed a nose bleed. She is confused and keeps trying to get out of bed. Which nursing diagnosis is appropriate for this situation?

1. Activity Intolerance

2. Altered Comfort: Pain

3. Ineffective Individual Coping

4. Altered Tissue Perfusion

Correct Answer: 4

Rationale 1: There is no evidence that this patient is not tolerating activity.

Rationale 2: There is no information in this scenario to support the diagnosis of pain.

Rationale 3: The confusion and behaviors described in this scenario are not associated with coping dysfunction.

Rationale 4: The confusion noted in this scenario is an indicator that cerebral tissues are not being well perfused. Low platelets have resulted in a nose bleed and the patient may be bleeding occultly as well.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 28-6

Question 18

Type: MCMA

The nurse is making a follow-up call to a patient recently released from the acute care unit following treatment for thrombocytopenia. Which patient statements would the nurse consider reason to suggest contacting the primary health provider?

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

Standard Text: Select all that apply.

1. You didnt tell me that I would have such bad, smelly diarrhea once I got home.

2. I feel fine but my skin is a little off color.

3. My appetite is coming back slowly.

4. I was able to take a walk with my dog yesterday.

5. I keep getting headaches in the late afternoon if I am tired.

Correct Answer: 1,2,5

Rationale 1: Diarrhea, particularly diarrhea with a very bad smell, may indicate gastrointestinal bleeding. This finding requires further assessment.

Rationale 2: Skin condition can reveal information about health. This comment may indicate the patient has jaundice, petechiae, or other findings associated with bleeding. This finding requires further assessment.

Rationale 3: Return to pre-illness appetite may take time, so this is a positive statement.

Rationale 4: This statement reveals activity tolerance and a desire for activity which indicate positive recovery.

Rationale 5: Headaches should be investigated further as they may indicate bleeding disorders.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 28-6

Question 19

Type: MCSA

A patient has been admitted with a tentative diagnosis of thrombocytopenia. Which patient statement would the nurse evaluate as significant to that disorder?

1. I started taking cimetidine for heartburn about a month ago.

2. My family and I just got back from a vacation in the mountains.

3. I spend a lot of time working at my computer.

4. I have been taking a new calcium supplement.

Correct Answer: 1

Rationale 1: Cimetidine can be associated with thrombocytopenia.

Rationale 2: Change of altitude is not associated with development of thrombocytopenia.

Rationale 3: Computer work and sedentary work are not associated with development of thrombocytopenia.

Rationale 4: Calcium supplements are not associated with thrombocytopenia.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 28-4

Question 20

Type: MCSA

A patient has been brought to the emergency department after a traumatic amputation of his leg. His skin is pale and very cool, heart rate is 120, respirations are 28, and systolic blood pressure is dropping. From these findings the nurse would estimate that this patient has lost which percent of blood?

1. Less than 15%

2. 1530%

3. 3040%

4. Over 40%

Correct Answer: 3

Rationale 1: With blood loss of less than 15% the patients blood pressure would be stable and respirations would be stable.

Rationale 2: The patient would be cool and clammy. Heart rate elevation would be milder and systolic blood pressure would be stable.

Rationale 3: Once the patient has lost 3040% of blood, they become severely cool and pale. Heart rate is markedly increased and systolic blood pressure begins to fall. Respiratory rate is also markedly increased.

Rationale 4: A patient who has lost over 40% of blood volume will be severely cold, pale, and mottled. Heart rate will be very high or may drop, systolic blood pressure will be low, and respiratory rate will start to drop.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 28-1

Wagner, High Acuity Nursing, 6/E Test Bank

Copyright 2014 by Pearson Education, Inc.

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