Chapter 31: Nursing Management: Hematologic Problems My Nursing Test Banks

Lewis: Medical-Surgical Nursing, 8th Edition

Chapter 31: Nursing Management: Hematologic Problems

Test Bank

MULTIPLE CHOICE

1. A patient with anemia is experiencing increased fatigue and occasional palpitations at rest. The nurse would expect the patients laboratory findings to include

a.

normal red blood cell (RBC) indices.

b.

a hematocrit (Hct) of 38%.

c.

a hemoglobin (Hb) of 8.6 g/dL (86 g/L).

d.

an RBC count of 4,500,000/mL.

ANS: C

The patients clinical manifestations indicate moderate anemia, which is consistent with an Hb of 6 to 10 g/dL. The other values are all within the range of normal.

DIF: Cognitive Level: Comprehension REF: 662 | 663

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

2. Which menu choice indicates that the patient understands the nurses teaching about best dietary choices for iron-deficiency anemia?

a.

Omelet and whole wheat toast

b.

Cantaloupe and cottage cheese

c.

Strawberry and banana fruit plate

d.

Cornmeal muffin and orange juice

ANS: A

Eggs and whole grain breads are high in iron. The other choices are appropriate for other nutritional deficiencies, but are not the best choice for a patient with iron-deficiency anemia.

DIF: Cognitive Level: Application REF: 666 TOP: Nursing Process: Evaluation

MSC: NCLEX: Physiological Integrity

3. A patient who is receiving methotrexate develops a megaloblastic anemia. The nurse will anticipate teaching the patient about increasing oral intake of

a.

iron.

b.

folic acid.

c.

cobalamin (vitamin B12).

d.

ascorbic acid (vitamin C).

ANS: B

Methotrexate use can lead to folic acid deficiency. Supplementation with oral folic acid supplements is the usual treatment. The other nutrients would not correct folic acid deficiency, although they would be used to treat other types of anemia.

DIF: Cognitive Level: Application REF: 669 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

4. A 52-year-old patient has a new diagnosis of pernicious anemia. After teaching the patient about pernicious anemia, the nurse determines that the patient understands the disorder when the patient states,

a.

I need to start eating more red meat or liver.

b.

I will stop having a glass of wine with dinner.

c.

I will need to take a proton pump inhibitor like omeprazole (Prilosec).

d.

I would rather use the nasal spray than have to get injections of vitamin B12.

ANS: D

Since pernicious anemia prevents the absorption of vitamin B12, this patient requires injections or intranasal administration of cobalamin. Alcohol use does not cause cobalamin deficiency. Proton pump inhibitors decrease the absorption of vitamin B12. Eating more foods rich in vitamin B12 is not helpful because the lack of intrinsic factor prevents absorption of the vitamin.

DIF: Cognitive Level: Application REF: 669 TOP: Nursing Process: Evaluation

MSC: NCLEX: Physiological Integrity

5. A patient is hospitalized for treatment of severe hemolytic anemia. An appropriate nursing action for the patient is to

a.

provide a diet high in vitamin K.

b.

place the patient on protective isolation.

c.

alternate periods of rest and activity.

d.

teach the patient how to avoid injury.

ANS: C

Nursing care for patients with anemia should alternate periods of rest and activity to encourage activity without causing undue fatigue. There is no indication that the patient has a bleeding disorder, so a high vitamin K diet or teaching about how to avoid injury is not needed. Protective isolation might be used for a patient with aplastic anemia, but it is not indicated for hemolytic anemia.

DIF: Cognitive Level: Application REF: 664-665

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

6. After the nurse has finished teaching a patient about taking oral ferrous sulfate, which patient statement indicates that additional instruction is needed?

a.

I will call the doctor if my stools start to turn black.

b.

I will take a stool softener if I feel constipated occasionally.

c.

I should take the iron with orange juice about an hour before eating.

d.

I should increase my fluid and fiber intake while I am taking the iron tablets.

ANS: A

It is normal for the stools to appear black when a patient is taking iron and the patient should not call the doctor about this. The other patient statements are correct.

DIF: Cognitive Level: Application REF: 666-667 TOP: Nursing Process: Evaluation

MSC: NCLEX: Physiological Integrity

7. A patient is admitted to the hospital with idiopathic aplastic anemia. Which of these collaborative problems will the nurse include when developing the care plan?

a.

Potential complication: seizures

b.

Potential complication: infection

c.

Potential complication: neurogenic shock

d.

Potential complication: pulmonary edema

ANS: B

Because the patient with aplastic anemia has pancytopenia, the patient is at risk for infection and bleeding. There is no increased risk for seizures, neurogenic shock, or pulmonary edema.

DIF: Cognitive Level: Application REF: 670-671 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

8. A patient is admitted to the hospital with a sickle cell crisis. While caring for the patient during the crisis, it is important for the nurse to

a.

limit the patients intake of oral and IV fluids.

b.

evaluate the effectiveness of opioid analgesics.

c.

encourage the patient to ambulate as much as tolerated.

d.

teach the patient about high-protein, high-calorie foods.

ANS: B

Pain is the most common clinical manifestation of a crisis and usually requires large doses of continuous opioids for control. Fluid intake should be increased to reduce blood viscosity and improve perfusion. Rest is usually ordered to decrease metabolic requirements. Patients are instructed about the need for dietary folic acid, but high-protein, high-calorie diets are not emphasized.

DIF: Cognitive Level: Application REF: 673-675

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

9. Which statement by a patient with sickle cell anemia indicates good understanding of the nurses teaching about prevention of sickle cell crisis?

a.

Home oxygen therapy is frequently used to decrease sickling.

b.

There are no effective medications that can help prevent sickling.

c.

Routine continuous dosage narcotics are prescribed to prevent a crisis.

d.

Risk for a crisis can be lowered by having an annual influenza vaccination.

ANS: D

Since infection is the most common cause of a sickle cell crisis, influenza, Haemophilus influenzae, pneumococcal pneumonia, and hepatitis immunizations should be administered. Although continuous dose opioids and oxygen may be administered during a crisis, patients do not receive these therapies to prevent crisis. Hydroxyurea (Hydrea) is used for many patients to decrease the number of sickle cell crises.

DIF: Cognitive Level: Application REF: 672 | 674-675

TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

10. When planning discharge teaching for the patient who was admitted with a sickle cell crisis, which instruction will the nurse include?

a.

Limit fluids to 2 to 3 quarts a day.

b.

Take a daily multivitamin with iron.

c.

Avoid exposure to crowds as much as possible.

d.

Drink only one or two caffeinated beverages daily.

ANS: C

Exposure to crowds increases the patients risk for infection, the most common cause of sickle cell crisis. There is no restriction on caffeine use. Iron supplementation is generally not recommended. A high-fluid intake is recommended.

DIF: Cognitive Level: Application REF: 673-675 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

11. During the admission assessment of a patient with hemolytic anemia, the nurse notes jaundice of the sclerae. The nurse will plan to check the laboratory results for

a.

the Schilling test.

b.

the bilirubin level.

c.

the stool occult blood test.

d.

the gastric analysis testing.

ANS: B

Jaundice is caused by the elevation of bilirubin level associated with red blood cell (RBC) hemolysis. The other tests would not be helpful in monitoring or treating a hemolytic anemia.

DIF: Cognitive Level: Application REF: 667 | 672

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

12. A patient who has been receiving a heparin infusion and warfarin (Coumadin) for a deep vein thrombosis (DVT) is diagnosed with heparin-induced thrombocytopenia (HIT). Which action will the nurse include in the plan of care?

a.

Use low-molecular-weight heparin (LMWH) only.

b.

Flush all intermittent IV lines using normal saline.

c.

Administer the warfarin (Coumadin) at the scheduled time.

d.

Teach the patient about the purpose of platelet transfusions.

ANS: B

All heparin is discontinued when the HIT is diagnosed. The patient should be instructed to never receive heparin or LMWH. Warfarin is usually not given until the platelet count has returned to 150,000/l. The platelet count does not drop low enough in HIT for a platelet transfusion, and platelet transfusions increase the risk for thrombosis.

DIF: Cognitive Level: Application REF: 679 | 680-681

TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

13. During treatment of the patient with an acute exacerbation of polycythemia vera, a critical action by the nurse is to

a.

place the patient on bed rest.

b.

administer iron supplements.

c.

avoid use of aspirin products.

d.

monitor fluid intake and output.

ANS: D

Monitoring hydration status is important during an acute exacerbation because the patient is at risk for fluid overload or underhydration. Aspirin therapy is used to decrease risk for thrombosis. The patient should be encouraged to ambulate to prevent deep vein thrombosis (DVT). Iron is contraindicated in patients with polycythemia vera.

DIF: Cognitive Level: Application REF: 677

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

14. Which nursing intervention will be included in the care plan for a patient with immune thrombocytopenic purpura (ITP)?

a.

Assign the patient to a private room.

b.

Avoid intramuscular (IM) injections.

c.

Use rinses rather than a toothbrush for oral care.

d.

Restrict activity to passive and active range of motion.

ANS: B

IM or subcutaneous injections should be avoided because of the risk for bleeding. A soft toothbrush can be used for oral care. There is no need to restrict activity or place the patient in a private room.

DIF: Cognitive Level: Application REF: 682-683 TOP: Nursing Process: Planning

MSC: NCLEX: Safe and Effective Care Environment

15. Which laboratory information will the nurse monitor to detect heparin-induced thrombocytopenia (HIT) in a patient who is receiving a continuous heparin infusion?

a.

Prothrombin time

b.

Erythrocyte count

c.

Fibrinogen degradation products

d.

Activated partial thromboplastin time

ANS: D

Platelet aggregation in HIT causes neutralization of heparin, so that the activated partial thromboplastin time will be shorter and more heparin will be needed to maintain therapeutic levels. The other data will not be affected by HIT.

DIF: Cognitive Level: Application REF: 679

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

16. A patient with type A hemophilia has been admitted to the hospital with severe pain and swelling in the right knee. During the initial care of the patient, the nurse should

a.

immobilize the knee.

b.

apply heat to the joint.

c.

assist the patient with light weight bearing.

d.

perform passive range of motion to the knee.

ANS: A

The initial action should be total rest of the knee to minimize bleeding. Ice packs are used to decrease bleeding. Range of motion (ROM) and weight-bearing exercise are contraindicated initially, but after the bleeding stops, ROM and physical therapy are started.

DIF: Cognitive Level: Application REF: 686

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

17. A patient with von Willebrand disease is admitted to the hospital for minor knee surgery. The nurse will review the coagulation survey to check the

a.

platelet count.

b.

bleeding time.

c.

thrombin time.

d.

prothrombin time.

ANS: B

The bleeding time is affected by von Willebrand disease. Platelet count, prothrombin time, and thrombin time are normal in von Willebrand disease.

DIF: Cognitive Level: Comprehension REF: 685

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

18. A routine complete blood count indicates that a patient may have myelodysplastic syndrome. At this time, the nurse will plan to teach the patient about

a.

packed red blood cells (PRBCs) transfusion.

b.

bone marrow biopsy.

c.

filgrastim (Neupogen) administration.

d.

erythropoietin (Epogen) administration.

ANS: B

Bone marrow biopsy is needed to make the diagnosis and determine the specific type of myelodysplastic syndrome. The other treatments may be necessary if there is progression of the myelodysplastic syndrome, but the initial action for this asymptomatic patient will be a bone marrow biopsy.

DIF: Cognitive Level: Application REF: 692-693 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

19. Which action will be included in the care plan for a hospitalized patient who is neutropenic?

a.

Avoid any IM or subcutaneous injections.

b.

Check the oral temperature every 4 hours.

c.

Omit all fruits or vegetables from the diet.

d.

Place a No Visitors sign on the patient door.

ANS: B

The earliest sign of infection in a neutropenic patient is an elevation in temperature. Although unpeeled fresh fruits and vegetables should be avoided, fruits and vegetables that are peeled or cooked are acceptable. Injections may be required for administration of medications such as filgrastim (Neupogen). The number of visitors may be limited and visitors with communicable diseases should be avoided, but a no visitors policy is not needed.

DIF: Cognitive Level: Application REF: 693 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

20. Which laboratory test will the nurse use to determine whether the prescribed filgrastim (Neupogen) is effective in the treatment of a patient who is receiving chemotherapy for acute lymphocytic leukemia?

a.

Platelet count

b.

Reticulocyte count

c.

Total lymphocyte count

d.

Absolute neutrophil count

ANS: D

Filgrastim increases the neutrophil count and function in neutropenic patients. Although total lymphocyte, platelet, and reticulocyte counts also are important to monitor in this patient, the absolute neutrophil count is used to evaluate the effects of filgrastim.

DIF: Cognitive Level: Application REF: 691-692 TOP: Nursing Process: Evaluation

MSC: NCLEX: Physiological Integrity

21. A 64-year-old with acute myelogenous leukemia (AML) who has induction therapy prescribed asks the nurse whether the planned chemotherapy will be worth undergoing. Which response by the nurse is appropriate?

a.

If you do not want to have chemotherapy, there are other options for treatment such as stem cell transplantation.

b.

The decision about chemotherapy is one that you and the doctor need to make rather than asking what I would do.

c.

You dont need to make a decision about treatment right now since leukemias in adults tend to progress quite slowly.

d.

The side effects of the chemotherapy are difficult, but AML frequently does go into remission with chemotherapy.

ANS: D

This response uses therapeutic communication by addressing the patients question and giving accurate information. The other responses either give inaccurate information or fail to address the patients question, which will discourage the patient from asking the nurse for information.

DIF: Cognitive Level: Application REF: 696 | 697-698

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

22. A patient who has a history of a transfusion-related acute lung injury (TRALI) is to receive a transfusion of packed red blood cells (PRBCs). Which action will the nurse take to decrease the risk for TRALI for this patient?

a.

Infuse the PRBCs slowly over 4 hours.

b.

Transfuse only leukocyte-reduced PRBCs.

c.

Administer the scheduled oral diuretic before the transfusion.

d.

Give the PRN dose of antihistamine before starting the transfusion.

ANS: B

TRALI is caused by a reaction between the donor and the patient leukocytes that causes pulmonary inflammation and capillary leaking. The other actions may help prevent respiratory problems caused by circulatory overload or by allergic reactions, but they will not prevent TRALI.

DIF: Cognitive Level: Application REF: 708

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

23. A 45-year-old patient with acute myelogenous leukemia (AML) is considering the possibility of treatment with a hematopoietic stem cell transplant (HSCT). To assist the patient with treatment decisions, the best approach for the nurse to use is to

a.

emphasize the positive outcomes of a bone marrow transplant.

b.

discuss the need for adequate insurance to cover post-HSCT care.

c.

ask the patient whether there are any questions or concerns about HSCT.

d.

explain that a cure is not possible with any other treatment except HSCT.

ANS: C

Offering the patient an opportunity to ask questions or discuss concerns about HSCT will encourage the patient to voice concerns about this treatment and also will allow the nurse to assess whether the patient needs more information about the procedure. Treatment of AML using chemotherapy is another option for the patient. It is not appropriate for the nurse to ask the patient to consider insurance needs in making this decision.

DIF: Cognitive Level: Application REF: 697

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

24. Which nursing action will be included in the plan of care for a patient admitted with multiple myeloma?

a.

Monitor fluid intake and output.

b.

Administer calcium supplements.

c.

Assess lymph nodes for enlargement.

d.

Limit weight-bearing and ambulation.

ANS: A

A high fluid intake and urine output helps prevent the complications of kidney stones caused by hypercalcemia and renal failure caused by deposition of Bence-Jones protein in the renal tubules. Weight bearing and ambulation are encouraged to help bone retain calcium. Lymph nodes are not enlarged with multiple myeloma. Calcium supplements will further increase the patients calcium level and are not used.

DIF: Cognitive Level: Application REF: 704 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

25. A patient with non-Hodgkins lymphoma develops a platelet count of 18,000/l during chemotherapy. An appropriate nursing intervention for the patient based on this finding is to

a.

provide oral hygiene every 2 hours.

b.

check all stools for occult blood.

c.

check the temperature every 4 hours.

d.

encourage fluids to 3000 mL/day.

ANS: B

Because the patient is at risk for spontaneous bleeding, the nurse should check stools for occult blood. A low platelet count does not require an increased fluid intake. Oral hygiene is important, but it is not necessary to provide oral care every 2 hours. The low platelet count does not increase risk for infection, so frequent temperature monitoring is not indicated.

DIF: Cognitive Level: Application REF: 683

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

26. A 22-year-old with acute myelogenous leukemia who is receiving outpatient chemotherapy develops an absolute neutrophil count of 900/l. Which action by the nurse in the outpatient clinic is most appropriate?

a.

Discuss the need for hospital admission to treat the neutropenia.

b.

Plan to discontinue the chemotherapy until the neutropenia resolves.

c.

Teach the patient how to administer filgrastim (Neupogen) injections at home.

d.

Obtain a high-efficiency particulate air (HEPA) filter for the patient for home use.

ANS: C

The patient may be taught to self-administer filgrastim injections. Although chemotherapy may be stopped with severe neutropenia (neutrophil count less than 500/l), administration of filgrastim usually allows the chemotherapy to continue. Patients with neutropenia are at higher risk for infection when exposed to other patients in the hospital. HEPA filters are expensive and are used in the hospital, where the number of pathogens is much higher than in the patients home environment.

DIF: Cognitive Level: Application REF: 690 | 693

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

27. Which of the following assessment data obtained by the nurse when caring for a patient with thrombocytopenia should be immediately communicated to the health care provider?

a.

The platelet count is 52,000/l.

b.

The patient is difficult to arouse.

c.

There are large bruises on the back.

d.

There are purpura on the oral mucosa.

ANS: B

Difficulty in arousing the patient may indicate a cerebral hemorrhage, which is life threatening and requires immediate action. The other information should be documented and reported, but would not be unusual in a patient with thrombocytopenia.

DIF: Cognitive Level: Application REF: 674

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

28. Which nursing action should the nurse delegate to nursing assistive personnel (NAP) when administering a transfusion of packed red blood cells (PRBCs) to a patient with blood loss?

a.

Verify the patient identification (ID) according to hospital policy.

b.

Obtain the temperature, blood pressure, and pulse before the transfusion.

c.

Double-check the product numbers on the PRBCs with the patient ID band.

d.

Monitor the patient for shortness of breath or chest pain during the transfusion.

ANS: B

NAP education includes measurement of vital signs. The NAP would report the vital signs to the RN. The other actions require more education and a larger scope of practice and should be done by licensed nursing staff members.

DIF: Cognitive Level: Application REF: 705-706 | 707

OBJ: Special Questions: Delegation TOP: Nursing Process: Implementation

MSC: NCLEX: Safe and Effective Care Environment

29. A patient receiving a transfusion of packed red blood cells develops chills, fever, headache, and anxiety 30 minutes after the transfusion is started. After stopping the transfusion, what is the first action that the nurse should take?

a.

Draw blood for a new crossmatch.

b.

Send a urine specimen to the laboratory.

c.

Give the PRN diphenhydramine (Benadryl).

d.

Administer the PRN acetaminophen (Tylenol).

ANS: D

The patients clinical manifestations are consistent with a febrile, nonhemolytic transfusion reaction. The transfusion should be stopped and antipyretics administered for the fever as ordered. A urine specimen is needed if an acute hemolytic reaction is suspected. Diphenhydramine (Benadryl) is used for allergic reactions. This type of reaction does not indicate incorrect crossmatching.

DIF: Cognitive Level: Application REF: 708

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

30. Fifteen minutes after a transfusion of packed red blood cells is started, a patient complains of back pain and dyspnea. The pulse rate is 124. The nurses first action should be to

a.

administer oxygen therapy at a high flow rate.

b.

obtain a urine specimen to send to the laboratory.

c.

notify the health care provider about the symptoms.

d.

disconnect the transfusion and infuse normal saline.

ANS: D

The patients symptoms indicate a possible acute hemolytic reaction caused by the transfusion. The first action should be to disconnect the transfusion and infuse normal saline. The other actions also are needed but are not the highest priority.

DIF: Cognitive Level: Application REF: 708

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

31. Which newly admitted patient should the nurse assign as a roommate for a patient who has aplastic anemia?

a.

A patient with severe heart failure

b.

A patient who has viral pneumonia

c.

A patient who has right leg cellulitis

d.

A patient with multiple abdominal drains

ANS: A

Patients with aplastic anemia are at risk for infection because of the low white blood cell production associated with this type of anemia, so the nurse should avoid assigning a roommate with any possible infectious process.

DIF: Cognitive Level: Application REF: 670-671

OBJ: Special Questions: Multiple Patients

TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment

32. All of the following patients are waiting to be admitted by the emergency department nurse. Which one requires the most rapid assessment and care by the nurse?

a.

The patient with hemochromatosis who is complaining of abdominal pain

b.

The patient with thrombocytopenia who has oozing after having a tooth extracted

c.

The patient with chemotherapy-induced neutropenia who has a temperature of 100.8 F

d.

The patient with a history of sickle cell anemia who has had nausea and diarrhea for 24 hours

ANS: C

A neutropenic patient with a fever is assumed to have an infection and is at risk for rapidly developing sepsis. Rapid assessment, cultures, and initiation of antibiotic therapy are needed. The other patients also require rapid assessment and care but not as urgently as the neutropenic patient.

DIF: Cognitive Level: Analysis REF: 691-692

OBJ: Special Questions: Multiple Patients

TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment

33. The nurse is caring for a patient with immune thrombocytopenic purpura (ITP) who has an order for a platelet transfusion. Which patient information indicates that the nurse should consult with the health care provider before administering platelets?

a.

The platelet count is 42,000/mL.

b.

Blood pressure (BP) is 94/56 mm Hg.

c.

Blood is oozing from the venipuncture site.

d.

Petechiae are present on the chest and back.

ANS: A

Platelet transfusions are not usually indicated until the platelet count is below 10,000 to 20,000/ml unless the patient is actively bleeding, so the nurse should clarify the order with the health care provider before giving the transfusion. The other data all indicate that bleeding caused by ITP may be occurring and indicate that the platelet transfusion is appropriate.

DIF: Cognitive Level: Application REF: 681

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

34. A patient with hemophilia calls the nurse in the hemophilia clinic to discuss all of these problems. Which problem is most important to communicate to the physician?

a.

Skin abrasions

b.

Bleeding gums

c.

Multiple bruises

d.

Dark tarry stools

ANS: D

Melena is a sign of gastrointestinal bleeding and requires collaborative actions such as checking hemoglobin and hematocrit and administration of coagulation factors. The other problems indicate a need for patient teaching about how to avoid injury, but are not indicators of possible serious blood loss.

DIF: Cognitive Level: Application REF: 686

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

35. A patient with septicemia develops prolonged bleeding from venipuncture sites and blood in the stools. Which action is most important for the nurse to take?

a.

Notify the patients physician.

b.

Avoid unnecessary venipunctures.

c.

Apply sterile dressings to the sites.

d.

Give prescribed proton-pump inhibitors.

ANS: A

The patients new onset of bleeding and diagnosis of sepsis suggest that disseminated intravascular coagulation (DIC) may have developed, which will require collaborative actions such as diagnostic testing, blood product administration, and heparin administration. The other actions also are appropriate, but the most important action should be to notify the physician so that DIC treatment can be initiated rapidly.

DIF: Cognitive Level: Application REF: 687-689

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

36. A patient with possible disseminated intravascular coagulation arrives in the emergency department with a blood pressure of 82/40, temperature 102 F (38.9 C), and severe back pain. Which of these physician orders will the nurse implement first?

a.

Administer morphine sulfate 4 mg IV.

b.

Infuse normal saline 500 mL over 30 minutes.

c.

Draw blood for complete blood count and coagulation studies.

d.

Give acetaminophen (Tylenol) 650 mg for temperature 102 F or higher.

ANS: B

The patients blood pressure indicates hypovolemia caused by blood loss and should be addressed immediately to improve perfusion to vital organs. The other actions also are appropriate and should be rapidly implemented, but improving perfusion is the priority for this patient.

DIF: Cognitive Level: Application REF: 688

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

37. Which of the following nursing actions included in the care plan for a patient with neutropenia is appropriate for the RN to delegate to an LPN/LVN who is assisting with patient care?

a.

Assessing the patient for signs and symptoms of infection

b.

Teaching the patient the purpose of neutropenic precautions

c.

Developing a discharge teaching plan for the patient and family

d.

Administering the ordered subcutaneous filgrastim (Neupogen) injection

ANS: D

Administration of medications is included in LPN/LVN education and scope of practice. Patient education, assessment, and developing the plan of care require RN level education and scope of practice.

DIF: Cognitive Level: Application REF: 690

OBJ: Special Questions: Delegation TOP: Nursing Process: Implementation

MSC: NCLEX: Safe and Effective Care Environment

38. All of these patients call the outpatient clinic and ask to make an appointment as soon as possible. Which patient should the nurse schedule to be seen first?

a.

19-year-old with no previous health problems who has a nontender lump in the axilla

b.

46-year-old with sickle cell anemia who says that my eyes always look sort of yellow

c.

21-year-old with hemophilia who wants to learn how to self-administer factor VII replacement

d.

50-year-old with early-stage chronic lymphocytic leukemia who has complaints of chronic fatigue

ANS: A

The patients age and presence of a nontender axillary lump suggest possible lymphoma, which needs rapid diagnosis and treatment. The other patients have questions about treatment or symptoms that are consistent with their diagnosis but do not need to be seen urgently.

DIF: Cognitive Level: Analysis REF: 698-699

OBJ: Special Questions: Multiple Patients

TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment

39. After receiving change-of-shift report for the following four patients with neutropenia, which patient should the nurse assess first?

a.

66-year-old who has white pharyngeal lesions

b.

35-year-old who has a fever of 100.8 F (38.2 C)

c.

56-year-old who has frequent explosive diarrhea

d.

23-year old who is complaining of severe fatigue

ANS: B

Any fever in a neutropenic patient indicates infection and can quickly lead to sepsis and septic shock. Rapid assessment and (if prescribed) initiation of antibiotic therapy within 1 hour are needed. The other patients also need to be assessed but do not exhibit symptoms of potentially life-threatening problems.

DIF: Cognitive Level: Application REF: 690-691

OBJ: Special Questions: Multiple Patients

TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment

Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

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