Chapter 56 My Nursing Test Banks

Osborn, Medical-Surgical Nursing, 2e
Chapter 56

Question 1

Type: MCSA

Which statement would the nurse manager of a hematology clinic evaluate as indicating that a newly employed nurse understands the process of thrombopoiesis?

1. Thrombopoiesis is a response to extrinsic factors that initiates the clotting cascade.

2. Thrombopoiesis is the process that mitigates blood loss due to injury to any blood vessel.

3. Thrombopoiesis is the development of three blood cell lines.

4. Thrombopoiesis is platelet development from hematopoietic stem cells to fully mature platelets.

Correct Answer: 4

Rationale 1: Thrombopoiesis does not describe the initiation of the clotting cascade.

Rationale 2: The process that mitigates blood loss due to injury to any blood vessel is called hemostasis.

Rationale 3: Hematopoiesis refers to blood cell development.

Rationale 4: Thrombopoiesis refers to platelet development, one component of blood cell development.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 56-1

Question 2

Type: MCMA

The nurse is providing discharge instructions to a patient who has a clotting disorder. Which instructions should the nurse reinforce?

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

Standard Text: Select all that apply.

1. Brush teeth only once per day.

2. Avoid drinking carbonated beverages.

3. Monitor skin condition.

4. Shave with an electric razor.

5. Assess the color of stools with each bowel movement.

Correct Answer: 3,4,5

Rationale 1: The number of times teeth are brushed is irrelevant and does not precipitate bleeding.

Rationale 2: There is no indication that carbonated beverages should be avoided.

Rationale 3: The patient should be taught to assess the skin for signs of bleeding such as petechiae and ecchymoses.

Rationale 4: The patient with a bleeding disorder should use an electric razor to prevent accidental injury.

Rationale 5: The patient with a clotting disorder should be taught to assess stools for color and presence of blood.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 56-5

Question 3

Type: MCMA

A patient is admitted with a diagnosis of generalized anemia. The nurse would conduct assessment for which types of associated

disorders?

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

Standard Text: Select all that apply.

1. Disorders that cause defective oxygenation in the lungs

2. Disorders that result in disruption in erythrocyte volume

3. Disorders that include airway obstruction as a major manifestation

4. Disorders that cause erythrocyte destruction

5. Disorders characterized by abnormal absorption of vitamin C

Correct Answer: 2,4

Rationale 1: Defective oxygenation in the lungs does not result in anemia but may result in overproduction of erythrocytes.

Rationale 2: A reduced erythrocyte volume results in anemic hypoxia or reduced oxygen availability to the tissues, specifically due to decreased concentration of functional hemoglobin or a reduced number of red blood cells.

Rationale 3: Airway obstruction disorders do not cause anemia.

Rationale 4: Disorders in which red blood cells are destroyed lead to anemia.

Rationale 5: Abnormal absorption of vitamin C is not related to anemia.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 56-3

Question 4

Type: MCMA

A patient is admitted with thrombocytopenia. Which assessment findings would the nurse expect?

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

Standard Text: Select all that apply.

1. Increased platelet count

2. Rashlike discoloration of the skin

3. Mucosal bleeding

4. Positive fecal occult test

5. A tendency to bleed after any invasive procedure

Correct Answer: 2,3,4,5

Rationale 1: Thrombocytopenia results from a decrease in the number of circulating platelets.

Rationale 2: Skin discoloration is caused by bleeding into the tissues, an effect of decreased platelets.

Rationale 3: Thrombocytopenia is defined as a decrease in the number of circulating platelets caused by impaired or suppressed production of platelets or accelerated destruction of platelets. This results in a clotting failure and the tendency to bleed when tissue is aggravated.

Rationale 4: Patients with thrombocytopenia may have gastrointestinal bleeding that results in positive fecal occult tests.

Rationale 5: Thrombocytopenia is defined as a decrease in the number of circulating platelets caused by impaired or suppressed production of platelets or accelerated destruction of platelets. This results in a clotting failure and the tendency to bleed.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 56-4

Question 5

Type: MCSA

A patient is admitted with immune thrombocytopenia purpura (ITP). How would the nurse explain the etiology of this disorder?

1. You are producing antibodies against your own platelets.

2. This is a disorder caused by an overproduction of neutrophils.

3. You are having a reaction to heparin therapy.

4. This disorder is caused by an overproduction of reticulocytes.

Correct Answer: 1

Rationale 1: Immune thrombocytopenic purpura (ITP) is an autoimmune disease marked by a decrease in the number of platelets due to destruction by antibodies produced against the patients own platelets.

Rationale 2: An overproduction of white blood cells, such as neutrophils, does not result in ITP.

Rationale 3: A reaction to heparin therapy is referred to as heparin-induced thrombocytopenia. ITP has a different etiology.

Rationale 4: An overproduction of reticulocytes, immature red blood cells, does not result in ITP.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 56-5

Question 6

Type: MCMA

A patient is being discharged after treatment for thrombocytopenia. Which topics should the nurse consider when developing discharge instructions?

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

Standard Text: Select all that apply.

1. Ensuring safety in the home environment

2. Recognizing the signs of cutaneous bleeding

3. Alerting the community pharmacist about the patients condition

4. Reducing alcohol consumption and increasing thiazide medications

5. Developing a plan for physical exercise

Correct Answer: 1,2,3,5

Rationale 1: The home environment should be free from safety hazards that may cause falls or other types of physical injury.

Rationale 2: The patient should be taught to monitor the skin for bruising, petechiae, and purpura.

Rationale 3: Medicationsprescription or over-the-countermay contribute to bleeding problems. The patients pharmacist should be made aware of the diagnosis.

Rationale 4: Alcohol has a marrow-depressing effect, leading to transient thrombocytopenia; its use should be reduced. Thiazide medications can produce mild thrombocytopenia; their use should also be reduced.

Rationale 5: The patient should engage in physical exercise that will maintain cardiomuscular strength but not expose the patient to injury.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 56-5

Question 7

Type: MCMA

A patient has been admitted for treatment of hemolytic anemia. Which assessment findings would the nurse immediately discuss with the health care provider?

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

Standard Text: Select all that apply.

1. Decreased amounts of very dark urine

2. Jaundice

3. Bradycardia

4. Liver palpated below the right costal margin

5. Itching

Correct Answer: 1,3

Rationale 1: Decreased, concentrated urine is an indicator of renal failure associated with hemolytic anemia. The health care provider should be contacted immediately about this finding.

Rationale 2: As the red blood cells are hemolyzed, bilirubin is released, resulting in jaundice. Jaundice is an expected condition in hemolytic anemia.

Rationale 3: The expected cardiac effect of anemia is tachycardia. If the patient becomes bradycardic, the health care provider should be contacted immediately.

Rationale 4: Enlargement of the liver is an indicator of persistent hemolysis and will likely be present when the patient is first admitted.

Rationale 5: Itching is caused by the increased bilirubin in the skin. This is not an emergent condition.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 56-3

Question 8

Type: MCSA

A patient has been taking oral iron supplementation for one week. The nurse would evaluate this treatment as effective if laboratory results indicate an increase in which blood component?

1. Basophils

2. Eosinophils

3. Reticulocytes

4. Platelets

Correct Answer: 3

Rationale 1: Basophils are a type of white blood cell whose growth is not influenced by iron therapy.

Rationale 2: Eosinophils are a type of white blood cell whose growth is not influenced by iron therapy.

Rationale 3: Reticulocytes are red blood cells that respond positively to iron therapy, resulting in increased reticulocytes.

Rationale 4: Platelets are necessary for clotting but are not responsive to iron therapy.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 56-3

Question 9

Type: MCSA

A child has been admitted with assessment findings suggestive of hemophilia. Which laboratory test would the nurse evaluate as supporting that diagnosis?

1. Decreased red blood cell count on CBC

2. Prolonged partial thromboplastin time (aPTT)

3. Decreased factor VI

4. A positive d-dimer

Correct Answer: 2

Rationale 1: Any person who is bleeding would have a decreased red blood cell count; this is not specific to hemophilia.

Rationale 2: Because hemophilia is a disorder of the intrinsic pathway, the patient typically will have a prolonged aPTT.

Rationale 3: The factors that are insufficient in hemophilia are factors VIII and IX.

Rationale 4: The d-dimer test indicates excessive fibrinolysis, the end point of excessive activation of the clotting pathways. This is not part of the pathophysiology of hemophilia.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 56-6

Question 10

Type: MCSA

A patient is suspected of having iron deficiency anemia (IDA). Which laboratory value would the nurse evaluate as supporting this diagnosis?

1. High levels of ferritin

2. Low levels of serum transferrin

3. Increased total iron binding capacity (TIBC)

4. High hematocrit level

Correct Answer: 3

Rationale 1: Ferritin is an iron-storage protein that is produced in the liver, spleen, and bone marrow. High ferritin levels are related to the amount of iron stored in the body tissues and would not indicate IDA.

Rationale 2: Serum transferrin, also referred to a total iron binding capacity, increases in IDA to harvest more iron from the intestine.

Rationale 3: TIBC increases as a compensatory attempt to harvest more iron from the intestines; thus, its value increases in IDA.

Rationale 4: A high hematocrit level indicates hemoconcentration resulting from dehydration, which does not typically occur in IDA.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 56-3

Question 11

Type: MCMA

A patient has been hospitalized with hemophilia. Nursing management of this patients care will include which interventions?

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

Standard Text: Select all that apply.

1. Administration of replacement factors

2. Providing education to the patient and family

3. Achieving a cure for the disorder

4. Managing pain

5. Environmental control of risk

Correct Answer: 1,2,4,5

Rationale 1: The administration of replacement factors is a primary nursing responsibility when caring for patients diagnosed with hemophilia.

Rationale 2: Patient and family education is critical to ensure understanding of the disease process and the importance of complying with the goals of the disease management plan.

Rationale 3: Hemophilia is a chronic condition for which there is no cure.

Rationale 4: Hemophilia can result in painful bleeding into joints. Pain management is an essential part of the nursing care of these patients.

Rationale 5: Patients with hemophilia are at risk of injury from environmental factors that are not significant to those without the disease. The nurse should help the patient identify and control for these factors.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 56-6

Question 12

Type: MCMA

A nurse is assigned to care for a female patient diagnosed with aplastic anemia. What are the expected outcomes of the nurses interventions?

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 will list three sources of iron that should be included in the daily diet.

2. The patient will identify activities that increase her risk for falls.

3. The patient will demonstrate no complications from blood transfusions.

4. The patient will maintain a hematocrit level of 32%.

5. The patient will have regrowth of hair.

Correct Answer: 2,3

Rationale 1: The patient with aplastic anemia has increased iron stores and may need iron chelation therapy. Increased dietary iron is not indicated.

Rationale 2: The patient with aplastic anemia is at risk for falls because of the reduced oxygen-carrying capacity of the blood. The patient should be able to identify activities that increase the risk for falls and describe a plan to reduce that risk.

Rationale 3: Blood transfusions may be necessary to replace red blood cells and platelets. The nurse should follow transfusion protocols to help prevent transfusion reactions.

Rationale 4: A hematocrit of 32% is a low value for a female. The goal is a normal hematocrit of 36.1 to 44.3%.

Rationale 5: The patient with aplastic anemia is not expected to lose her hair.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 56-3

Question 13

Type: MCSA

The nurse preparing to provide care to a patient with thrombocytopenia would review the administration instructions for which category of medications?

1. Vitamin supplements

2. Erythropoietic agents

3. Immune-suppressive medications

4. Parenteral iron supplementation

Correct Answer: 3

Rationale 1: Vitamin supplementation is used to correct deficiencies in key elements, such as vitamin B12 and serum folate, required for hemoglobin synthesis. This treatment is indicated for anemia.

Rationale 2: Erythropoietic agents are used to treat anemias by stimulating, differentiating, and proliferating the hematopoietic cascade.

Rationale 3: Immune-suppressive medications, such as steroids and intravenous immunoglobulin, are used to suppress the immune response, including the autoimmune response. This treatment is useful for patients with immune thrombocytopenia purpura. Suppression of the immune system results in platelet survival.

Rationale 4: Parenteral iron supplements are used to treat anemias, not thrombocytopenia.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 56-5

Question 14

Type: MCMA

A patient has been admitted to the emergency department with severe bleeding from a gunshot wound to the right thigh. The nurse would expect therapy to be based in part on which laboratory values?

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

Standard Text: Select all that apply.

1. Blood urea nitrogen (BUN)

2. Platelet count

3. WBC (white blood cell) count

4. Hematocrit

5. Hemoglobin

Correct Answer: 2,5

Rationale 1: BUN measures the urea excreted by the kidneys and is used to detect a renal disorder or dehydration associated with increased BUN levels. It would not offer information about blood loss.

Rationale 2: The platelet count measures the circulating platelets in the blood; platelets facilitate the clotting process.

Rationale 3: The white blood cell (WBC) count is part of a complete blood count and is used to determine the presence of an infection.

Rationale 4: Hematocrit is not a good indicator of the severity of bleeding in acute blood loss. The RBC mass is lost at the same time as total blood volume; thus, the percentage of RBCs in the blood may be unaffected.

Rationale 5: As blood is lost, the hemoglobin drops. Sharp decreases in hemoglobin indicate the need to consider blood transfusion.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 56-3

Question 15

Type: MCSA

A middle-aged female is experiencing numbness and tingling in her lower extremities as well as difficulty ambulating. The patients recent complete blood count indicates large, oval-shaped red blood cells with thin membranes. Which therapy would the nurse anticipate discussing in the discharge plan?

1. A diet high in green, leafy vegetables, broccoli, wheat germ, and asparagus

2. A daily multivitamin with extra iron

3. Subcutaneous injections of erythropoietin for a few weeks

4. Lifelong intramuscular parenteral injections of vitamin B12

Correct Answer: 4

Rationale 1: Green, leafy vegetables, broccoli, wheat germ, and asparagus are foods high in folic acid but not high in the vitamin B12 needed by this patient.

Rationale 2: Iron deficiency results in microcytic and hypochromic RBCs. Extra iron and vitamins would not correct the symptoms.

Rationale 3: Erythropoietin stimulates new RBC production by the bone marrow, but if B12 is not present in the body to manufacture the DNA, the RBCs will not have the shape or size of normal RBCs.

Rationale 4: Larger macrocytic and oval-shaped RBCs with thin membranes, paresthesia, and proprioception are symptoms of a deficiency of B12. Because the gastrointestinal (GI) tract is permanently unable to make the intrinsic factor needed to absorb B12 from foods, an alternate absorption method that bypasses the GI tract is necessary. Intramuscular treatments are lifelong.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 56-3

Question 16

Type: MCSA

A patient is admitted with a diagnosis of sickle-cell crisis. The nurse assesses a temperature of 102 F, O2 saturation of 89%, and complaints of severe abdominal pain. Which prescription should the nurse implement first?

1. Give Tylenol (acetaminophen) 650 mg for elevated temperature.

2. Apply oxygen per nasal cannula at 3L/minute.

3. Administer morphine sulfate 4 mg IV.

4. Assess and document peripheral pulses.

Correct Answer: 2

Rationale 1: Although the temperature is elevated and will increase oxygen demands in the body by increased basal metabolic activity, this is not the first action the nurse should take.

Rationale 2: Hypoxia is often the cause of sickling crisis from the clumping of damaged RBCs, which creates an obstruction and hypoxia distal to the clumping. Administering oxygen will improve the pain and increase the oxygen saturation of body tissues.

Rationale 3: Morphine should be administered as soon as possible, but this is not the nurses first action.

Rationale 4: A full body assessment, including peripheral pulses, is needed to identify the location of the potential obstruction, but this is not the nurses primary action.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 56-3

Question 17

Type: MCSA

After several doses of chemotherapy, a patient complains of fatigue, pallor, progressive weakness, exertional dyspnea, headache, and tachycardia. Which NANDA nursing diagnosis would the nurse list as the first priority?

1. Imbalanced Nutrition: Less than Body Requirements

2. Activity Intolerance

3. Powerlessness

4. Ineffective Coping

Correct Answer: 2

Rationale 1: Nutrition or iron deficiency is not the likely cause of these symptoms.

Rationale 2: The symptoms indicate that the patient is not tolerant of activity, probably because of the bone marrow depression from chemotherapy and the resulting decrease in RBC production.

Rationale 3: Powerlessness is the lack of control over current situations, but this is not the patients current problem.

Rationale 4: Although the patient might have coping issues, the physical symptoms are the greatest complaints; therefore, coping is not the top priority in planning care. Physiological needs must be met prior to self-actualization needs.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 56-3

Question 18

Type: MCSA

Which nursing intervention is appropriate for the patient diagnosed with heparin-induced thrombocytopenia who has the nursing diagnosis of Risk for Bleeding?

1. Avoid invasive procedures, such as rectal temperatures, urinary catheterizations, and parenteral injections.

2. Hold pressure on laboratory testing venipuncture sites for at least 15 mintues.

3. Give enemas to avoid straining during bowel movements.

4. Encourage frequent independent ambulation.

Correct Answer: 1

Rationale 1: With bleeding disorders, any trauma carries the risk of extensive bleeding from platelet agglutination, which results in prolonged bleeding due to removal of platelets by phagocytosis.

Rationale 2: Venous punctures require 5 minutes to make sure a clot has formed in the patient who has a prolonged clotting time.

Rationale 3: An enema is an invasive procedure, and the patients risk of bleeding from trauma is increased. The patient should be provided with stool softeners to avoid straining during a bowel movement, but enemas should not be given.

Rationale 4: The patient who has a risk for bleeding should be assisted as necessary with activities of daily living and ambulation to avoid injury.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 56-5

Question 19

Type: MCSA

A patient has been diagnosed with disseminated intravascular coagulation (DIC). The patients condition has not improved after administration of fresh frozen plasma and platelets. Which therapy does the nurse anticipate?

1. Administration of heparin

2. Rapid infusion of intravenous normal saline

3. Bone marrow transplant

4. Surgical removal of the spleen

Correct Answer: 1

Rationale 1: Anticoagulants such as unfractionated or low-molecular-weight heparin can prevent the formation of new thrombi. Low doses are titrated carefully.

Rationale 2: Intravenous fluids will be continued, but high volume is not indicated.

Rationale 3: A bone marrow transplant is not indicated for this patient.

Rationale 4: A splenectomy would not improve this patients condition, and a surgical procedure could cause additional uncontrolled bleeding.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 56-6

Question 20

Type: FIB

A patient with anemia of chronic disease is prescribed erythropoietin (Epogen) 50 units per kilogram three times a week. The patient weighs 188 pounds. The home health nurse would be certain that at least _____ units of Epogen are available for this weeks doses.

Standard Text:

Correct Answer: 12,825

Rationale : The patient weighs 85.5 kg (188/2.2).
85.5 x 50 units x 3 doses = 12,825

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 56-3

Question 21

Type: MCSA

A 45-year-old patient with a history of chronic renal failure reports feeling so fatigued that he cannot work a full day at his job. The nurse would anticipate testing for levels of which substance most likely implicated in these findings?

1. Testosterone

2. Growth hormone

3. Erythropoietin

4. Magnesium

Correct Answer: 3

Rationale 1: As this patient has a history of chronic renal disease, a different substance is likely implicated in this complaint.

Rationale 2: Growth hormone may be implicated to some degree in this finding, but it is not the most likely causative factor.

Rationale 3: Erythropoietin is a hormone produced in the kidney that stimulates the production of red blood cells. Being fatigued may indicate that there are not enough red cells to transport oxygen to the tissues.

Rationale 4: Magnesium is involved in production of RBCs, but this is not the most likely imbalance in this patients condition.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 56-2

Question 22

Type: MCSA

Review of a patients medical record reveals a diagnosis of anemic hypoxia. Which condition would the nurse suspect was the underlying cause of this diagnosis?

1. Reduced production of erythropoietin

2. Airway obstruction

3. Pneumonia

4. Right-to-left shunt in the heart

Correct Answer: 1

Rationale 1: Erythropoietin stimulates the production of red blood cells. An inadequate supply of erythropoietin results in anemia and can cause anemic hypoxia.

Rationale 2: Airway obstruction results in hypoxic hypoxia.

Rationale 3: Pneumonia is a pulmonary dysfunction that would result in hypoxic hypoxemia.

Rationale 4: A right-to-left shunt in the heart results in hypoxic hypoxia.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 56-2

Question 23

Type: MCMA

A person who weighs approximately 80 kg is brought to the emergency department with a stab wound. Which assessment findings would the nurse evaluate as indicating this patient has lost more than 30% of total blood volume?

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

Standard Text: Select all that apply.

1. Blood pressure 78 mmHg systolic

2. Heart rate 118 bpm

3. Dry, hot skin

4. Loss of consciousness when trying to sit up on the gurney

5. Slight restlessness with complaint of pain

Correct Answer: 1,4

Rationale 1: A blood pressure of 7090 mmHg systolic indicates significant blood loss, approximately 30% to 40%.

Rationale 2: The heart rate would probably be over 120 beats per minute if over 30% of total blood volume were lost.

Rationale 3: Significant blood loss typically results in cool or cold skin that may be clammy.

Rationale 4: Syncope on sitting or standing is associated with blood loss of 30 to 40%.

Rationale 5: Slight restlessness would indicate a lesser amount of blood loss, perhaps less than 20%.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 56-3

Question 24

Type: MCSA

A patient has no complaints when she comes to the clinic for a routine physical. Laboratory results reveal a hemoglobin level of 8.2 g/dL. How should the nurse interpret this result?

1. This patient has a normal hemoglobin level for an adult female.

2. The patient has lost some blood in the last few hours.

3. The patient should be encouraged to eat more iron-rich foods.

4. The patient has been bleeding slowly for an extended period.

Correct Answer: 4

Rationale 1: This hemoglobin level is not normal for either a female or a male adult.

Rationale 2: If the patient has lost enough blood to produce this hemoglobin level in the last few hours, the patient would likely be symptomatic.

Rationale 3: This hemoglobin level is significantly low and is likely not treatable with dietary management.

Rationale 4: The most likely explanation of this hemoglobin level is that the patient has been bleeding slowly over a long period, which has given her body time to compensate for the losses.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 56-4

Question 25

Type: FIB

A patient has lost 800 mL of blood during surgery. The nurse calculates that the patient has lost _______ mg of iron.

Standard Text:

Correct Answer: 400

Rationale : One mL of blood loss is equal to about 0.5 mg of iron loss. A blood loss of 800mL means a total iron loss of 400 mg.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 56-3

Question 26

Type: FIB

A patient who has iron deficiency anemia is prescribed approximately 200 mg of oral elemental iron to be taken daily in three individual doses with meals. The nurse would teach this patient to take ______ tablet(s) of over-the-counter ferrous sulfate for each dose.

Standard Text:

Correct Answer: 1

Rationale : Each tablet of over-the-counter ferrous sulfate has 6065 mg of elemental iron. The patient would take 1 tablet with meals three times a day for a daily total of 180195 mg of elemental iron.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 56-3

Question 27

Type: MCMA

A patient has been prescribed over-the-counter oral iron supplementation. What medication 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. Take the iron supplement right before bedtime.

2. Iron is absorbed better if taken with food or liquids that contain vitamin C.

3. Iron may be constipating, so a stool softener may be necessary.

4. Take the iron at mealtime or with a snack to prevent heartburn.

5. Do not take iron with any dairy foods.

Correct Answer: 2,3,4

Rationale 1: The patient should avoid lying down for at least an hour after taking oral iron.

Rationale 2: Taking iron with a vitamin Ccontaining food increases absorption.

Rationale 3: Iron is very constipating to some people. Stool softeners are often prescribed at the same time iron is prescribed.

Rationale 4: Iron can cause heartburn if taken on an empty stomach. Taking iron with food can reduce this effect.

Rationale 5: There is no reason iron should not be taken with dairy foods.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 56-3

Question 28

Type: MCMA

A patient has been prescribed 100 mg of iron dextran IV push daily for 5 days. How should the nurse prepare to administer this medication?

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

Standard Text: Select all that apply.

1. Give a test dose of 25 mg slow IV push.

2. Plan on giving the medication over 10 to 15 minutes.

3. Dilute the iron is 20 mL of D5W prior to administration.

4. Report any patient complaint of nausea during or just after the injection.

5. Observe the patient for anorexia.

Correct Answer: 1,4

Rationale 1: A test dose of 25 mg slow IV push, followed by close observation for 1 hour, is necessary at the beginning of treatment.

Rationale 2: The medication can be given over 2 to 5 minutes.

Rationale 3: Diluting the iron in this amount of fluid is not required.

Rationale 4: Nausea is a significant side effect of parenteral iron therapy and should be reported.

Rationale 5: Parenteral iron therapy is not associated with anorexia.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 56-3

Question 29

Type: MCMA

A patient who is living with AIDS has developed anemia of chronic disease (ACD). Which laboratory results would the nurse attribute to this condition?

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

Standard Text: Select all that apply.

1. Hemoglobin level of 10.4 g/dL

2. Decrease in total erythrocytes

3. Increased transferrin levels

4. Changes in MCHC and MCV

5. Increasing iron depletion over time

Correct Answer: 2,4,5

Rationale 1: ACD typically presents with a hemoglobin level between 8 and 9.5 g/dL.

Rationale 2: The CBC of patients with ACD usually indicates decreased total erythrocytes.

Leave a Reply