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

Chapter 31: Nursing Management: Hematologic Problems

Test Bank

MULTIPLE CHOICE

1. A 62-year old man with chronic anemia is experiencing increased fatigue and occasional palpitations at rest. The nurse would expect the patients laboratory findings to include

a.

a hematocrit (Hct) of 38%.

b.

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

c.

normal red blood cell (RBC) indices.

d.

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

ANS: D

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

DIF: Cognitive Level: Understand (comprehension) REF: 633

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: Apply (application) REF: 637

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

3. A patient who is receiving methotrexate for severe rheumatoid arthritis 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: Apply (application) REF: 640

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

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

a.

need to start eating more red meat and liver.

b.

will stop having a glass of wine with dinner.

c.

could choose nasal spray rather than injections of vitamin B12.

d.

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

ANS: C

Because 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: Apply (application) REF: 641

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

5. An appropriate nursing intervention for a hospitalized patient with severe hemolytic anemia is to

a.

provide a diet high in vitamin K.

b.

alternate periods of rest and activity.

c.

teach the patient how to avoid injury.

d.

place the patient on protective isolation.

ANS: B

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 diet high in vitamin K 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: Apply (application) REF: 635

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

6. Which patient statement to the nurse indicates a need for additional instruction about taking oral ferrous sulfate?

a.

I will call my health care provider if my stools 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 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: Apply (application) REF: 638

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

7. Which collaborative problem will the nurse include in a care plan for a patient admitted to the hospital with idiopathic aplastic anemia?

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: Apply (application) REF: 642

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

8. It is important for the nurse providing care for a patient with sickle cell crisis 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: Apply (application) REF: 645-646

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

9. Which statement by a patient 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 is decreased by having an annual influenza vaccination.

ANS: D

Because 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 a medication used to decrease the number of sickle cell crises.

DIF: Cognitive Level: Apply (application) REF: 645

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

10. Which instruction will the nurse plan to include in discharge teaching for the patient admitted with a sickle cell crisis?

a.

Take a daily multivitamin with iron.

b.

Limit fluids to 2 to 3 quarts per day.

c.

Avoid exposure to crowds when possible.

d.

Drink only 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: Apply (application) REF: 644-645

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

11. The nurse notes scleral jaundice in a patient being admitted with hemolytic anemia. The nurse will plan to check the laboratory results for the

a.

Schilling test.

b.

bilirubin level.

c.

stool occult blood test.

d.

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: Apply (application) REF: 633

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) when her platelet level drops to 110,000/L. Which action will the nurse include in the plan of care?

a.

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

b.

Administer the warfarin (Coumadin) at the scheduled time.

c.

Teach the patient about the purpose of platelet transfusions.

d.

Discontinue heparin and flush intermittent IV lines using normal saline.

ANS: D

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: Apply (application) REF: 653

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

13. A critical action by the nurse caring for a patient with an acute exacerbation of polycythemia vera 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: Apply (application) REF: 650

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

14. Which intervention will be included in the nursing 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 soft 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: Apply (application) REF: 651

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

15. Which laboratory result will the nurse expect to show a decreased value if a patient develops heparin-induced thrombocytopenia (HIT)?

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: Apply (application) REF: 651

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

16. The nurse caring for a patient with type A hemophilia being admitted to the hospital with severe pain and swelling in the right knee will

a.

immobilize the joint.

b.

apply heat to the knee.

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: Apply (application) REF: 657

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

17. A 28-year-old man 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: Understand (comprehension) REF: 656

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

18. A routine complete blood count indicates that an active 80-year-old man may have myelodysplastic syndrome. The nurse will plan to teach the patient about

a.

blood 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: Apply (application) REF: 663

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

19. Which action will the admitting nurse include in the care plan for a 30-year old woman who is neutropenic?

a.

Avoid any injections.

b.

Check temperature every 4 hours.

c.

Omit fruits or vegetables from the diet.

d.

Place a No Visitors sign on the 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: Apply (application) REF: 661

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

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

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: Apply (application) REF: 660 | 662

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

21. A 68-year-old woman with acute myelogenous leukemia (AML) 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, other treatment options include stem cell transplantation.

b.

The side effects of chemotherapy are difficult, but AML frequently goes into remission with chemotherapy.

c.

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

d.

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

ANS: B

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: Apply (application) REF: 668 | 669

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

22. A patient with a history of a transfusion-related acute lung injury (TRALI) is to receive a transfusion of packed red blood cells (PRBCs). Which action by the nurse will 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 diuretic before the transfusion.

d.

Give the PRN dose of antihistamine before 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: Apply (application) REF: 679

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

23. A 54-year-old woman with acute myelogenous leukemia (AML) is considering treatment with a hematopoietic stem cell transplant (HSCT). The best approach for the nurse to assist the patient with a treatment decision 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: Apply (application) REF: 668-669

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

24. Which action will the nurse include in the plan of care for a 72-year-old woman 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: Apply (application) REF: 674-675

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

25. An appropriate nursing intervention for a patient with non-Hodgkins lymphoma whose platelet count drops to 18,000/L during chemotherapy is to

a.

check all stools for occult blood.

b.

encourage fluids to 3000 mL/day.

c.

provide oral hygiene every 2 hours.

d.

check the temperature every 4 hours.

ANS: A

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: Apply (application) REF: 650-651

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

26. A 30-year-old man with acute myelogenous leukemia develops an absolute neutrophil count of 850/L while receiving outpatient chemotherapy. Which action by the outpatient clinic nurse is most appropriate?

a.

Discuss the need for hospital admission to treat the neutropenia.

b.

Teach the patient to administer filgrastim (Neupogen) injections.

c.

Plan to discontinue the chemotherapy until the neutropenia resolves.

d.

Order a high-efficiency particulate air (HEPA) filter for the patients home.

ANS: B

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: Apply (application) REF: 662

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

27. Which information obtained by the nurse 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 purpura on the oral mucosa.

d.

There are large bruises on the patients back.

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: Apply (application) REF: 651

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

MSC: NCLEX: Physiological Integrity

28. The nurse is planning to administer a transfusion of packed red blood cells (PRBCs) to a patient with blood loss from gastrointestinal hemorrhage. Which action can the nurse delegate to unlicensed assistive personnel (UAP)?

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

UAP education includes measurement of vital signs. UAP would report the vital signs to the registered nurse (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: Apply (application) REF: 661

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

MSC: NCLEX: Safe and Effective Care Environment

29. A postoperative patient receiving a transfusion of packed red blood cells develops chills, fever, headache, and anxiety 35 minutes after the transfusion is started. After stopping the transfusion, what action should the nurse take?

a.

Draw blood for a new crossmatch.

b.

Send a urine specimen to the laboratory.

c.

Administer PRN acetaminophen (Tylenol).

d.

Give the PRN diphenhydramine (Benadryl).

ANS: C

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: Apply (application) REF: 678

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

30. A patient in the emergency department complains of back pain and difficulty breathing 15 minutes after a transfusion of packed red blood cells is started. 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: Apply (application) REF: 678

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

MSC: NCLEX: Physiological Integrity

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

a.

A patient with chronic 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: Apply (application) REF: 642

OBJ: Special Questions: Multiple Patients

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

32. Which patient requires the most rapid assessment and care by the emergency department nurse?

a.

The patient with hemochromatosis who reports abdominal pain

b.

The patient with neutropenia who has a temperature of 101.8 F

c.

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

d.

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

ANS: B

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: Analyze (analysis) REF: 662-663

OBJ: Special Questions: Multiple Patients; Prioritization

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

33. A 19-year-old woman with immune thrombocytopenic purpura (ITP) has an order for a platelet transfusion. Which information indicates that the nurse should consult with the health care provider before obtaining and administering platelets?

a.

The platelet count is 42,000/mL.

b.

Petechiae are present on the chest.

c.

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

d.

Blood is oozing from the venipuncture site.

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. Therefore 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 that the platelet transfusion is appropriate.

DIF: Cognitive Level: Apply (application) REF: 653

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

34. Which problem reported by a patient with hemophilia is most important for the nurse to communicate to the physician?

a.

Leg bruises

b.

Tarry stools

c.

Skin abrasions

d.

Bleeding gums

ANS: B

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: Apply (application) REF: 655

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.

Avoid venipunctures.

b.

Notify the patients physician.

c.

Apply sterile dressings to the sites.

d.

Give prescribed proton-pump inhibitors.

ANS: B

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: Apply (application) REF: 658-659

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 physician order will the nurse implement first?

a.

Administer morphine sulfate 4 mg IV.

b.

Give acetaminophen (Tylenol) 650 mg.

c.

Infuse normal saline 500 mL over 30 minutes.

d.

Schedule complete blood count and coagulation studies.

ANS: C

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: Apply (application) REF: 659

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

MSC: NCLEX: Physiological Integrity

37. Which action for a patient with neutropenia is appropriate for the registered nurse (RN) to delegate to a licensed practical/vocational nurse (LPN/LVN)?

a.

Assessing the patient for signs and symptoms of infection

b.

Teaching the patient the purpose of neutropenic precautions

c.

Administering subcutaneous filgrastim (Neupogen) injection

d.

Developing a discharge teaching plan for the patient and family

ANS: C

Administration of subcutaneous 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: Apply (application) REF: 661

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

MSC: NCLEX: Safe and Effective Care Environment

38. Several 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.

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

b.

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

c.

50-year-old with early-stage chronic lymphocytic leukemia who reports chronic fatigue

d.

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

ANS: B

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: Analyze (analysis) REF: 670

OBJ: Special Questions: Multiple Patients

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

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

a.

56-year-old with frequent explosive diarrhea

b.

33-year-old with a fever of 100.8 F (38.2 C)

c.

66-year-old who has white pharyngeal lesions

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: Apply (application) REF: 661-62

OBJ: Special Questions: Prioritization; Multiple Patients

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

40. Which action will the nurse include in the plan of care for a patient who has thalassemia major?

a.

Teach the patient to use iron supplements.

b.

Avoid the use of intramuscular injections.

c.

Administer iron chelation therapy as needed.

d.

Notify health care provider of hemoglobin 11g/dL.

ANS: C

The frequent transfusions used to treat thalassemia major lead to iron toxicity in patients unless iron chelation therapy is consistently used. Iron supplementation is avoided in patients with thalassemia. There is no need to avoid intramuscular injections. The goal for patients with thalassemia major is to maintain a hemoglobin of 10 g/dL or greater.

DIF: Cognitive Level: Apply (application) REF: 639-640

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

41. Which patient information is most important for the nurse to monitor when evaluating the effectiveness of deferoxamine (Desferal) for a patient with hemochromatosis?

a.

Skin color

b.

Hematocrit

c.

Liver function

d.

Serum iron level

ANS: D

Because iron chelating agents are used to lower serum iron levels, the most useful information will be the patients iron level. The other parameters will also be monitored, but are not the most important to monitor when determining the effectiveness of deferoxamine.

DIF: Cognitive Level: Apply (application) REF: 648

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

MSC: NCLEX: Physiological Integrity

42. Which finding about a patient with polycythemia vera is most important for the nurse to report to the health care provider?

a.

Hematocrit 55%

b.

Presence of plethora

c.

Calf swelling and pain

d.

Platelet count 450,000/mL

ANS: C

The calf swelling and pain suggest that the patient may have developed a deep vein thrombosis, which will require diagnosis and treatment to avoid complications such as pulmonary embolus. The other findings will also be reported to the health care provider but are expected in a patient with this diagnosis.

DIF: Cognitive Level: Apply (application) REF: 649

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

MSC: NCLEX: Physiological Integrity

43. Following successful treatment of Hodgkins lymphoma for a 55-year-old woman, which topic will the nurse include in patient teaching?

a.

Potential impact of chemotherapy treatment on fertility

b.

Application of soothing lotions to treat residual pruritus

c.

Use of maintenance chemotherapy to maintain remission

d.

Need for follow-up appointments to screen for malignancy

ANS: D

The chemotherapy used in treating Hodgkins lymphoma results in a high incidence of secondary malignancies; follow-up screening is needed. The fertility of a 55-year-old woman will not be impacted by chemotherapy. Maintenance chemotherapy is not used for Hodgkins lymphoma. Pruritus is a clinical manifestation of lymphoma, but should not be a concern after treatment.

DIF: Cognitive Level: Apply (application) REF: 670-671

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

44. A patient who has non-Hodgkins lymphoma is receiving combination treatment with rituximab (Rituxan) and chemotherapy. Which patient assessment finding requires the most rapid action by the nurse?

a.

Anorexia

b.

Vomiting

c.

Oral ulcers

d.

Lip swelling

ANS: D

Lip swelling in angioedema may indicate a hypersensitivity reaction to the rituximab. The nurse should stop the infusion and further assess for anaphylaxis. The other findings may occur with chemotherapy, but are not immediately life threatening.

DIF: Cognitive Level: Apply (application) REF: 672

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

MSC: NCLEX: Physiological Integrity

45. Which information obtained by the nurse assessing a patient admitted with multiple myeloma is most important to report to the health care provider?

a.

Serum calcium level is 15 mg/dL.

b.

Patient reports no stool for 5 days.

c.

Urine sample has Bence-Jones protein.

d.

Patient is complaining of severe back pain.

ANS: A

Hypercalcemia may lead to complications such as dysrhythmias or seizures, and should be addressed quickly. The other patient findings will also be discussed with the health care provider, but are not life threatening.

DIF: Cognitive Level: Apply (application) REF: 674-675

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

MSC: NCLEX: Physiological Integrity

46. When a patient with splenomegaly is scheduled for splenectomy, which action will the nurse include in the preoperative plan of care?

a.

Discourage deep breathing to reduce risk for splenic rupture.

b.

Teach the patient to use ibuprofen (Advil) for left upper quadrant pain.

c.

Schedule immunization with the pneumococcal vaccine (Pneumovax).

d.

Avoid the use of acetaminophen (Tylenol) for 2 weeks prior to surgery.

ANS: C

Asplenic patients are at high risk for infection with Pneumococcus and immunization reduces this risk. There is no need to avoid acetaminophen use before surgery, but nonsteroidal antiinflammatory drugs (NSAIDs) may increase bleeding risk and should be avoided. The enlarged spleen may decrease respiratory depth and the patient should be encouraged to take deep breaths.

DIF: Cognitive Level: Apply (application) REF: 676

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

47. The nurse has obtained the health history, physical assessment data, and laboratory results shown in the accompanying figure for a patient admitted with aplastic anemia. Which information is most important to communicate to the health care provider?

a.

Neutropenia

b.

Increasing fatigue

c.

Thrombocytopenia

d.

Frequent constipation

ANS: A

The low white blood cell count indicates that the patient is at high risk for infection and needs immediate actions to diagnose and treat the cause of the leucopenia. The other information may require further assessment or treatment, but does not place the patient at immediate risk for complications.

DIF: Cognitive Level: Analyze (analysis) REF: 676

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

MSC: NCLEX: Physiological Integrity

SHORT ANSWER

1. A patient is to receive an infusion of 250 mL of platelets over 2 hours through tubing that is labeled: 1 mL equals 10 drops. How many drops per minute will the nurse infuse?

ANS:

21

To infuse 250 mL over 2 hours, the calculated drip rate is 20.8 drops/minute or 21 drops/minute.

DIF: Cognitive Level: Apply (application) REF: 676

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

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