Immune And Hematologic Disorders

2.

A client has been taking a decongestant for allergic rhinitis. During a follow-up visit, which finding suggests that the decongestant has been effective?

Increased salivation
Increased tearing
Reduced sneezing
Headache

Correct Answer

A. Reduced sneezing

Explanation

RATIONALE: Decongestants relieve congestion and sneezing and reduce labored respirations. When effective, decongestants dry the mucous membranes; therefore, the client shouldn't experience increased salivation or tearing. Because decongestants alleviate congestion, they also relieve headaches, which may be caused by congestion.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1870.

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1

3.

A client with rheumatoid arthritis is being discharged with a prescription for aspirin (Ecotrin), 600 mg P.O. every 6 hours. Which statement by the client indicates understanding of the adverse effects of the medication?

I'll call my physician if I have difficulty voiding.
I'll call my physician if I have ringing in the ears.
I'll call my physician if I have leg cramps.
I'll call my physician if I have fewer bowel movements than normal.

Correct Answer

A. I'll call my physician if I have ringing in the ears.

Explanation

RATIONALE: The client with rheumatoid arthritis typically takes a relatively high dosage of aspirin for its anti-inflammatory effect. The nurse should instruct the client to report signs and symptoms of aspirin toxicity, such as tinnitus (ringing in the ears). Dysuria, leg cramps, and constipation aren't associated with aspirin use or toxicity.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Application

REFERENCE: Karch, A.M. 2007 Lippincott's Nursing Drug Guide. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 147.

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4.

A female client with human immunodeficiency virus (HIV) receives family-planning counseling. Which statement about safer sex practices for persons with HIV is accurate?

If the client and her sexual partners are HIV-positive, unprotected sex is permitted.
A latex condom with spermicide provides the best protection against HIV transmission during sexual intercourse.
Contraceptive methods, such as hormonal contraceptives, implants, and injections, are recommended to prevent HIV transmission.
The intrauterine device is recommended for a client with HIV.

Correct Answer

A. A latex condom with spermicide provides the best protection against HIV transmission during sexual intercourse.

Explanation

RATIONALE: A latex condom with spermicide provides the best protection against HIV transmission during sexual intercourse. The nurse should caution the client not to have unprotected sex because continued exposure to HIV in a seropositive client may hasten the course of the disease or result in infection with another strain of HIV. Hormonal contraceptives, implants, and injections offer no protection against HIV transmission. The intrauterine device isn't recommended for a client with HIV because it may increase her susceptibility to pelvic inflammatory disease.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Knowledge

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1842.

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5.

A client with anemia has been admitted to the medical-surgical unit. Which assessment findings are characteristic of iron deficiency anemia?

Nights sweats, weight loss, and diarrhea
Dyspnea, tachycardia, and pallor
Nausea, vomiting, and anorexia
Itching, rash, and jaundice

Correct Answer

A. Dyspnea, tachycardia, and pallor

Explanation

RATIONALE: Signs of iron deficiency anemia include dyspnea, tachycardia, and pallor, as well as fatigue, listlessness, irritability, and headache. Night sweats, weight loss, and diarrhea may signal acquired immunodeficiency syndrome. Nausea, vomiting, and anorexia may be signs of hepatitis B. Itching, rash, and jaundice may result from an allergic or hemolytic reaction.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1046.

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6.

A nurse assesses a client in the physician's office. Which assessment findings support a suspicion of systemic lupus erythematosus (SLE)?

Facial erythema, pericarditis, pleuritis, fever, and weight loss
Photosensitivity, polyarthralgia, and painful mucous membrane ulcers
Weight gain, hypervigilance, hypothermia, and edema of the legs
Hypothermia, weight gain, lethargy, and edema of the arms

Correct Answer

A. Facial erythema, pericarditis, pleuritis, fever, and weight loss

Explanation

RATIONALE: An autoimmune disorder characterized by chronic inflammation of the connective tissues, SLE causes fever, weight loss, malaise, fatigue, skin rashes, and polyarthralgia. Nearly half of clients with SLE have facial erythema, (the classic butterfly rash). SLE also may cause profuse proteinuria (excretion of more than 0.5 g/day of protein), pleuritis, pericarditis, photosensitivity, and painless mucous membrane ulcers. Weight gain, hypervigilance, hypothermia, and edema of the legs and arms don't suggest SLE.

CLIENT NEEDS CATEGORY: Health promotion and maintenance
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Knowledge

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1910.

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7.

A client who agreed to become an organ donor is pronounced dead. What is the most important factor in selecting a transplant recipient?

Blood relationship
Sex and size
Compatible blood and tissue types
Need

Correct Answer

A. Compatible blood and tissue types

Explanation

RATIONALE: The donor and recipient must have compatible blood and tissue types. They should be fairly close in size and age, but these factors aren't as important as compatible blood and tissue types. When a living donor is considered, it's preferable to have a blood relative donate the organ. Need is important but it can't be the critical factor if a compatible donor isn't available.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Knowledge

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1560.

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8.

A nurse is caring for a client admitted with pernicious anemia. Which set of findings should the nurse expect when assessing the client?

Pallor, bradycardia, and reduced pulse pressure
Pallor, tachycardia, and a sore tongue
Sore tongue, dyspnea, and weight gain
Option 4

Correct Answer

A. Pallor, tachycardia, and a sore tongue

Explanation

RATIONALE: Pallor, tachycardia, and a sore tongue are all characteristic findings in pernicious anemia. Other clinical manifestations include anorexia; weight loss; a smooth, beefy red tongue; a wide pulse pressure; palpitations; angina pectoris; weakness; fatigue; and paresthesia of the hands and feet. Bradycardia, reduced pulse pressure, weight gain, and double vision aren't characteristic findings in pernicious anemia.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1805.

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9.

A client is diagnosed with human immunodeficiency virus (HIV). After recovering from the initial shock of the diagnosis, the client expresses a desire to learn as much as possible about HIV and acquired immunodeficiency syndrome (AIDS). When teaching the client about the immune system, the nurse states that humoral immunity is provided by which type of white blood cell?

Neutrophil
Basophil
Monocyte
Lymphocyte

Correct Answer

A. Lymphocyte

Explanation

RATIONALE: The lymphocyte provides humoral immunity — recognition of a foreign antigen and formation of memory cells against the antigen. Humoral immunity is mediated by B and T lymphocytes and can be acquired actively or passively. The neutrophil is crucial to phagocytosis. The basophil plays an important role in the release of inflammatory mediators. The monocyte functions in phagocytosis and monokine production.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Knowledge

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1786.

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10.

A client is diagnosed with megaloblastic anemia caused by vitamin B12 deficiency. The physician begins the client on cyanocobalamin (Betalin-12), 100 mcg I.M. daily. Which substance influences vitamin B12 absorption?

Intrinsic factor
Hydrochloric acid
Histamine
Liver enzyme

Correct Answer

A. Intrinsic factor

Explanation

RATIONALE: Vitamin B12 absorption depends on intrinsic factor, which is secreted by parietal cells in the stomach. The vitamin binds with intrinsic factor and is absorbed in the ileum. Hydrochloric acid, histamine, and liver enzymes don't influence vitamin B12 absorption.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Knowledge

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1123.

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11.

A client diagnosed with acquired immunodeficiency syndrome is admitted to the emergency department with a closed head injury after being found unconscious on the kitchen floor by her neighbor. Based on information from the client's neighbor, the staff suspects domestic abuse. The client has a restraining order against the husband. The husband repeatedly attempts to visit the client. Which nursing action ensures client safety?

Place the client in a reverse isolation room and post an isolation sign on the door restricting visitors.
Instruct the client that she should put on her call light if her husband enters her room.
Admit the client to the pediatric unit under an assumed name so that the husband can't find her.
Inform hospital security personnel of the restraining order and formulate an action plan with security that protects the client.

Correct Answer

A. Inform hospital security personnel of the restraining order and formulate an action plan with security that protects the client.

Explanation

RATIONALE: The nurse should inform hospital security personnel about the restraining order and formulate an action plan with security that protects the client. Placing the client in a reverse isolation room isolates the client and doesn't incorporate protective measures. Instructing the client to use her call light if her husband enters the room may alert hospital staff but doesn't allow for implementation of safety measures. Measures should be in place to stop the husband before he enters the client's room. Admitting the client to the pediatric unit doesn't protect the client from harm.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 675.

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12.

A client diagnosed with idiopathic thrombocytopenia purpura needs a peripherally inserted central catheter (PICC) placed. When explaining the catheter to the client, the nurse explains that one advantage of a catheter is that it can be used:

To administer only blood products and I.V. fluids.
In clients with infections in the blood.
To provide long-term access to central veins.
For 2 weeks without being replaced.

Correct Answer

A. To provide long-term access to central veins.

Explanation

RATIONALE: A PICC provides long-term access (longer than 2 weeks) to central veins. It can be used to administer blood products, medications, I.V. fluids, and total parenteral nutrition. Moreover, the PICC can be used to obtain blood specimens. As with any other central venous catheter, this catheter shouldn't be inserted when systemic infection (infection in the blood) is present.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Knowledge

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1706.

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13.

A client with autoimmune thrombocytopenia and a platelet count of 8,000/μl develops epistaxis and melena. Treatment with corticosteroids and immunoglobulins has been unsuccessful, and the physician recommends a splenectomy. The client states, "I don't need surgery — this will go away on its own." In considering her response to the client, the nurse must depend on the ethical principle of:

Beneficence.
Autonomy.
Advocacy.
Justice.

Correct Answer

A. Autonomy.

Explanation

RATIONALE: Autonomy is the right of the individual to make his own decisions. In this case, the client is capable of making his own decision and the nurse should support his autonomy. Beneficence, promoting and doing good, and justice (being fair) aren't the principles that directly relate to the situation. Advocacy is the nurse's role in supporting the principle of autonomy.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 102.

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14.

A client on the oncology floor is ordered a blood transfusion. The nurse explains the procedure and informs the client that an informed consent form must be signed before the blood may be administered. The client asks why consent is necessary. Which response by the nurse best explains why consent is necessary for blood transfusions?

The Joint Commission requires a signed informed consent from all clients receiving blood transfusions.
We can administer blood transfusions without a signed informed consent only in the event of an emergency.
The consent allows you to make an informed decision about the indications, possible alternatives, risks, and benefits of a blood transfusion.
When clients who require blood sign an informed consent, it indicates they understand blood transfusions can be hazardous.

Correct Answer

A. The consent allows you to make an informed decision about the indications, possible alternatives, risks, and benefits of a blood transfusion.

Explanation

RATIONALE: Informed consent provides clients with information needed to make informed decisions about their health care. Clients need information about their health care regardless of the requirements mandated by the Joint Commission. Telling the client that blood transfusions may be administered without a signed informed consent in an emergency doesn't explain the purpose of signing a consent form. Informed consent provides the client with more information about blood transfusions than the hazards.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 133.

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15.

While obtaining a health history, a nurse learns that a client is allergic to bee stings. When obtaining this client's medication history, the nurse should determine if the client keeps which medication on hand?

Diphenhydramine (Benadryl)
Pseudoephedrine (Sudafed)
Guaifenesin (Robitussin)
Loperamide (Imodium)

Correct Answer

A. Diphenhydramine (Benadryl)

Explanation

RATIONALE: A client who is allergic to bee stings should keep diphenhydramine on hand because its antihistamine action can prevent a severe allergic reaction. Pseudoephedrine is a decongestant, which is used to treat cold symptoms. Guaifenesin is an expectorant, which is used for coughs. Loperamide is an antidiarrheal agent.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Comprehension

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 376.

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16.

A nurse assesses a client shortly after living donor kidney transplant surgery. Which postoperative finding must the nurse report to the physician immediately?

Serum potassium level of 4.9 mEq/L
Serum sodium level of 135 mEq/L
Temperature of 99.2° F (37.3° C)
Urine output of 20 ml/hour

Correct Answer

A. Urine output of 20 ml/hour

Explanation

RATIONALE: Because kidney transplantation carries the risk of transplant rejection, infection, and other serious complications, the nurse should monitor the client's urinary function closely. A decrease from the normal urine output of 30 ml/hour is significant and warrants immediate physician notification. A serum potassium level of 4.9 mEq/L, a serum sodium level of 135 mEq/L, and a temperature of 99.2° F are normal assessment findings.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1562.

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17.

A client with acquired immunodeficiency syndrome is admitted with Pneumocystis carinii pneumonia. During a bath, the client begins to cry and says that most friends and relatives have stopped visiting and calling. What should the nurse do?

Continue with the bath and tell the client not to worry.
Ask the physician to obtain a psychiatric consultation.
Listen and show interest as the client expresses feelings.
State that his friends' behavior shows they aren't true friends.

Correct Answer

A. Listen and show interest as the client expresses feelings.

Explanation

RATIONALE: The nurse should listen actively and nonjudgmentally as the client expresses feelings. Telling the client not to worry would provide false reassurance. A psychiatric consultation would be appropriate only after further assessment. Stating that the client's friends aren't true friends would discount the client's feelings.

CLIENT NEEDS CATEGORY: Psychosocial integrity
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Comprehension

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1849.

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18.

Which nursing diagnosis should a nurse expect to see in a care plan for a client in sickle cell crisis?

Imbalanced nutrition: Less than body requirements related to poor intake
Disturbed sleep pattern related to external stimuli
Impaired skin integrity related to pruritus
Acute pain related to sickle cell crisis

Correct Answer

A. Acute pain related to sickle cell crisis

Explanation

RATIONALE: In sickle cell crisis, sickle-shaped red blood cells clump together in a blood vessel, which causes occlusion, ischemia, and extreme pain. Therefore, Acute pain related to sickle cell crisis is the appropriate choice. Although nutrition is important, poor nutritional intake isn't necessarily related to sickle cell crisis. During sickle cell crisis, pain or another internal stimulus is more likely to disturb the client's sleep than external stimuli. Although clients with sickle cell anemia can develop chronic leg ulcers caused by small vessel blockage, they don't typically experience pruritus.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Comprehension

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1058.

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19.

A client was recently discharged with a peripherally inserted central catheter, and the home care nurse begins teaching him how to care for the catheter. The client states, "I'm so confused. The nurses in the hospital started to show me how to care for this catheter, but I don't think I'll be able to keep it all straight." Which response by the nurse is most appropriate?

Don't worry. That's why your physician ordered home care for you. If you aren't able to learn how to care for the catheter, we can do it for you.
We'll make sure that you feel comfortable caring for your catheter. Can you show me what the nurses in the hospital showed you?
Your insurance covers only two nursing visits, so you'll need to learn quickly.
Don't underestimate yourself; you'll know how to care for your catheter in no time.

Correct Answer

A. We'll make sure that you feel comfortable caring for your catheter. Can you show me what the nurses in the hospital showed you?

Explanation

RATIONALE: The client received instruction before discharge, so the home care nurse should ask the client to demonstrate what he learned while hospitalized. The home care nurse can then develop her teaching plan based on the client's learning needs. Telling the client not to worry and that home care staff will care for the catheter doesn't promote client autonomy. The nurse shouldn't increase the client's anxiety level by mentioning that insurance covers only two home visits. Telling the client not to underestimate himself minimizes the client's concerns.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 522.

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20.

A college student comes to the campus health care center complaining of headache, malaise, and a sore throat that has worsened over the past 10 days. The nurse measures a temperature of 102.6° F (39.2° C) and finds an enlarged spleen and liver and exudative tonsillitis. Laboratory tests reveal a leukocyte count of 20,000/mm3, antibodies to Epstein-Barr virus, and abnormal liver function tests. These findings suggest:

Mumps.
Poliomyelitis.
Herpangina.
Infectious mononucleosis.

Correct Answer

A. Infectious mononucleosis.

Explanation

RATIONALE: The client's clinical manifestations and laboratory test results suggest infectious mononucleosis. Mumps, a viral disease, usually causes an earache and fever from parotid gland involvement. Poliomyelitis is an acute communicable disease that has been largely eradicated by the polio vaccine. Although its symptoms resemble those of mononucleosis, it typically has a central nervous system component, causing back, neck, and arm pain or paralysis. Herpangina is an acute viral infection that causes seizures, vomiting, stomach pain, and grayish papulovesicles on the soft palate.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 2477.

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21.

Which type of white blood cell (WBC) is the most numerous?

Neutrophil
Lymphocyte
Eosinophil
Basophil

Correct Answer

A. Neutrophil

Explanation

RATIONALE: Neutrophils are the most numerous of the WBCs, comprising about 65%. Lymphocytes are the second most abundant. Eosinophils account for about 2%, whereas basophils are the least abundant.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Knowledge

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1037.

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22.

A client with rheumatoid arthritis has been on aspirin therapy for an extended time. Which assessment is the most important for the nurse to obtain?

Weight
Gait
Hearing
Muscle mass

Correct Answer

A. Hearing

Explanation

RATIONALE: Prolonged use of aspirin and other salicylates sometimes causes bilateral hearing loss of 30 to 40 decibels. Usually, this adverse effect resolves within 2 weeks after the therapy is discontinued. Aspirin doesn't lead to weight gain, gait problems, or changes in muscle mass.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Analysis

REFERENCE: Karch, A.M. Lippincott's Nursing Drug Guide. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 147.

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23.

While monitoring a client for the development of disseminated intravascular coagulation (DIC), the nurse should take note of which assessment parameters?

Platelet count, prothrombin time, and partial thromboplastin time
Platelet count, blood glucose levels, and white blood cell (WBC) count
Thrombin time, calcium levels, and potassium levels
Fibrinogen level, WBC, and platelet count

Correct Answer

A. Platelet count, prothrombin time, and partial thromboplastin time

Explanation

RATIONALE: The diagnosis of DIC is based on the results of laboratory studies of prothrombin time, platelet count, thrombin time, partial thromboplastin time, and fibrinogen level as well as client history and other assessment factors. Blood glucose levels, WBC count, calcium levels, and potassium levels aren't used to confirm a diagnosis of DIC.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1093.

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24.

During chemotherapy for lymphocytic leukemia, a client develops abdominal pain, fever, and "horse barn"-smelling diarrhea. It would be most important for the nurse to advise the physician to order:

An enzyme-linked immunosuppressant assay (ELISA) test.
An electrolyte panel and a hemogram.
Stools for a Clostridium difficile test.
A flat plate X-ray of the abdomen.

Correct Answer

A. Stools for a Clostridium difficile test.

Explanation

RATIONALE: Immunosuppressed clients — for example, clients receiving chemotherapy — are at risk for infection with C. difficile, which causes "horse barn"-smelling diarrhea. Successful treatment begins with an accurate diagnosis, which includes a stool test. The ELISA test is diagnostic for human immunodeficiency virus and isn't indicated in this case. An electrolyte panel and hemogram may be useful in the overall evaluation of a client but aren't diagnostic for specific causes of diarrhea. A flat plate of the abdomen may provide useful information about bowel function but isn't indicated in the case of "horse barn"-smelling diarrhea.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 2476.

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25.

A client with pernicious anemia is receiving parenteral vitamin B12 therapy. Which client statement indicates effective teaching about this therapy?

I will receive parenteral vitamin B12 therapy until my signs and symptoms disappear.
I will receive parenteral vitamin B12 therapy until my vitamin B12 level returns to normal.
I will receive parenteral vitamin B12 therapy monthly for 6 months to a year.
I will receive parenteral vitamin B12 therapy for the rest of my life.

Correct Answer

A. I will receive parenteral vitamin B12 therapy for the rest of my life.

Explanation

RATIONALE: Because a client with pernicious anemia lacks intrinsic factor, oral vitamin B12 can't be absorbed. Therefore, parenteral vitamin B12 therapy is recommended and required for life.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Comprehension

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1052.

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26.

The wife of a client with end-stage acquired immunodeficiency syndrome (AIDS) is caring for her husband at home. The hematologist recommends hospice care and the couple agrees. During the initial admission visit, the hospice nurse provides information to the client and his family about an advance directive. During the next day's visit, the client states that since he and his wife filled out the advance directive form, he feels abandoned by his physician. Which statement by the hospice nurse best addresses the client's concerns?

Your physician will continue to care for you. The advance directive simply puts in writing the care you want, so he will be able to provide it if you can't tell him yourself.
You don't need to feel that way. Your physician is required by law to sign your orders and the hospice nurses will be contacting him with updates on your condition.
Many people first feel that way when they are admitted into hospice. Although the focus of your care has changed from curative to supportive, your physician will still continue directing it.
It's understandable to feel that way. But clients with end-stage AIDS who have advanced directives generally experience a less painful death that those individuals who don't.

Correct Answer

A. Your physician will continue to care for you. The advance directive simply puts in writing the care you want, so he will be able to provide it if you can't tell him yourself.

Explanation

RATIONALE: Option 1 provides correct information about advance directives. The advance directive outlines the client's treatment wishes should he be unable to communicate his wishes at any time during his illness. The physician continues to provide care for clients admitted to hospice care. Option 2 invalidates the client's fears and doesn't emphasize the physician's role or the client's role in his care plan. Option 3 doesn't address the purpose of the advance directive, and it discusses treatment options that may not have been discussed with the client. Option 4 doesn't provide evidence-based information about advance directives.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Analysis

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 174.

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27.

A nurse is teaching high school students about transmission of the human immunodeficiency virus (HIV). Which comment by a student warrants clarification by the nurse?

A man should wear a latex condom during intimate sexual contact.
I've heard about people who got AIDS from blood transfusions.
I won't donate blood because I don't want to get AIDS.
I.V. drug users can get HIV from sharing needles.

Correct Answer

A. I won't donate blood because I don't want to get AIDS.

Explanation

RATIONALE: HIV is transmitted through infected blood, semen, and certain other body fluids. Although a transfusion with infected blood may cause HIV infection in the recipient, a person can't become infected by donating blood. The other options reflect accurate understanding of HIV transmission.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1816.

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28.

A nurse is preparing a client with systemic lupus erythematosus (SLE) for discharge. Which instruction should the nurse include in the teaching plan?

Exposure to sunlight will help control skin rashes.
There are no activity limitations between flare-ups.
Monitor your body temperature.
Corticosteroids may be stopped when symptoms are relieved.

Correct Answer

A. Monitor your body temperature.

Explanation

RATIONALE: The nurse should instruct the client to monitor body temperature. Fever can signal an exacerbation and should be reported to the physician. Sunlight and other sources of ultraviolet light may precipitate severe skin reactions and exacerbate the disease. Fatigue can cause a flare-up of SLE. Clients should be encouraged to pace activities and plan rest periods. Corticosteroids must be gradually tapered because they can suppress the function of the adrenal gland. Abruptly stopping corticosteroids can cause adrenal insufficiency, a potentially life-threatening situation.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1911.

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29.

A nurse on the hematology floor feels the charge nurse has been unfairly assigning complex clients to her by not dividing enough of the workload among the rest of the staff. This nurse is creating tension among the staff. What is the charge nurse's best approach?

Instruct this staff member to bring her concerns to her directly.
Assure the staff member that the she is being as fair as possible and that the nurse needs to pull her weight.
Meet with this nurse privately and give her an opportunity to further express her concerns.
Write the nurse up, then sit down to counsel her in a private setting.

Correct Answer

A. Meet with this nurse privately and give her an opportunity to further express her concerns.

Explanation

RATIONALE: Before taking punitive action, the charge nurse should meet with the staff member privately to enhance communication and model problem-solving behaviors. Instructing the staff member in how to present her concerns and assuring her that she's distributing assignments fairly are linear and directive; these responses don't give the staff member adequate opportunity to interact with the charge nurse in a productive manner. Writing the nurse up and providing counseling is a better response, but writing the nurse up may not be necessary if the charge nurse takes time to talk with her.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Analysis

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 541.

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30.

A client is admitted to the facility with an exacerbation of her chronic systemic lupus erythematosus (SLE). She gets angry when her call bell isn't answered immediately. The nurse's most appropriate response is:

You seem angry. Would you like to talk about it?
Calm down. You know that stress will make your symptoms worse.
Would you like to talk about the problem with the nursing supervisor?
I can see you're angry. I'll come back when you've calmed down.

Correct Answer

A. You seem angry. Would you like to talk about it?

Explanation

RATIONALE: Verbalizing the observed behavior is a therapeutic communication technique in which the nurse acknowledges what the client is feeling. Offering to listen to the client express her anger can help both the nurse and the client understand its cause and begin to deal with it. Although stress can exacerbate the symptoms of SLE, telling the client to calm down doesn't acknowledge her feelings. Offering to get the nursing supervisor also ignores the client's feelings. Ignoring the client's feelings by leaving suggests that the nurse has no interest in what the client has said.

CLIENT NEEDS CATEGORY: Psychosocial integrity
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Analysis

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2006, p. 376.

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31.

A client with chronic progressive multiple sclerosis is learning to use a walker. What instruction will best ensure the client's safety?

Place the walker directly in front of you and step into it as you move it forward.
When you move the walker, set the back legs down first. Then step forward.
Maintain a firm grip on the front bar as you step into the walker.
Use a walker with wheels to help you move forward.

Correct Answer

A. Place the walker directly in front of you and step into it as you move it forward.

Explanation

RATIONALE: When the client places the walker directly in front of him, he creates a stable base for forward movement and reduces the likelihood of falls. The client shouldn't set the back leg down first because this creates an unstable base that could lead to a fall. The client should firmly grip the side bars; doing so provides a more stable base of support than gripping the front bar. The nurse shouldn't suggest that the client use a walker with wheels. Only a physician or physical therapist may order a walker with wheels.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Analysis

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1305.

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32.

A nurse is caring for a client who is receiving antibiotics to treat a gram-negative bacterial infection. The client experiences an adverse effect related to the destruction of the normal flora in the GI tract. What finding does the nurse expect to assess?

Oliguria
Dysuria
Constipation
Diarrhea

Correct Answer

A. Diarrhea

Explanation

RATIONALE: Broad-spectrum antibiotics that destroy aerobic and anaerobic bacteria also destroy the normal flora of the GI tract, which are responsible for absorbing water and certain nutrients (such as vitamin K). Destruction of the GI flora, in turn, leads to diarrhea. Although antibiotics may cause platelet dysfunction, stomatitis, renal dysfunction (indicated by oliguria and dysuria), and liver dysfunction, these adverse effects don't result from destruction of the GI flora.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Analysis

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1559.

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33.

A nurse is teaching a female client, who is positive for human immunodeficiency virus, about pregnancy. The nurse should know more teaching is necessary when the client says:

The baby can get the virus from my placenta.
I'm planning on starting on birth control pills.
Not everyone who has the virus gives birth to a baby who has the virus.
I'll need to have a cesarean birth if I become pregnant and have a baby.

Correct Answer

A. I'll need to have a cesarean birth if I become pregnant and have a baby.

Explanation

RATIONALE: The client requires more teaching if she states she'll need to have a cesarean birth if she becomes pregnant. HIV is transmitted from mother to child via the transplacental route, but a cesarean birth isn't necessary when the mother is HIV-positive. The use of birth control will prevent the conception of a child who might have HIV. It's true that a mother who's HIV-positive can give birth to a baby who's HIV-negative; however, all neonates born to HIV-positive mothers will be HIV-positive for about 6 months because of maternal antibodies.

CLIENT NEEDS CATEGORY: Health promotion and maintenance
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Application

REFERENCE: Pillitteri, A. Maternal and Child Health Nursing: Care of the Childbearing and Childrearing Family, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2006, p. 353.

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34.

A client with acquired immunodeficiency syndrome (AIDS) is ordered zidovudine (azidothymidine, AZT [Retrovir]), 200 mg P.O. every 4 hours. When teaching the client about this drug, the nurse should provide which instruction?

Take zidovudine with meals.
Take zidovudine on an empty stomach.
Take zidovudine every 4 hours around the clock.
Take over-the-counter (OTC) drugs to treat minor adverse reactions.

Correct Answer

A. Take zidovudine every 4 hours around the clock.

Explanation

RATIONALE: To be effective, zidovudine must be taken every 4 hours around the clock. Food doesn't affect absorption of this drug, so the client may take zidovudine either with food or on an empty stomach. To avoid serious drug interactions, the client should check with the physician before taking OTC medications.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Knowledge

REFERENCE: Karch, A.M. 2007 Lippincott's Nursing Drug Guide. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 1224.

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35.

A client receiving a blood transfusion experiences an acute hemolytic reaction. Which nursing intervention is the most important?

Immediately stop the transfusion, infuse dextrose 5% in water (D5W), and call the physician.
Slow the transfusion and monitor the client closely.
Stop the transfusion, notify the blood bank, and administer antihistamines.
Immediately stop the transfusion, infuse normal saline solution, call the physician, and notify the blood bank.

Correct Answer

A. Immediately stop the transfusion, infuse normal saline solution, call the physician, and notify the blood bank.

Explanation

RATIONALE: When a transfusion reaction occurs, the transfusion should be immediately stopped, normal saline solution should be infused to maintain venous access, and the physician and blood bank should be notified immediately. Other nursing actions include saving the blood bag and tubing, rechecking the blood type and identification numbers on the blood tags, monitoring vital signs, obtaining necessary laboratory blood and urine samples, providing proper documentation, and monitoring and treating for shock. Because they can cause red blood cell hemolysis, dextrose solutions shouldn't be infused with blood products. Antihistamines are administered for a mild allergic reaction, not a hemolytic reaction.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1109.

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36.

A complete blood count is commonly performed before a client goes into surgery. What does this test seek to identify?

Potential hepatic dysfunction indicated by decreased blood urea nitrogen (BUN) and creatinine levels
Low levels of urine constituents normally excreted in the urine
Abnormally low hematocrit (HCT) and hemoglobin (Hb) levels
Electrolyte imbalance that could affect the blood's ability to coagulate properly

Correct Answer

A. Abnormally low hematocrit (HCT) and hemoglobin (Hb) levels

Explanation

RATIONALE: Low preoperative HCT and Hb levels indicate the client may require a blood transfusion before surgery. If the HCT and Hb levels decrease during surgery because of blood loss, the potential need for a transfusion increases. Possible renal failure is indicated by elevated BUN or creatinine levels. Urine constituents aren't found in the blood. Coagulation is determined by the presence of appropriate clotting factors, not electrolytes.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1044.

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37.

A nurse is working in a support group for clients with acquired immunodeficiency syndrome (AIDS). Which point is most important for the nurse to stress?

Avoiding the use of recreational drugs and alcohol
Refraining from telling anyone about the diagnosis
Following safer-sex practices
Telling potential sex partners about the diagnosis, as required by law

Correct Answer

A. Following safer-sex practices

Explanation

RATIONALE: It's essential for clients with AIDS to follow safer-sex practices to prevent transmission of the human immunodeficiency virus. Although it's helpful if clients with AIDS avoid using recreational drugs and alcohol, it's more important that I.V. drug users use clean needles and dispose of used needles for purposes of avoiding transmission. Whether the client with AIDS chooses to tell anyone about the diagnosis is his decision; there is no legal obligation to do so.

CLIENT NEEDS CATEGORY: Psychosocial integrity
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1841.

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38.

After receiving a dose of penicillin, a client develops dyspnea and hypotension. The nurse suspects the client is experiencing anaphylactic shock. What should the nurse do first?

Page an anesthesiologist immediately and prepare to intubate the client.
Administer epinephrine, as ordered, and prepare to intubate the client, if necessary.
Administer the antidote for penicillin, as ordered, and continue to monitor the client's vital signs.
Insert an indwelling urinary catheter and begin to infuse I.V. fluids, as ordered.

Correct Answer

A. Administer epinephrine, as ordered, and prepare to intubate the client, if necessary.

Explanation

RATIONALE: To reverse anaphylactic shock, the nurse first should administer epinephrine, a potent bronchodilator, as ordered. The physician is likely to order additional medications, such as antihistamines and corticosteroids; if these medications don't relieve the respiratory compromise associated with anaphylaxis, the nurse should prepare to intubate the client. No antidote for penicillin exists; however, the nurse should continue to monitor the client's vital signs. A client who remains hypotensive may need fluid resuscitation and fluid intake and output monitoring; however, administering epinephrine is the first priority.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1868.

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39.

A staff member on the transplant unit is having problems logging into the computer to chart client information. The staff member asks a nurse for her personal identification number (PIN) to log in. What is the nurse' best response?

I'll be happy to contact Information Services to assist you with the problem.
I don't think this is appropriate. You need to talk with the charge nurse.
Sure. Just be sure to destroy the information after you are finished charting.
I'll log you in. Be sure to log out when you are finished charting.

Correct Answer

A. I'll be happy to contact Information Services to assist you with the problem.

Explanation

RATIONALE: By telling the staff member she'll contact information services, the nurse is providing support and help without disclosing private information. Although telling the staff member that her request is inappropriate maintains confidentiality and security, this response may create interpersonal tension. Sharing a PIN or allowing someone to chart under another person's name may inadvertently put confidential client information at risk.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Analysis

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 130.

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40.

A client in a late stage of acquired immunodeficiency syndrome (AIDS) shows signs of AIDS-related dementia. Which nursing diagnosis takes highest priority?

Bathing or hygiene self-care deficit
Ineffective cerebral tissue perfusion
Complicated grieving
Risk for injury

Correct Answer

A. Risk for injury

Explanation

RATIONALE: In a client with AIDS, central nervous system (CNS) deterioration can lead to AIDS-related dementia. This type of dementia impairs cognition and judgment, placing the client at risk for injury. Although Bathing or hygiene self-care deficit and Complicated grieving may be relevant in AIDS, these diagnoses don't take precedence in a client with AIDS-related dementia. Because CNS deterioration results from infection, Ineffective cerebral tissue perfusion isn't applicable.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1847.

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41.

When preparing a client with acquired immunodeficiency syndrome (AIDS) for discharge to home, the nurse should be sure to include which instruction?

Put on disposable gloves before bathing.
Sterilize all plates and utensils in boiling water.
Avoid sharing such articles as toothbrushes and razors.
Avoid eating foods from serving dishes shared by other family members.

Correct Answer

A. Avoid sharing such articles as toothbrushes and razors.

Explanation

RATIONALE: The human immunodeficiency virus (HIV), which causes AIDS, is most concentrated in the blood. For this reason, the client shouldn't share personal articles that may be blood-contaminated, such as toothbrushes and razors, with other family members. HIV isn't transmitted by bathing or by eating from plates, utensils, or serving dishes used by a person with AIDS.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Comprehension

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1850.

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42.

A client with mild dementia related to end-stage acquired immunodeficiency syndrome is preparing for discharge. He has decided against further curative treatment and wishes to return home. Before discharge, he develops ocular cytomegalovirus (CMV). His physician recommends treatment with a ganciclovir-impregnated implant (Vitrasert), which requires a surgical procedure. The client's partner feels the implant won't help the client and asks the nurse if the implant will cure CMV. Which answer from the nurse best answers the partner's question reflecting client advocacy?

The implant won't cure the virus. I'll tell the physician that you don't want your partner to have the procedure.
The implant won't cure the virus but it may protect his sight. Just because your partner has dementia doesn't mean he shouldn't be given the opportunity to see.
The implant won't cure the virus in your partner's eye. The dementia he has means he is terminally ill. You are right to refuse further treatments because nothing more will help him.
The implant won't cure the virus, but it may help preserve his vision. Not being able to see you or his surroundings may worsen his dementia and make caring for him at home more difficult.

Correct Answer

A. The implant won't cure the virus, but it may help preserve his vision. Not being able to see you or his surroundings may worsen his dementia and make caring for him at home more difficult.

Explanation

RATIONALE: In option 4, the nurse is advocating for the client's wishes. She is explaining the client's wishes for no further curative treatment, yet promoting an improved quality of life and safety while the client is being cared for at home. Option 1 answers the partner's question, but it doesn't advocate for the client's needs. Option 2 provides factual information, but it's delivered in a confrontational manner. Option 3 also provides factual information but doesn't show client advocacy.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Analysis

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 102.

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43.

A client with suspected lymphoma is scheduled for lymphangiography. The nurse should inform the client that this procedure may cause which harmless temporary change?

Purplish stools
Bluish urine
Redness of the upper part of the feet
Coldness of the soles

Correct Answer

A. Bluish urine

Explanation

RATIONALE: Lymphangiography may turn the urine blue temporarily; it doesn't alter stool color. For several months after the procedure, the upper part of the feet may appear blue, not red. Lymphangiography doesn't affect the soles.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Knowledge

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 983.

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44.

Which step must be done first when administering a blood transfusion?

Verify the blood product and client identity.
Verify the physician's order.
Verify client identity and blood product with another nurse.
Assess the I.V. site.

Correct Answer

A. Verify the physician's order.

Explanation

RATIONALE: The nurse must first verify the physician's order and then make sure the informed consent form is signed. Next, the nurse should make sure that an appropriate-size I.V. catheter is in place and she should assess the site for patency. After doing so, the nurse should verify the blood product and client identity with another nurse.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Analysis

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1737.

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45.

A client must receive a blood transfusion of packed red blood cells (RBCs) for severe anemia. What I.V. fluid should the nurse use to prime the tubing before hanging this blood product?

Dextrose 5% in water
Dextrose 5% in normal saline solution
Lactated Ringer's solution
Normal saline solution

Correct Answer

A. Normal saline solution

Explanation

RATIONALE: Normal saline solution is used for administering blood transfusions. Lactated Ringer's solution or dextrose solutions may cause blood clotting or RBC hemolysis.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1738.

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46.

A clinical nurse specialist (CNS) is orienting a new graduate registered nurse to an oncology unit where blood product transfusions are frequently administered. In discussing ABO compatibility, the CNS presents several hypothetical scenarios. The new graduate knows that the greatest likelihood of an acute hemolytic reaction would occur when giving:

A-positive blood to an A-negative client.
O-negative blood to an O-positive client.
O-positive blood to an A-positive client.
B-positive blood to an AB-positive client.

Correct Answer

A. A-positive blood to an A-negative client.

Explanation

RATIONALE: An acute hemolytic reaction occurs when there is an ABO or Rh incompatibility. For example, giving A blood to a B client would cause a hemolytic reaction. Likewise, giving Rh-positive blood to an Rh-negative client would cause a hemolytic reaction. It's safe to give Rh-negative blood to an Rh-positive client if there is a blood type compatibility. O-negative blood is the universal donor and can be given to all other blood types. AB clients can receive either A or B blood as long as there isn't an Rh incompatibility.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1109.

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47.

A client with lymphoma tells the nurse that he's found an overseas holistic physician who can cure him with coffee enemas. What should the nurse say?

That unproven alternative therapy can be very dangerous.
You should ask your physician if this is a helpful approach.
It's illegal for unlicensed physicians to prescribe your care.
This treatment is questionable. It could be dangerous.

Correct Answer

A. You should ask your physician if this is a helpful approach.

Explanation

RATIONALE: In this situation, the nurse should try to maintain open communication and a strong therapeutic connection with the client. Although the treatment may be unproven, questionable, dangerous, or illegal, telling the client so may make the nurse appear to be harsh and judgmental, shut down dialog, and alienate the client. By referring the client to the physician, the nurse keeps lines of communication open and gives the client an opportunity to discuss treatment options in a difficult life situation.

CLIENT NEEDS CATEGORY: Psychosocial integrity
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Analysis

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 747.

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48.

A client is receiving chemotherapy for cancer. The nurse reviews the client's laboratory report and notes that he has thrombocytopenia. To which nursing diagnosis should the nurse give the highest priority?

Activity intolerance
Impaired tissue integrity
Impaired oral mucous membranes
Ineffective tissue perfusion: Cerebral, cardiopulmonary, GI

Correct Answer

A. Ineffective tissue perfusion: Cerebral, cardiopulmonary, GI

Explanation

RATIONALE: These are all appropriate nursing diagnoses for the client with thrombocytopenia. However, the risk of cerebral and GI hemorrhage and hypotension pose the greatest risk to the physiological integrity of the client.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1076.

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49.

A home care nurse is making the initial home visit to a client with lung cancer who had a peripherally inserted central catheter placed during hospitalization for an upper respiratory infection. During the visit, the nurse must administer an antibiotic, teach the client how to care for the catheter, and provide information about when to notify the home care agency and physician. When the nurse arrives at the client's home, the client's face is flushed and he complains of feeling tired. Which actions should the nurse take first?

Call the physician to update him on the client's condition and administer the antibiotic.
Obtain the client's vital signs and then administer the antibiotic.
Obtain the client's vital signs and assess breath sounds.
Administer the antibiotic, obtain vital signs, assess breath sounds, and then begin the teaching session.

Correct Answer

A. Obtain the client's vital signs and assess breath sounds.

Explanation

RATIONALE: The nurse should assess the client to see why his condition has changed since discharge. After assessment, the nurse should notify the physician of the change in the client's condition. The nurse shouldn't just obtain vital signs and administer the antibiotic without further assessing the client. It's inappropriate for the nurse to begin a teaching session when the client isn't physically able.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 241.

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Immune And Hematologic Disorders

A client with systemic lupus erythematosus (SLE) has the classic rash of lesions on the cheeks and bridge of the nose. What term should the nurse use to describe this characteristic pattern?

Quiz Preview

A client has been taking a decongestant for allergic rhinitis. During a follow-up visit, which finding suggests that the decongestant has been effective?

A client with rheumatoid arthritis is being discharged with a prescription for aspirin (Ecotrin), 600 mg P.O. every 6 hours. Which statement by the client indicates understanding of the adverse effects of the medication?

A female client with human immunodeficiency virus (HIV) receives family-planning counseling. Which statement about safer sex practices for persons with HIV is accurate?

A client with anemia has been admitted to the medical-surgical unit. Which assessment findings are characteristic of iron deficiency anemia?

A nurse assesses a client in the physician's office. Which assessment findings support a suspicion of systemic lupus erythematosus (SLE)?

A client who agreed to become an organ donor is pronounced dead. What is the most important factor in selecting a transplant recipient?

A nurse is caring for a client admitted with pernicious anemia. Which set of findings should the nurse expect when assessing the client?

A client is diagnosed with megaloblastic anemia caused by vitamin B12 deficiency. The physician begins the client on cyanocobalamin (Betalin-12), 100 mcg I.M. daily. Which substance influences vitamin B12 absorption?

A client diagnosed with idiopathic thrombocytopenia purpura needs a peripherally inserted central catheter (PICC) placed. When explaining the catheter to the client, the nurse explains that one advantage of a catheter is that it can be used:

While obtaining a health history, a nurse learns that a client is allergic to bee stings. When obtaining this client's medication history, the nurse should determine if the client keeps which medication on hand?

A nurse assesses a client shortly after living donor kidney transplant surgery. Which postoperative finding must the nurse report to the physician immediately?

A client with acquired immunodeficiency syndrome is admitted with Pneumocystis carinii pneumonia. During a bath, the client begins to cry and says that most friends and relatives have stopped visiting and calling. What should the nurse do?

Which nursing diagnosis should a nurse expect to see in a care plan for a client in sickle cell crisis?

Which type of white blood cell (WBC) is the most numerous?

A client with rheumatoid arthritis has been on aspirin therapy for an extended time. Which assessment is the most important for the nurse to obtain?

While monitoring a client for the development of disseminated intravascular coagulation (DIC), the nurse should take note of which assessment parameters?

During chemotherapy for lymphocytic leukemia, a client develops abdominal pain, fever, and "horse barn"-smelling diarrhea. It would be most important for the nurse to advise the physician to order:

A client with pernicious anemia is receiving parenteral vitamin B12 therapy. Which client statement indicates effective teaching about this therapy?

A nurse is teaching high school students about transmission of the human immunodeficiency virus (HIV). Which comment by a student warrants clarification by the nurse?

A nurse is preparing a client with systemic lupus erythematosus (SLE) for discharge. Which instruction should the nurse include in the teaching plan?

A nurse on the hematology floor feels the charge nurse has been unfairly assigning complex clients to her by not dividing enough of the workload among the rest of the staff. This nurse is creating tension among the staff. What is the charge nurse's best approach?

A client is admitted to the facility with an exacerbation of her chronic systemic lupus erythematosus (SLE). She gets angry when her call bell isn't answered immediately. The nurse's most appropriate response is:

A client with chronic progressive multiple sclerosis is learning to use a walker. What instruction will best ensure the client's safety?

A nurse is caring for a client who is receiving antibiotics to treat a gram-negative bacterial infection. The client experiences an adverse effect related to the destruction of the normal flora in the GI tract. What finding does the nurse expect to assess?

A nurse is teaching a female client, who is positive for human immunodeficiency virus, about pregnancy. The nurse should know more teaching is necessary when the client says:

A client with acquired immunodeficiency syndrome (AIDS) is ordered zidovudine (azidothymidine, AZT [Retrovir]), 200 mg P.O. every 4 hours. When teaching the client about this drug, the nurse should provide which instruction?

A client receiving a blood transfusion experiences an acute hemolytic reaction. Which nursing intervention is the most important?

A complete blood count is commonly performed before a client goes into surgery. What does this test seek to identify?

A nurse is working in a support group for clients with acquired immunodeficiency syndrome (AIDS). Which point is most important for the nurse to stress?

After receiving a dose of penicillin, a client develops dyspnea and hypotension. The nurse suspects the client is experiencing anaphylactic shock. What should the nurse do first?

A staff member on the transplant unit is having problems logging into the computer to chart client information. The staff member asks a nurse for her personal identification number (PIN) to log in. What is the nurse' best response?

A client in a late stage of acquired immunodeficiency syndrome (AIDS) shows signs of AIDS-related dementia. Which nursing diagnosis takes highest priority?

When preparing a client with acquired immunodeficiency syndrome (AIDS) for discharge to home, the nurse should be sure to include which instruction?

A client with suspected lymphoma is scheduled for lymphangiography. The nurse should inform the client that this procedure may cause which harmless temporary change?

Which step must be done first when administering a blood transfusion?

A client must receive a blood transfusion of packed red blood cells (RBCs) for severe anemia. What I.V. fluid should the nurse use to prime the tubing before hanging this blood product?

A client with lymphoma tells the nurse that he's found an overseas holistic physician who can cure him with coffee enemas. What should the nurse say?

A client is receiving chemotherapy for cancer. The nurse reviews the client's laboratory report and notes that he has thrombocytopenia. To which nursing diagnosis should the nurse give the highest priority?