Immune And Hematologic Disorders

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Immune And Hematologic Disorders - Quiz

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Questions and Answers
  • 1. 

    A client diagnosed with acquired immunodeficiency syndrome (AIDS) is experiencing end-stage Kaposi's sarcoma. Concerned that the health care team is investing too much energy in keeping him alive, he asks that they not attempt any more interventions. How should a nurse respond to this client?

    • A.

      You might consider consulting with a therapist to be sure this is what you really want.

    • B.

      AIDS is no longer an automatic death sentence. You might want to reconsider.

    • C.

      We have to make sure you've signed an advance directive.

    • D.

      I need to get your physician to make this recommendation and write an order.

    Correct Answer
    C. We have to make sure you've signed an advance directive.
    Explanation
    RATIONALE: The nurse should tell the client he must sign an advance directive to prevent future health care interventions. This client has lived with AIDS for many years; suggesting that he talk with a therapist or reconsider his decision is disrespectful and disregards his experience of the disease. An advance directive doesn't require a physician's order.

    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. 175.

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  • 2. 

    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:

    • A.

      To administer only blood products and I.V. fluids.

    • B.

      In clients with infections in the blood.

    • C.

      To provide long-term access to central veins.

    • D.

      For 2 weeks without being replaced.

    Correct Answer
    C. 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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  • 3. 

    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.

      The baby can get the virus from my placenta.

    • B.

      I'm planning on starting on birth control pills.

    • C.

      Not everyone who has the virus gives birth to a baby who has the virus.

    • D.

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

    Correct Answer
    D. 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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  • 4. 

    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.

      Take zidovudine with meals.

    • B.

      Take zidovudine on an empty stomach.

    • C.

      Take zidovudine every 4 hours around the clock.

    • D.

      Take over-the-counter (OTC) drugs to treat minor adverse reactions.

    Correct Answer
    C. 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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  • 5. 

    A client is to receive a blood transfusion of packed red blood cells (RBCs) for severe anemia. The nurse identifies the client using two client identifiers, then prepares to administer the transfusion. Place the following steps in the order the nurse should follow to administer this product. Use all options.1. Flush the I.V. Tubing and line with NSS.2. Check blood bag against the client's information.3. Watch for a transfusion reaction.4. Record vital signs.5. Put on gloves, a gown, and a face shield.6. Check packed RBCs for the date and abnormalities

    Correct Answer
    462513
    Explanation
    The correct answer is 4,6,2,5,1,3.

    RATIONALE: To administer a blood transfusion, the nurse should first record the client's vital signs. Next, she should check the packed RBCs for abnormal color, clumping, gas bubbles, and expiration date. The nurse should also verify the blood bag identification, ABO group, and Rh compatibility against the client's information. She should then put on gloves, a gown, and a face shield. The nurse should flush the I.V. tubing and line with normal saline solution (NSS). Finally, the nurse should remain with the client and watch for signs of a transfusion reaction. Note that the transfusion may be withheld if the client's temperature is 100° F (37.7° C) or higher.

    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. 1737.

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  • 6. 

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

    • A.

      Platelet count, prothrombin time, and partial thromboplastin time

    • B.

      Platelet count, blood glucose levels, and white blood cell (WBC) count

    • C.

      Thrombin time, calcium levels, and potassium levels

    • D.

      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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  • 7. 

    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.

      Page an anesthesiologist immediately and prepare to intubate the client.

    • B.

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

    • C.

      Administer the antidote for penicillin, as ordered, and continue to monitor the client's vital signs.

    • D.

      Insert an indwelling urinary catheter and begin to infuse I.V. fluids, as ordered.

    Correct Answer
    B. 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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  • 8. 

    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.

      If the client and her sexual partners are HIV-positive, unprotected sex is permitted.

    • B.

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

    • C.

      Contraceptive methods, such as hormonal contraceptives, implants, and injections, are recommended to prevent HIV transmission.

    • D.

      The intrauterine device is recommended for a client with HIV.

    Correct Answer
    B. 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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  • 9. 

    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.

      That unproven alternative therapy can be very dangerous.

    • B.

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

    • C.

      It's illegal for unlicensed physicians to prescribe your care.

    • D.

      This treatment is questionable. It could be dangerous.

    Correct Answer
    B. 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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  • 10. 

    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?

    • A.

      Butterfly rash

    • B.

      Papular rash

    • C.

      Pustular rash

    • D.

      Bull's eye rash

    Correct Answer
    A. Butterfly rash
    Explanation
    RATIONALE: In the classic lupus rash, lesions appear on the cheeks and the bridge of the nose, creating a characteristic butterfly pattern. The rash may vary in severity from malar erythema to discoid lesions (plaque). Papular and pustular rashes aren't associated with SLE. The bull's eye rash is classic in client's with Lyme disease.

    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Physiological adaptation
    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. 1911.

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  • 11. 

    A physician orders tests to determine if a client has systemic lupus erythematosus (SLE). Which test result helps to confirm an SLE diagnosis?

    • A.

      Increased total serum complement levels

    • B.

      Negative antinuclear antibody test

    • C.

      Negative lupus erythematosus cell test

    • D.

      An above-normal anti-deoxyribonucleic acid (DNA) test

    Correct Answer
    D. An above-normal anti-deoxyribonucleic acid (DNA) test
    Explanation
    RATIONALE: Laboratory results specific for SLE include an above-normal anti-DNA test, a positive antinuclear antibody test, and a positive lupus erythematosus cell test. Because the anti-DNA test rarely is positive in other diseases, this test is important in diagnosing SLE. (The anti-DNA antibody level may be depressed in clients who are in remission from SLE.) Decreased total serum complement levels indicate active 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. 1911.

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  • 12. 

    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.

      An enzyme-linked immunosuppressant assay (ELISA) test.

    • B.

      An electrolyte panel and a hemogram.

    • C.

      Stools for a Clostridium difficile test.

    • D.

      A flat plate X-ray of the abdomen.

    Correct Answer
    C. 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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  • 13. 

    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.

      Instruct this staff member to bring her concerns to her directly.

    • B.

      Assure the staff member that the she is being as fair as possible and that the nurse needs to pull her weight.

    • C.

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

    • D.

      Write the nurse up, then sit down to counsel her in a private setting.

    Correct Answer
    C. 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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  • 14. 

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

    • A.

      I will receive parenteral vitamin B12 therapy until my signs and symptoms disappear.

    • B.

      I will receive parenteral vitamin B12 therapy until my vitamin B12 level returns to normal.

    • C.

      I will receive parenteral vitamin B12 therapy monthly for 6 months to a year.

    • D.

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

    Correct Answer
    D. 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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  • 15. 

    A client diagnosed with metastatic cancer is preparing for discharge. The physician orders morphine sulfate controlled-release tablets 100 mg every 12 hours as needed after discharge. What legal rights and responsibilities should the nurse address when teaching the client about morphine sulfate use?

    • A.

      You must avoid driving or other activities that require alertness while taking controlled-release morphine sulfate.

    • B.

      Morphine sulfate is an opioid and you may develop tolerance. This is an expected response and isn't harmful.

    • C.

      Federal law prevents refills of this medication. Your physician will give you a new prescription when you need more medicine.

    • D.

      If you no longer require the morphine sulfate controlled-release tablets for your cancer pain, don't take any leftover pills for other disorders.

    Correct Answer
    C. Federal law prevents refills of this medication. Your physician will give you a new prescription when you need more medicine.
    Explanation
    RATIONALE: Federal law prevents the refill of opioids. Therefore, the nurse should tell the client to contact the physician for a new prescription when the current prescription is empty. The client should be instructed to avoid driving or operating hazardous machinery while under the effects of morphine; however, this is a safety issue not a legal one. Long-term morphine sulfate use may lead to drug tolerance; however, this isn't a legal issue surrounding its use. The client with metastatic cancer will most likely require pain medication for the rest of his life.

    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. 785.

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  • 16. 

    A nurse is caring for a client with acquired immunodeficiency syndrome. To adhere to standard precautions, the nurse should:

    • A.

      Maintain strict isolation.

    • B.

      Keep the client in a private room, if possible.

    • C.

      Wear gloves when providing mouth care.

    • D.

      Wear a gown when delivering the client's food tray.

    Correct Answer
    C. Wear gloves when providing mouth care.
    Explanation
    RATIONALE: Standard precautions stipulate that a health care worker wear gloves when contact with a client's blood or body fluids is anticipated, such as when providing mouth care. Such barrier protection helps prevent viruses from entering the bloodstream. Maintaining strict isolation isn't needed because human immunodeficiency virus is spread by contact with contaminated blood or body fluids, which can be avoided by following standard precautions. A private room wouldn't provide barrier protection, which is needed for standard precautions. Wearing a gown is appropriate only when anticipating splashing of blood or body fluids.

    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. 717.

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  • 17. 

    A nurse is planning care for a client with human immunodeficiency virus (HIV). She's being assisted by a licensed practical nurse (LPN). Which statements by the LPN indicate her understanding of HIV transmission? Select all that apply.

    • A.

      I'll wear a gown, mask, and gloves for all client contact.

    • B.

      I don't need to wear any personal protective equipment because nurses have a low risk of occupational exposure.

    • C.

      I'll wear a mask if the client has a cough caused by an upper respiratory infection.

    • D.

      I'll wear a mask, gown, and gloves when splashing of body fluids is likely.

    • E.

      I'll wear a mask, gown, and gloves when splashing of body fluids is likely.

    Correct Answer(s)
    D. I'll wear a mask, gown, and gloves when splashing of body fluids is likely.
    E. I'll wear a mask, gown, and gloves when splashing of body fluids is likely.
    Explanation
    RATIONALE: Standard precautions include wearing gloves for any known or anticipated contact with blood or other body fluids, tissue, mucous membranes, or nonintact skin. If the task may result in splashing or splattering of blood or body fluids to the face, a mask and goggles or face shield should be worn. If the task may result in splashing or splattering of blood or body fluids to the body, a fluid-resistant gown or apron should be worn. Hands should be washed before and after client care and after removing gloves. A gown, mask, and gloves aren't necessary for client care unless contact with body fluids, tissue, mucous membranes, or nonintact skin is expected. Nurses have an increased, not decreased, risk of occupational exposure to blood-borne pathogens. HIV isn't transmitted in sputum unless blood is present.

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

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

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  • 18. 

    Which one do you like?

    • A.

      Rinse her eyes with water, record the incident on the client's chart, and see Employee Health.

    • B.

      Wash her hands, complete an incident report, and see a physician as soon as possible.

    • C.

      Rinse her eyes with water, report the incident, and go to Employee Health.

    • D.

      Rinse her eyes, contact Employee Health and document their findings.

    Correct Answer
    C. Rinse her eyes with water, report the incident, and go to Employee Health.
    Explanation
    RATIONALE: Transmission of the AIDS virus can occur through contact with mucous membranes, so it's vital that the nurse immediately flush her eyes with water. She should properly report and document the incident in an incident report and seek follow-up care with a medical professional. The nurse shouldn't record this incident on the client's care record. A nurse who fails to rinse her eyes may allow viral transmission through contact with the mucous membranes.

    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. 717.

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  • 19. 

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

    • A.

      Nights sweats, weight loss, and diarrhea

    • B.

      Dyspnea, tachycardia, and pallor

    • C.

      Nausea, vomiting, and anorexia

    • D.

      Itching, rash, and jaundice

    Correct Answer
    B. 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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  • 20. 

    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.

      I'll call my physician if I have difficulty voiding.

    • B.

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

    • C.

      I'll call my physician if I have leg cramps.

    • D.

      I'll call my physician if I have fewer bowel movements than normal.

    Correct Answer
    B. 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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  • 21. 

    Which client is most at risk for developing disseminated intravascular coagulation (DIC)?

    • A.

      A client admitted with suspected cocaine overdose

    • B.

      A client with an amniotic fluid embolism

    • C.

      A client with a stage IV pressure ulcer

    • D.

      A client with heart failure and renal failure

    Correct Answer
    B. A client with an amniotic fluid embolism
    Explanation
    RATIONALE: The client with the amniotic fluid embolism is at greatest risk for developing DIC. Other risk factors for developing DIC include trauma, cancer, shock, and sepsis. Possible cocaine overdose, a stage IV pressure ulcer, and heart failure and renal failure aren't risk factors for DIC.

    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. 1093.

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  • 22. 

    A client has had heavy menstrual bleeding for 6 months. Her physician diagnoses microcytic hypochromic anemia and orders ferrous sulfate (Feosol), 300 mg P.O. daily. Before initiating iron therapy, the nurse reviews the client's medical history. The nurse should question this order when she notes that the client:

    • A.

      Is pregnant.

    • B.

      Has asthma.

    • C.

      Has ulcerative colitis.

    • D.

      Has severely impaired liver function.

    Correct Answer
    C. Has ulcerative colitis.
    Explanation
    RATIONALE: Conditions that contraindicate the use of ferrous sulfate include primary hemochromatosis, infectious kidney disease in the acute phase, peptic ulcer, regional enteritis, ulcerative colitis, and known hypersensitivity to iron. Iron dextran requires cautious use in pregnant or breast-feeding clients and in those with severely impaired liver function, significant allergies, or asthma.

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

    REFERENCE: Karch, A.M. 2007 Lippincott's Nursing Drug Guide. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 513.

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  • 23. 

    A nurse is monitoring a client who developed facial edema after receiving a medication. Which white blood cells stimulated the edema?

    • A.

      Basophils

    • B.

      Eosinophils

    • C.

      Monocytes

    • D.

      Neutrophils

    Correct Answer
    A. Basophils
    Explanation
    RATIONALE: The client's edema is related to an allergic reaction to the medication. Basophils are responsible for releasing histamine during an allergic reaction. Eosinophils' major function is phagocytosis of antigen-antibody complexes that are formed in allergic reactions. Monocytes and neutrophils are predominately phagocytic.

    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Basic care and comfort
    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. 1785.

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  • 24. 

    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?

    • 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.

    • B.

      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.

    • C.

      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.

    • D.

      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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  • 25. 

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

    • A.

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

    • B.

      Photosensitivity, polyarthralgia, and painful mucous membrane ulcers

    • C.

      Weight gain, hypervigilance, hypothermia, and edema of the legs

    • D.

      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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  • 26. 

    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:

    • A.

      Beneficence.

    • B.

      Autonomy.

    • C.

      Advocacy.

    • D.

      Justice.

    Correct Answer
    B. 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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  • 27. 

    A pregnant client who developed deep vein thrombosis (DVT) in her right leg is receiving heparin I.V. on the medical floor. Physical therapy is ordered to maintain her mobility and prevent additional DVT. A nursing assistant working on the medical unit helps the client with bathing, range-of-motion exercises, and personal care. Which collaborative multidisciplinary considerations should the care plan address?

    • A.

      The client is at risk for heparin-induced thrombocytopenia; therefore, the care plan should include sequential compression device application and strict bed rest.

    • B.

      The client is at risk for heparin-induced thrombocytopenia; therefore, the care plan should include reporting evidence of bleeding or easy bruising.

    • C.

      The client is at risk for developing another DVT; therefore, the care plan should include reporting redness, tenderness, or edema in the other lower extremity.

    • D.

      The client is pregnant and receiving I.V. heparin, placing her at risk for premature labor; therefore, the care plan should include reporting signs of premature labor.

    Correct Answer
    B. The client is at risk for heparin-induced thrombocytopenia; therefore, the care plan should include reporting evidence of bleeding or easy bruising.
    Explanation
    RATIONALE: Feedback about possible bleeding and bruising from physical therapy and other caregivers should be incorporated into the care plan to ensure safety and optimal outcomes. Using a sequential compression device, mandating strict bed rest, and reporting signs of DVT don't incorporate collaborative care. Reporting signs of premature labor doesn't address the consequences of thrombocytopenia, which may occur with I.V. heparin therapy.

    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. 1007.

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  • 28. 

    Which nonpharmacologic interventions should a nurse include in a care plan for a client who has moderate rheumatoid arthritis (RA)? Select all that apply.

    • A.

      Massaging inflamed joints

    • B.

      Avoiding range-of-motion (ROM) exercises

    • C.

      Applying splints to inflamed joints

    • D.

      Using assistive devices at all times

    • E.

      Selecting clothing that has Velcro fasteners

    • F.

      Applying moist heat to joints

    Correct Answer(s)
    C. Applying splints to inflamed joints
    E. Selecting clothing that has Velcro fasteners
    F. Applying moist heat to joints
    Explanation
    RATIONALE: Supportive, nonpharmacologic measures for the client with RA include applying splints to rest inflamed joints, using Velcro fasteners on clothes to aid in dressing, and applying moist heat to joints to relax muscles and relieve pain. Inflamed joints should never be massaged because doing so can aggravate inflammation. A physical therapy program, including ROM exercises and carefully individualized therapeutic exercises, prevents loss of joint function. Assistive devices should be used only when marked loss of ROM occurs.

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

    REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1909.

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  • 29. 

    A nurse preparing to discharge a child with leukemia observes a family member who has a cold sharing a meal with the child. How should the nurse approach the situation?

    • A.

      Instruct family members not share food because it isn't healthful.

    • B.

      Offer a face mask to the person with the cold and use this as an opportunity for further teaching.

    • C.

      Tell family members to be careful to avoid the child if they're sick.

    • D.

      Post isolation signs on the child's door and carefully assess the health status of all visitors.

    Correct Answer
    B. Offer a face mask to the person with the cold and use this as an opportunity for further teaching.
    Explanation
    RATIONALE: Offering a face mask is the best approach; it protects the child while supporting the family and using the situation as an opportunity for learning. Instructing family members that it isn't healthful to share food and to avoid the child if they're sick are technically correct, but these responses don't include a rationale that enables the family to understand why these actions are important. The nurse should have posted an isolation sign on the child's door long before the time of his discharge.

    CLIENT NEEDS CATEGORY: Health promotion and maintenance
    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. 508.

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  • 30. 

    A nurse encourages a client with an immunologic disorder to eat a nutritionally balanced diet to promote optimal immunologic function. Which snacks have the greatest probability of stimulating autoimmunity?

    • A.

      Raisins and carrot sticks

    • B.

      Potato chips and chocolate milk shakes

    • C.

      Fruit salad and mineral water

    • D.

      Applesauce and saltine crackers

    Correct Answer
    B. Potato chips and chocolate milk shakes
    Explanation
    RATIONALE: A diet containing excessive fat, such as that found in potato chips and milk shakes, seems to contribute to autoimmunity — overreaction of the body against constituents of its own tissues. Raisins, carrot sticks, fruit, mineral water, applesauce, and saltine crackers are snacks containing adequate amounts of vitamin A, zinc, and carotene, which are beneficial for the body.

    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Basic care and comfort
    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. 1797.

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  • 31. 

    A client involved in a motor vehicle accident arrives at the emergency department unconscious and severely hypotensive. The nurse suspects he has several fractures in the pelvis and legs. Which parenteral fluid is the best choice for the client's current condition?

    • A.

      Fresh frozen plasma

    • B.

      Normal saline solution

    • C.

      Lactated Ringer's solution

    • D.

      Packed red blood cells (RBCs)

    Correct Answer
    D. Packed red blood cells (RBCs)
    Explanation
    RATIONALE: In a trauma situation, the first blood product given is unmatched (O negative) packed RBCs. Fresh frozen plasma is commonly used to replace clotting factors. Normal saline or lactated Ringer's solution is used to increase volume and blood pressure; however, too much colloid will hemodilute the blood and doesn't improve oxygen-carrying capacity as well as packed RBCs do.

    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. 1103.

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  • 32. 

    The couple with the lowest risk of having a child with sickle cell anemia disease is the one in which the:

    • A.

      Father is HbS and the mother is HbS.

    • B.

      Father is HbS and the mother is HbAS.

    • C.

      Father is HbA and the mother is HbS.

    • D.

      Father is HbAS and the mother is HbAS.

    Correct Answer
    C. Father is HbA and the mother is HbS.
    Explanation
    RATIONALE: If the father has normal hemoglobin (HbA) and the mother has sickle cell anemia (HbS), the couple has a 0% chance of having a child with sickle cell anemia. If both parents have sickle cell anemia, the couple has a 100% chance of having a child with sickle cell anemia. If the father has sickle cell anemia and the mother has sickle cell trait (HbAS), the couple has a 50% chance of having a child with sickle cell anemia. If both parents have sickle cell trait, the couple has a 25% chance of having a child with sickle cell anemia.

    CLIENT NEEDS CATEGORY: Health promotion and maintenance
    CLIENT NEEDS SUBCATEGORY: None
    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. 1056.

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  • 33. 

    When a relief charge nurse posts assignments, a nurse notes that she is no longer assigned to a client whom she has cared for the previous 2 nights. How should the nurse respond to this assignment?

    • A.

      Tell the charge nurse that she'd like to continue with the same assignment.

    • B.

      Ask the nurse if there's a reason she changed the assignment.

    • C.

      Accept the assignment and discuss the situation with the charge nurse at a later time.

    • D.

      Tell the charge nurse she feels she's the best person to care for this particular client.

    Correct Answer
    B. Ask the nurse if there's a reason she changed the assignment.
    Explanation
    RATIONALE: Asking the charge nurse if there's a reason why she changed the assignment is the most professional response. This response encourages communication and exchange of ideas. Although it's acceptable for this nurse to tell the charge nurse she'd like to continue with the same assignment or accept the assignment and discuss the change with the charge nurse at a later time, these responses don't give the nurse an opportunity to resolve her concerns. Telling the charge nurse that she feels she's the best person to care for a particular client is too direct and could put the charge nurse in a defensive position.

    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. 172.

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  • 34. 

    Which client is most likely to develop systemic lupus erythematosus (SLE)?

    • A.

      A 25-year-old white male

    • B.

      A 25-year-old Jewish female

    • C.

      A 27-year-old black female

    • D.

      A 35-year-old Hispanic male

    Correct Answer
    C. A 27-year-old black female
    Explanation
    RATIONALE: SLE strikes nearly 10 times as many women as men and is most common in women between ages 15 and 40. SLE affects more black women than white women; its incidence is about 1 in every 250 black women, compared to 1 in every 700 white women.

    CLIENT NEEDS CATEGORY: Health promotion and maintenance
    CLIENT NEEDS SUBCATEGORY: None
    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. 1909.

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  • 35. 

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

    • A.

      Purplish stools

    • B.

      Bluish urine

    • C.

      Redness of the upper part of the feet

    • D.

      Coldness of the soles

    Correct Answer
    B. 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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  • 36. 

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

    • A.

      Blood relationship

    • B.

      Sex and size

    • C.

      Compatible blood and tissue types

    • D.

      Need

    Correct Answer
    C. 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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  • 37. 

    A client newly diagnosed with acute lymphocytic leukemia has a right subclavian central venous catheter in place. The nurse who's caring for the client is teaching a graduate nurse about central venous catheter care. The nurse should instruct the graduate nurse to change the central venous catheter dressing every:

    • A.

      Shift.

    • B.

      24 hours.

    • C.

      48 hours.

    • D.

      72 hours.

    Correct Answer
    C. 48 hours.
    Explanation
    RATIONALE: The nurse should instruct the graduate nurse to change the central venous catheter dressing every 48 hours or when the dressing becomes damaged or soiled.

    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. 1198.

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  • 38. 

    A client with acquired immunodeficiency syndrome is receiving zidovudine (azidothymidine, AZT [Retrovir]). Which laboratory value indicates an adverse reaction to zidovudine?

    • A.

      Red blood cell (RBC) count of 1.8 million/μl

    • B.

      Fasting blood glucose of 104 mg/dl

    • C.

      Serum calcium level of 8.9 mg/dl

    • D.

      Platelet count of 240,000/mm3

    Correct Answer
    A. Red blood cell (RBC) count of 1.8 million/μl
    Explanation
    RATIONALE: Because anemia (characterized by a decrease in RBCs below 4.0 million/μl) is a major adverse effect of zidovudine, the nurse should monitor the client's RBC count and assess for signs and symptoms of decreased cellular oxygenation. Zidovudine doesn't affect the blood glucose level, serum calcium level, or platelet count and the values listed are within normal limits.

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

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

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  • 39. 

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

    • A.

      Pallor, bradycardia, and reduced pulse pressure

    • B.

      Pallor, tachycardia, and a sore tongue

    • C.

      Sore tongue, dyspnea, and weight gain

    • D.

      Option 4

    Correct Answer
    B. 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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  • 40. 

    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?

    • A.

      Neutrophil

    • B.

      Basophil

    • C.

      Monocyte

    • D.

      Lymphocyte

    Correct Answer
    D. 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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  • 41. 

    A client newly diagnosed with multiple sclerosis worries that his employer will fire him now that he has a condition that might interfere with his work. How should the nurse respond?

    • A.

      Groups like the National Multiple Sclerosis Society can assist with this issue.

    • B.

      I'm sure your physician can assist you with your work limitations.

    • C.

      You aren't required to tell your employer you have a chronic health problem.

    • D.

      The Americans with Disabilities Act protects you in relation to issues like this.

    Correct Answer
    A. Groups like the National Multiple Sclerosis Society can assist with this issue.
    Explanation
    RATIONALE: The nurse should refer the client to organizations with appropriate resources, such as the National Multiple Sclerosis Society. She shouldn't assure the client that his physician will help him deal with work-related limitations; the physician isn't adequately qualified to advise the client about his relationship with his employer. By telling the client he doesn't have to tell his employer that he has a chronic illness, the nurse is making a legal determination without benefit of legal consultation; she could be performing duties beyond her scope of practice. The Americans with Disabilities Act provides valuable protections, but unless the nurse has definite knowledge of the legal issues involved, she should refer the client to specialized organizations that have resources to guide him in this area of need.

    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. 527.

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  • 42. 

    A client with human immunodeficiency virus undergoes intradermal anergy testing using Candida and mumps antigen. During the 3 days following the tests, there is no induration or evidence of reaction at the intradermal injection sites. The most accurate conclusion the nurse can make is:

    • A.

      The client has no previous exposure to the antigens injected.

    • B.

      The client has antibodies to the antigens.

    • C.

      The client is immunodeficient and won't have a skin response.

    • D.

      The client isn't allergic to the antigens and therefore doesn't react.

    Correct Answer
    C. The client is immunodeficient and won't have a skin response.
    Explanation
    RATIONALE: Anergy testing determines the level of immune response an individual has to common microbes. A normal response is a local skin reaction to all the antigens injected intradermally. Absence of a response within 3 days suggests the individual is immunodeficient and can't produce a normal immune response. It doesn't imply nonexposure to the antigens, which are environmentally prevalent. A positive skin reaction demonstrates presence of antibodies to the antigens. An expected reaction to the antigens isn't considered an allergic or hypersensitive reaction.

    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. 1831.

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  • 43. 

    Which finding should a nurse identify as requiring further investigation?

    • A.

      Red blood cell (RBC) count of 4.9 million/μl

    • B.

      Platelet count of 115,000/μl

    • C.

      White blood cell (WBC) count of 7,000/μl

    • D.

      Hematocrit of 45%

    Correct Answer
    B. Platelet count of 115,000/μl
    Explanation
    RATIONALE: A platelet count of 115,000/μl is abnornal and requires further investigation. Normal values are 150,000 to 300,000 platelets/μl; 5,000 to 10,000 WBCs/μl; 4.5 to 5.5 million RBCs/μl; and an average hematocrit of 45%.

    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. 1042.

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  • 44. 

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

    • A.

      Imbalanced nutrition: Less than body requirements related to poor intake

    • B.

      Disturbed sleep pattern related to external stimuli

    • C.

      Impaired skin integrity related to pruritus

    • D.

      Acute pain related to sickle cell crisis

    Correct Answer
    D. 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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  • 45. 

    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.

      Increased salivation

    • B.

      Increased tearing

    • C.

      Reduced sneezing

    • D.

      Headache

    Correct Answer
    C. 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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  • 46. 

    What nursing interventions should a nurse expect to implement when caring for a child in acute sickle cell crisis? Select all that apply.

    • A.

      Maintaining adequate hydration

    • B.

      Providing adequate pain control

    • C.

      Assessing family education needs

    • D.

      Encouraging healthful eating habits

    • E.

      Frequently monitoring vital signs

    • F.

      Anticipating play needs

    Correct Answer(s)
    A. Maintaining adequate hydration
    B. Providing adequate pain control
    E. Frequently monitoring vital signs
    Explanation
    RATIONALE: Because the child is in acute crisis, providing adequate hydration, controlling pain, and carefully monitoring vital signs are priority points of care. When the child's condition has stabilized, the nurse may evaluate family learning needs, encourage healthful eating habits, and attend to play needs.

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

    REFERENCE: Smeltzer, S.C., et. al. Brunner & Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1059.

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  • 47. 

    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.

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

    • B.

      Calm down. You know that stress will make your symptoms worse.

    • C.

      Would you like to talk about the problem with the nursing supervisor?

    • D.

      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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  • 48. 

    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.

      A man should wear a latex condom during intimate sexual contact.

    • B.

      I've heard about people who got AIDS from blood transfusions.

    • C.

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

    • D.

      I.V. drug users can get HIV from sharing needles.

    Correct Answer
    C. 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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  • 49. 

    A nurse is poviding care for a client with progressive systemic sclerosis. For a client with this disease, the nurse is most likely to formulate which nursing diagnosis?

    • A.

      Risk for impaired skin integrity

    • B.

      Constipation

    • C.

      Ineffective thermoregulation

    • D.

      Risk for imbalanced nutrition: More than body requirements

    Correct Answer
    A. Risk for impaired skin integrity
    Explanation
    RATIONALE: Progressive systemic sclerosis is a connective tissue disease characterized by fibrosis and degenerative changes of the skin, synovial membranes, and digital arteries. Therefore, the nurse is most likely to formulate a nursing diagnosis of Risk for impaired skin integrity. Because clients with the disease are prone to diarrhea from GI tract hypermotility (caused by pathologic changes), Constipation is an unlikely nursing diagnosis. Progressive systemic sclerosis doesn't cause Ineffective thermoregulation. GI hypermotility may lead to malabsorption, and esophageal dysfunction may cause dysphagia; these conditions put the client with the disease at risk for inadequate nutrition, making Risk for imbalanced nutrition: More than body requirements an improbable nursing diagnosis.

    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. 1912.

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  • 50. 

    Nurses were identified by the Centers for Disease Control and Prevention (CDC) as the people most likely to care for clients infected after the intentional release of the smallpox virus. Based on CDC guidelines, which group should volunteer to receive the smallpox vaccine?

    • A.

      Nurses age 50 and older who work in the emergency departments of community hospitals.

    • B.

      Nurses who served in the military and are now working in public health settings.

    • C.

      Nurses born after 1971 who are employed as triage nurses in large medical center emergency departments.

    • D.

      Nurses vaccinated against smallpox as children who are now working in a pediatric unit.

    Correct Answer
    A. Nurses age 50 and older who work in the emergency departments of community hospitals.
    Explanation
    RATIONALE: The CDC recommends the smallpox vaccine for nurses who received the vaccine as children (which includes those older than age 50) who work in the emergency department; emergency department nurses are most likely to care for those infected with the smallpox virus. Nurses born after 1971 weren't previously vaccinated against smallpox so the vaccine isn't currently recommended for those nurses. Military history doesn't dictate whether or not the vaccine is recommended. Nurses who work in the pediatric unit aren't at high risk for smallpox exposure; therefore, the vaccine isn't recommended for this group.

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

    REFERENCE: Wharton M., et al. (2003, April 4). "Recommendations for Using Smallpox Vaccine in a Pre-Event Vaccination Program" [Online]. Available: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5207a1.htm [2007, April 23].

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  • Current Version
  • Mar 21, 2023
    Quiz Edited by
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  • Jan 24, 2016
    Quiz Created by
    Suarezenriquec1

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