med surg 2 final exam (test bank) | Quizlet
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Test: med surg 2 final exam (test bank)

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91 Multiple choice questions

Term
The nurse is preparing for a home visit to a patient after surgery for a compound fracture. Which specific care does the nurse anticipate for this patient?
1 of 91
Term
A patient experiences a fracture of the lower leg and undergoes a closed reduction and placement of a fiberglass cast. The patient is 65 years old and has a medical 30-year history of diabetes mellitus. Which condition does the nurse recognize as a possible complication for this patient?
2 of 91
Term
An older adult patient is postoperative for a total hip joint replacement. Which nursing care is inappropriate for this patient on the day of surgery?
3 of 91
Term
The nurse is providing care for a patient who is scheduled for joint replacement the next day. Which patient care goals are appropriate at this time?
4 of 91
Term
The nurse is providing care for a patient following an open reduction of a compound fracture. Which neurologic finding does the nurse report immediately to the HCP or registered nurse (RN)?
5 of 91
Term
A patient with gout has been instructed on the prescribed medication allopurinol (Zyloprim). Which patient statement indicates understanding of the action of this medication?
6 of 91
Term
The nurse is contributing to the plan of care for a patient who has an upper extremity amputation. Which factor does the nurse keep in mind about this type of amputation being more debilitating than a lower extremity amputation?
7 of 91
Term
A patient who has a displaced midshaft fracture of the left femur is in balanced suspension skeletal traction with 35 pounds of weight. The patient reports calf pain with right foot dorsiflexion. Which action does the nurse take?
8 of 91
Term
The home-care nurse is attending to a patient with osteomyelitis in a lower extremity from a traumatic bone fracture. The patient has an open wound that is infected. Which observation prompts the nurse to provide additional information to the patient and family?
9 of 91
Term
The nurse is providing care for a patient being treated after a complicated femur fracture. The nurse has noticed drowsiness, tachycardia, and a low-grade fever. Which additional manifestation alerts the nurse to the possibility of a fat emboli?
10 of 91
Term
The nurse is assisting with the preparation of materials for a health fair aimed at promoting health in women. Which reason does the nurse recognize as a probable cause of an increase in the incidence of osteoporosis?
11 of 91
Term
The nurse is providing care for a patient who experienced a closed reduction to a fracture of the ulna. Which manifestation does the nurse recognize as an early symptom of acute compartment syndrome?
12 of 91
Term
The nurse is providing care for a patient after an above-the-knee amputation because of ischemia related to diabetes mellitus complications. Which nursing care is essential for promoting ambulation?
13 of 91
Term
A patient is being prepared for a prosthesis following surgery for an amputation. Which information will the nurse provide to the client regarding the use of a prosthesis?
14 of 91
Term
The nurse is providing care for a patient with external fixation for a fracture involving severe bone damage. Which is the most important focus for the nurse during care of this patient?
15 of 91
Term
The nurse is assisting with the care of a patient with rheumatoid arthritis (RA). The nurse must remember in which way RA care is different from osteoarthritis care. Which nursing care does the nurse specifically provide for the patient with RA?
16 of 91
Term
The nurse is assisting with patients on an orthopedic unit. Which is an important factor to remember when caring for patients after a total hip replacement?
17 of 91
Term
The nurse is assisting with the care of patients who have had joint replacement surgery. Which action is unnecessary for the patient after a total knee replacement (TKR)?
18 of 91
Term
A patient asks the difference between osteoarthritis and RA. Which manifestations does the nurse explain are characteristic of RA? (Select all that apply.)
19 of 91
Term
The nurse is collecting data from a patient suspected of developing a fat embolus from a fracture of the right femur. Which manifestations does the nurse expect? (Select all that
apply.)
20 of 91
Term
The patient asks the nurse how much blood is in the body. Which response by the nurse is accurate?
21 of 91
Term
The nurse is reviewing laboratory values for a patient with thrombocytopenia. Which result would concern the nurse the most?
22 of 91
Term
The nurse is taking a health history and notes the patient has a history of a splenectomy. For which condition is this patient at risk?
23 of 91
Term
The nurse is caring for a patient who reports feeling several enlarged lymph nodes. The nurse should plan to prepare the patient for which test?
24 of 91
Term
The nurse is reviewing laboratory values for a female patient and notes a hemoglobin level
of 8.2 g/100 mL and a hematocrit level of 21%. These levels are found in patients with
which condition?
25 of 91
Term
A patient has a bone marrow aspiration from the posterior iliac crest. Before the procedure, the patient's vital signs were blood pressure 132/82 mm Hg and pulse 88 beats/min. One hour after the procedure, the blood pressure is 108/70 mm Hg and pulse is 96 beats/min. Which assessment is the least important for the patient at this time?
26 of 91
Term
The nurse is caring for a group of patients. Which patient should the nurse see first?
27 of 91
Term
A patient is prescribed to receive two units of packed red blood cells (PRBCs). What approach should the nurse use to ensure that the correct blood will be provided to this patient?
28 of 91
Term
A patient is being prepared to receive a prescribed blood transfusion. What is the best way that the licensed practical nurse (LPN) can assist the health team to prevent a transfusion reaction?
29 of 91
Term
The nurse is caring for a patient who underwent a bone marrow biopsy. What is the role of the licensed practical nurse/licensed vocational nurse (LPN/LVN) in this patient's care?
30 of 91
Term
A patient who underwent lymphangiography the day before asks the LPN, "Why does my urine look blue?" What should the LPN respond to this patient's concern?
31 of 91
Term
The nurse is caring for a patient with folic acid deficiency anemia. Which patient is at risk for this condition?
32 of 91
Term
The nurse is preparing a patient for a blood transfusion. The patient has type O blood. Which blood type can this patient receive?
33 of 91
Term
The nurse is caring for a patient with a clotting disorder. Which should the nurse plan to administer?
34 of 91
Term
While receiving a unit of PRBCs, the patient begins to experience hives around the neck and upper chest. What actions should the nurse perform because of this reaction? (Select all that apply.)
35 of 91
Term
The nurse is caring for a patient with anemia. Which clinical manifestations can the nurse expect to document? (Select all that apply.)
36 of 91
Term
The nurse is providing education to a patient newly diagnosed with iron deficiency anemia. Which of the following would be a component of the education?
37 of 91
Term
The nurse is assisting in the development of a care plan for a patient with pernicious anemia. Which of the following would be the most common nursing diagnosis with this medical condition?
38 of 91
Term
The nurse is providing care to the patient with thrombocytopenia. Which of the following activities should the patient avoid?
39 of 91
Term
The nurse is caring for a patient in sickle cell crisis. What is the rationale for providing warm compresses and blankets for this patient?
40 of 91
Term
The nurse is preparing to provide therapeutic treatment to the patient with an exacerbation of polycythemia vera (PV). Which of the following is the expected treatment for this patient?
41 of 91
Term
The nurse is providing care to a patient with a hematological disorder. Which of the following would be a manifestation of disseminated intravascular coagulation (DIC)?
42 of 91
Term
. The nurse is caring for a patient with thrombocytopenia. Which of the following products would the nurse anticipate being prescribed?
43 of 91
Term
The nurse is triaging several patients in an urgent care center. One patient states that he has hemophilia and is bleeding, with no apparent signs of bleeding. Which action by the nurse is most appropriate at this time?
44 of 91
Term
The nurse caring for a patient with chronic leukemia in an acute care setting. The patient asks the nurse to observe the patient's last bowel movement as it is very dark. The nurse immediately contacts the primary health care provider (HCP). What would explain the nurse's action?
45 of 91
Term
The home care nurse is providing teaching to the family of a patient with multiple myeloma. Which nursing diagnosis should guide the nurse for this teaching?
46 of 91
Term
The nurse is assisting the patient with multiple myeloma in arranging a meal plan to lower the risk of complications from hypercalcemia. Which of the following would be the most important component of the patient's intake?
47 of 91
Term
The nurse is providing care to the patient with Hodgkin disease who has cervical lymph node enlargement. Which of the following symptoms should the nurse attend to first?
48 of 91
Term
The nurse is caring for a patient with stage IV Hodgkin disease. Where should the nurse expect to find enlarged lymph nodes during the assessment?
49 of 91
Term
The nurse is caring for the patient with iron deficiency anemia, who has been taking oral iron supplements. Which of the following laboratory tests would determine the effectiveness of this intervention?
50 of 91
Term
The nurse is caring for the patient with pernicious anemia. The patient asks why this happened when she has regularly taken iron supplements while following a strict vegetarian diet. Which of the following would be the nurse's most appropriate response?
51 of 91
Term
The nurse is caring for a patient receiving treatment for a hemolytic anemia due to a reaction from a mismatched blood transfusion. The nurse understands that hemolytic anemia is a definition of what type of anemia?
52 of 91
Term
The nurse is caring for a patient with iron deficiency anemia, which of the following would be the most appropriate nursing intervention for this patient?
53 of 91
Term
The nurse is providing care to the patient with suspected aplastic anemia. The HCP has completed a bone marrow biopsy. Which of the following would be a description of the bone marrow that would signify a positive diagnosis of aplastic anemia?
54 of 91
Term
The nurse is caring for the patient with hemoglobin less than 6 g/dL. Which of the following clinical manifestations would the nurse expect the patient to present?
55 of 91
Term
The nurse is following the care plan risk for ineffective peripheral perfusion related to sickled cells and infarction. Which of the following would be the most appropriate intervention?
56 of 91
Term
The nurse is caring for a patient with chronic episodes of hypoxia secondary to chronic obstructive pulmonary disease. The nurse will monitor the patient's laboratory results for increased RBCs due to the low oxygen levels. Which of the following blood disorders will the nurse expect to find?
57 of 91
Term
The nurse is caring for the patient who recently underwent a colectomy due to a bowel perforation and peritonitis. The nurse is preparing to administer the anticoagulant heparin to prevent which of the following blood disorders?
58 of 91
Term
The nurse is caring for a patient who has CLL when the patient suddenly develops petechiae, nausea, and severe back pain. The nurse recognizes this life-threatening event as which of the following?
59 of 91
Term
The nurse is caring for the patient who underwent emergency treatment for DIC. The patient voices concern over how to explain the tubes and extensive bruising to his family members. Which of the following would be an appropriate nursing intervention for disturbed body image related to physical evidence of aggressive treatment procedures?
60 of 91
Term
The nurse is caring for a patient who must undergo a splenectomy for treatment for idiopathic thrombocytopenic purpura (ITP).Which of the following statements best describes the rationale for the splenectomy?
61 of 91
Term
The nurse is providing education to a patient with mild hemophilia on how to avoid bleeding episodes. Which one of the following would be most appropriate to include in the teaching plan?
62 of 91
Term
The nurse is assisting in developing a plan of care for the patient with hemophilia who is experiencing severe acute pain. Which of the following would be the most appropriate intervention based on the nursing diagnosis acute pain related to bleeding into tissues?
63 of 91
Term
The nurse is assessing the patient recently diagnosed with chronic myelogenous leukemia (CML). What of the following indicates a positive diagnosis for CML?
64 of 91
Term
The nurse is providing education to the patient with the nursing diagnosis of impaired oral membrane integrity related to chemotherapy and pancytopenia. The nurse is aware that the patient understands the teaching by which of the following actions?
65 of 91
Term
The nurse is caring for the patient who is 1 day status postsplenectomy. The patient complains of pain with breathing especially with inspiration. What would be the most appropriate nursing intervention for this patient?
66 of 91
Term
The nurse is caring for a patient with a folic acid deficiency. What foods should the nurse encourage the patient to improve this deficiency? (Select all that apply.)
67 of 91
Term
The nurse is assessing a patient in a family practice clinic. The patient had extensive testing to rule out Hodgkin disease. Which of the following characteristics would indicate Hodgkin disease? (Select all that apply.)
68 of 91
Term
The nurse is caring for a patient who has been recently diagnosed with aplastic anemia. Which of the following are indicators of this disease process? (Select all that apply.)
69 of 91
Term
The nurse is caring for a patient with a platelet count of <20,000/mm3 . Which of the following precautions should the nurse take in providing care for this patient? (Select all that apply.)
70 of 91
Term
The nurse is providing care to the patient who has arrived at the clinic to discuss his diagnostic results. The HCP suspects multiple myeloma. Which of the following results may confirm the HCP's suspicions? (Select all that apply.)
71 of 91
Term
The nurse is collecting data for a patient with osteoporosis. Which serum calcium result indicates the typical changes that occur in serum calcium levels with osteoporosis?
72 of 91
Term
The nurse is collecting data on a patient with manifestations of osteoarthritis. Which method of physical examination is unnecessary?
73 of 91
Term
The nurse is preparing material for a presentation about the musculoskeletal system. Which information is inaccurate in regard to the functioning of this system?
74 of 91
Term
The nurse is helping a patient understand all of the functions of the skeleton. Which function is incorrect?
75 of 91
Term
The nurse is caring for a patient with a suspected bone tumor. Which serum laboratory result indicates to the nurse that this health problem is present?
76 of 91
Term
The nurse is collecting data on an older adult patient. Which finding is indicative of normal changes in the musculoskeletal system of this patient?
77 of 91
Term
The nurse is collecting data on a patient who is experiencing hip pain. Which data does the nurse consider to be subjective?
78 of 91
Term
The nurse is providing care for a patient scheduled for an arthrography. Which explanation about pain during the procedure does the nurse provide?
79 of 91
Term
A patient diagnosed with curvature of the spine asks the nurse why breathing is so much more difficult. Which answer by the nurse best answers the question?
80 of 91
Term
The nurse is providing care for a patient who is diagnosed with rhabdomyolysis from a crushing injury. Laboratory results indicate elevated levels of CK, myoglobin, and serum potassium. Which nursing care is most important for the nurse implement?
81 of 91
Term
A patient arrives at a clinic with a knee joint that is noticeably swollen, warm to the touch, and painful. The HCP plans to perform an arthrocentesis. Given the patient's symptoms, which is the least likely reason for the procedure?
82 of 91
Term
The nurse is reviewing the laboratory results for a patient with severe bone pain. Which condition does the nurse suspect if the ALP level is elevated?
83 of 91
Term
A patient is scheduled for arthroscopic surgery on a knee. The patient is to receive light general anesthesia and will be discharged home. Which action will cause the nurse to contact the HCP or registered nurse (RN)?
84 of 91
Term
The nurse is providing care for a patient before a myelography for diagnosis of a spinal column condition. Which statement regarding nursing care related to this procedure is correct?
85 of 91
Term
A patient is receiving care for a torn ligament at the insertion site of an upper arm muscle. The patient asks the nurse how this condition will affect movement. Which information will the nurse correctly share?
86 of 91
Term
A female patient arrives at the HCP's office for a routine checkup. The nurse notes that the patient is thin, of Asian descent, and experienced a surgery-induced menopause. Which test does the nurse expect the HCP to prescribe?
87 of 91
Term
A patient is prepared for a nuclear medicine scan of the skeleton, using gallium and thallium as the radioisotopes. Which nursing care will the nurse provide if the scan reveals high thallium concentrations?
88 of 91
Term
A patient just had an arthrogram performed for pain in a synovial joint. Which nursing care is inappropriate following this procedure?
89 of 91
Term
A patient is recovering from a biopsy of the right femur and was given pain medication 1 hour ago. Which symptom does the nurse report and closely monitor in this patient? (Select all that apply.)
90 of 91
Term
A patient was an unrestrained passenger in a motor vehicle accident and hit the windshield. In addition, the patient's leg was fractured. Which areas should be included in this patient's neurovascular checks? (Select all that apply.)
91 of 91
Term
The nurse is preparing for a home visit to a patient after surgery for a compound fracture. Which specific care does the nurse anticipate for this patient?
Checking skin integrity
Changing wound dressings
Monitoring circulatory status
Validating immobilization
1 of 91
Term
A patient experiences a fracture of the lower leg and undergoes a closed reduction and placement of a fiberglass cast. The patient is 65 years old and has a medical 30-year history of diabetes mellitus. Which condition does the nurse recognize as a possible complication for this patient?
Delay or absence of healing
Impaired mobility function
Development of bone infection
Malalignment of healed bones
2 of 91
Term
An older adult patient is postoperative for a total hip joint replacement. Which nursing care is inappropriate for this patient on the day of surgery?
Pallor with extremity warmth
Prescribed weight-bearing is maintained
Medicated with oral pain medications
Provided with an elevated toilet seat
3 of 91
Term
The nurse is providing care for a patient who is scheduled for joint replacement the next day. Which patient care goals are appropriate at this time?
Teach postoperative exercises.
Ask if a consent form was signed.
Explain the use of assistive devices.
Manage preoperative pain.
4 of 91
Term
The nurse is providing care for a patient following an open reduction of a compound fracture. Which neurologic finding does the nurse report immediately to the HCP or registered nurse (RN)?
Absent peripheral pulses
Pallor elevated respiratory rate clubbed fingers
Pallor with extremity warmth
There exists numbness and tingling sensations
5 of 91
Term
A patient with gout has been instructed on the prescribed medication allopurinol (Zyloprim). Which patient statement indicates understanding of the action of this medication?
"It blocks formation of uric acid."
elevate the limb that was tested.
the ages of adults have increased.
"it increases metabolism of purines."
6 of 91
Term
The nurse is contributing to the plan of care for a patient who has an upper extremity amputation. Which factor does the nurse keep in mind about this type of amputation being more debilitating than a lower extremity amputation?
The upper extremity is more visible.
There is greater blood supply to the upper extremity.
The ages of adults have increased.
The upper extremity is more specialized.
7 of 91
Term
A patient who has a displaced midshaft fracture of the left femur is in balanced suspension skeletal traction with 35 pounds of weight. The patient reports calf pain with right foot dorsiflexion. Which action does the nurse take?
Check the Traction Setup.
Notify the RN.
Reposition the Patient.
Remove the Pillow under the Cast.
8 of 91
Term
The home-care nurse is attending to a patient with osteomyelitis in a lower extremity from a traumatic bone fracture. The patient has an open wound that is infected. Which observation prompts the nurse to provide additional information to the patient and family?
The spleen is the primary site for platelet destruction.
Clean technique is used when the dressing is changed.
The patient keeps her dentures in at all times except for cleaning.
The patient may have a gastrointestinal bleed.
9 of 91
Term
The nurse is providing care for a patient being treated after a complicated femur fracture. The nurse has noticed drowsiness, tachycardia, and a low-grade fever. Which additional manifestation alerts the nurse to the possibility of a fat emboli?
The spleen is the primary site for platelet destruction.
Presence of pain in knees joints in the morning
It is essential to monitor all body systems for effects of the disease.
Presence of a petechial rash on chest and neck
10 of 91
Term
The nurse is assisting with the preparation of materials for a health fair aimed at promoting health in women. Which reason does the nurse recognize as a probable cause of an increase in the incidence of osteoporosis?
The ages of adults have increased.
There is an increased number of smokers.
The upper extremity is more specialized.
The patient may have a gastrointestinal bleed.
11 of 91
Term
The nurse is providing care for a patient who experienced a closed reduction to a fracture of the ulna. Which manifestation does the nurse recognize as an early symptom of acute compartment syndrome?
Paralysis of the affected limb
Poikilothermia of the arm
Pallor with extremity warmth
Lack of a distal pulse
12 of 91
Term
The nurse is providing care for a patient after an above-the-knee amputation because of ischemia related to diabetes mellitus complications. Which nursing care is essential for promoting ambulation?
Elevate the limb that was tested.
Promoting coordination exercises
Lying on the abdomen as prescribed
Maintaining residual limb elevation
13 of 91
Term
A patient is being prepared for a prosthesis following surgery for an amputation. Which information will the nurse provide to the client regarding the use of a prosthesis?
Hematoma formation
Pain reported as 7 on a 0-to-10 scale
Skin inspection is performed each time the sock is removed.
Extend a willingness to sit and talk with the patient.
A pain level of 8 on a 0-to-10 scale after mild analgesia
14 of 91
Term
The nurse is providing care for a patient with external fixation for a fracture involving severe bone damage. Which is the most important focus for the nurse during care of this patient?
Monitoring pin and wound sites for signs of infection
Monitor the site for bleeding and infection.
Administer desmopressin intranasally prior to any dental procedure or sports.
There exists numbness and tingling sensations
15 of 91
Term
The nurse is assisting with the care of a patient with rheumatoid arthritis (RA). The nurse must remember in which way RA care is different from osteoarthritis care. Which nursing care does the nurse specifically provide for the patient with RA?
It is essential to monitor all body systems for effects of the disease.
Include citrus fruits while taking the medication for this disorder
The bone marrow is pale, fatty, and fibrous.
Joint articulations are maintained by moisture from the lymph system.
16 of 91
Term
The nurse is assisting with patients on an orthopedic unit. Which is an important factor to remember when caring for patients after a total hip replacement?
Avoid restrictive clothing and raising the knee gatch in the bed.
Administer opioids as prescribed, avoiding IM injections.
A triangular pillow is used between the legs to avoid adduction.
Instruct the patient to notify the HCP of nausea or constipation
17 of 91
Term
The nurse is assisting with the care of patients who have had joint replacement surgery. Which action is unnecessary for the patient after a total knee replacement (TKR)?
Check for indications of a dvt.
The patient may have a gastrointestinal bleed.
Ambulate as prescribed by hcp.
Maintain proper joint alignment.
18 of 91
Term
A patient asks the difference between osteoarthritis and RA. Which manifestations does the nurse explain are characteristic of RA? (Select all that apply.)
Hematoma formation
Pain reported as 7 on a 0-to-10 scale
Generalized throughout the Body within Multiple organs
Early morning stiffness
Autoimmune disease
Low-grade fever
"The thoracic cage has lost some flexibility."
19 of 91
Term
The nurse is collecting data from a patient suspected of developing a fat embolus from a fracture of the right femur. Which manifestations does the nurse expect? (Select all that
apply.)
Activity intolerance related to tissue hypoxia
Tachycardia
Mental confusion
Petechiae
Hemoglobin and hematocrit
There exists numbness and tingling sensations
20 of 91
Term
The patient asks the nurse how much blood is in the body. Which response by the nurse is accurate?
7-9 liters
10-12 liters
1-3 liters
4-6 liters
21 of 91
Term
The nurse is reviewing laboratory values for a patient with thrombocytopenia. Which result would concern the nurse the most?
Wbc 9,000/mm3
Serum albumin 4.5 g/dl
Platelets 50,000/mm3
6.5 mg/dl
22 of 91
Term
The nurse is taking a health history and notes the patient has a history of a splenectomy. For which condition is this patient at risk?
Tuberculosis
Pneumonia
Meningitis
Encephalitis
23 of 91
Term
The nurse is caring for a patient who reports feeling several enlarged lymph nodes. The nurse should plan to prepare the patient for which test?
A capillary blood sample
A complete blood count (CBC)
An arterial blood gas (abg) study
Fresh frozen plasma (ffp)
24 of 91
Term
The nurse is reviewing laboratory values for a female patient and notes a hemoglobin level
of 8.2 g/100 mL and a hematocrit level of 21%. These levels are found in patients with
which condition?
Hypertension
Hemophilia
Anemia
Leukemia
25 of 91
Term
A patient has a bone marrow aspiration from the posterior iliac crest. Before the procedure, the patient's vital signs were blood pressure 132/82 mm Hg and pulse 88 beats/min. One hour after the procedure, the blood pressure is 108/70 mm Hg and pulse is 96 beats/min. Which assessment is the least important for the patient at this time?
Notify the rn.
Observe the puncture site.
The patient may have a Gastrointestinal bleed.
Check the patient's most recent CBC report.
26 of 91
Term
The nurse is caring for a group of patients. Which patient should the nurse see first?
Activity intolerance related to tissue hypoxia
The patient should increase intake of fluids.
A patient with an RBC count of 2.4 million/mm3
Monitor the site for bleeding and infection.
27 of 91
Term
A patient is prescribed to receive two units of packed red blood cells (PRBCs). What approach should the nurse use to ensure that the correct blood will be provided to this patient?
Follow the organization's verification process.
The patient may have a gastrointestinal bleed.
Elevate the limb that was tested.
Check the patient's arm band.
28 of 91
Term
A patient is being prepared to receive a prescribed blood transfusion. What is the best way that the licensed practical nurse (LPN) can assist the health team to prevent a transfusion reaction?
Elevate the limb that was tested.
"You will be head down in bed so the medium flows to the neck."
Assist the registered nurse (RN) to correctly identify the patient and the blood product.
To mechanically inhibit the production of synovial fluid
29 of 91
Term
The nurse is caring for a patient who underwent a bone marrow biopsy. What is the role of the licensed practical nurse/licensed vocational nurse (LPN/LVN) in this patient's care?
Observe the color and amount of urine.
Prepare the client for a chest x-ray.
Monitor the site for bleeding and infection.
"there is temporary pain during dye injection."
30 of 91
Term
A patient who underwent lymphangiography the day before asks the LPN, "Why does my urine look blue?" What should the LPN respond to this patient's concern?
The patient keeps her dentures in at all times except for cleaning.
There exists numbness and tingling sensations
Heat increases circulation by preventing vasoconstriction.
The dye used in the procedure may cause bluish skin and urine for 2 days."
31 of 91
Term
The nurse is caring for a patient with folic acid deficiency anemia. Which patient is at risk for this condition?
A patient who drinks alcohol daily
Elevate the limb that was tested.
A patient who is vegan
The patient may have a gastrointestinal bleed.
32 of 91
Term
The nurse is preparing a patient for a blood transfusion. The patient has type O blood. Which blood type can this patient receive?
Absent peripheral pulses
Stridor
Type O
Manage preoperative pain.
33 of 91
Term
The nurse is caring for a patient with a clotting disorder. Which should the nurse plan to administer?
Packed red blood cells (prbcs)
Fresh frozen plasma (FFP)
A complete blood count (cbc)
Platelets
34 of 91
Term
While receiving a unit of PRBCs, the patient begins to experience hives around the neck and upper chest. What actions should the nurse perform because of this reaction? (Select all that apply.)
Stop the transfusion.
Notify the HCP.
Administer prescribed antihistamines.
Restart the infusion and carefully monitor
A pain level of 8 on a 0-to-10 scale after mild analgesia
Skin inspection is performed each time the sock is removed.
Extend a willingness to sit and talk with the patient.
35 of 91
Term
The nurse is caring for a patient with anemia. Which clinical manifestations can the nurse expect to document? (Select all that apply.)
Generalized throughout the body within multiple organs
Pallor
Elevated respiratory rate
Clubbed fingers
There Exists numbness and Tingling sensations
Generalized throughout the body within multiple organs
36 of 91
Term
The nurse is providing education to a patient newly diagnosed with iron deficiency anemia. Which of the following would be a component of the education?
Administer desmopressin intranasally prior to any dental procedure or sports.
The patient keeps her dentures in at all times except for cleaning.
Include citrus fruits while taking the medication for this disorder
Elevated alkaline phosphatase (ALP)
37 of 91
Term
The nurse is assisting in the development of a care plan for a patient with pernicious anemia. Which of the following would be the most common nursing diagnosis with this medical condition?
Activity intolerance related to tissue hypoxia
Risk for infection related to reduction in circulating wbcs
Chronic pain related to bone marrow dysfunction
Ineffective airway clearance related to dyspnea
38 of 91
Term
The nurse is providing care to the patient with thrombocytopenia. Which of the following activities should the patient avoid?
Cryoprecipitate
Receiving an influenza vaccination
There exists numbness and tingling sensations
Absent peripheral pulses
39 of 91
Term
The nurse is caring for a patient in sickle cell crisis. What is the rationale for providing warm compresses and blankets for this patient?
Monitor the site for bleeding and infection.
Observe the color and amount of urine.
Heat relaxes the muscles and distracts the patient from the pain.
Heat increases circulation by preventing vasoconstriction.
40 of 91
Term
The nurse is preparing to provide therapeutic treatment to the patient with an exacerbation of polycythemia vera (PV). Which of the following is the expected treatment for this patient?
Bone cancer
Therapeutic phlebotomy
Therapeutic drug monitoring
Aplastic anemia
41 of 91
Term
The nurse is providing care to a patient with a hematological disorder. Which of the following would be a manifestation of disseminated intravascular coagulation (DIC)?
Rapid, shallow breathing
Restlessness or anxiety
Absent peripheral pulses
Cool and clammy skin
42 of 91
Term
. The nurse is caring for a patient with thrombocytopenia. Which of the following products would the nurse anticipate being prescribed?
Fresh Frozen Plasma
Receiving An Influenza Vaccination
Cryoprecipitate
Platelets
43 of 91
Term
The nurse is triaging several patients in an urgent care center. One patient states that he has hemophilia and is bleeding, with no apparent signs of bleeding. Which action by the nurse is most appropriate at this time?
Place the patient in an examination room immediately and notify the physician of a potential bleeding crisis.
Enlist the aid of other members of the health care team to support the family.
Split pea soup with whole grain crackers
Garden salad with green leafy vegetables
Cereals made with fortified grain and wheat germ
The laboratory results show presence of Reed-Sternberg cells.
The patient has painless swelling of the cervical and axillary nodes.
44 of 91
Term
The nurse caring for a patient with chronic leukemia in an acute care setting. The patient asks the nurse to observe the patient's last bowel movement as it is very dark. The nurse immediately contacts the primary health care provider (HCP). What would explain the nurse's action?
The ages of adults have increased.
The patient may have a gastrointestinal bleed.
Follow the organization's verification process.
The upper extremity is more specialized.
45 of 91
Term
The home care nurse is providing teaching to the family of a patient with multiple myeloma. Which nursing diagnosis should guide the nurse for this teaching?
Activity intolerance related to tissue hypoxia
Monitoring pin and wound sites for signs of infection
Tachycardia
Mental confusion
Petechiae
Risk for injury related to compromised bone integrity
46 of 91
Term
The nurse is assisting the patient with multiple myeloma in arranging a meal plan to lower the risk of complications from hypercalcemia. Which of the following would be the most important component of the patient's intake?
The patient should avoid alcoholic beverages.
Observe the color and amount of urine.
The patient should increase intake of fluids.
The ages of adults have increased.
47 of 91
Term
The nurse is providing care to the patient with Hodgkin disease who has cervical lymph node enlargement. Which of the following symptoms should the nurse attend to first?
Stridor
Wheezing
Rhonchi
Wheezes
48 of 91
Term
The nurse is caring for a patient with stage IV Hodgkin disease. Where should the nurse expect to find enlarged lymph nodes during the assessment?
Changing wound dressings
Localized in the cervical neck area only
Generalized throughout the body within multiple organs
Medicated with oral pain medications
49 of 91
Term
The nurse is caring for the patient with iron deficiency anemia, who has been taking oral iron supplements. Which of the following laboratory tests would determine the effectiveness of this intervention?
Blood pressure
Culture and sensitivity
Hemoglobin and hematocrit
Intracranial pressure
50 of 91
Term
The nurse is caring for the patient with pernicious anemia. The patient asks why this happened when she has regularly taken iron supplements while following a strict vegetarian diet. Which of the following would be the nurse's most appropriate response?
"Increase dairy products such as yogurt to increase your intake of vitamin B12."
Skin inspection is performed each time the sock is removed.
A pain level of 8 on a 0-to-10 scale after mild analgesia
Extend a willingness to sit and talk with the patient.
51 of 91
Term
The nurse is caring for a patient receiving treatment for a hemolytic anemia due to a reaction from a mismatched blood transfusion. The nurse understands that hemolytic anemia is a definition of what type of anemia?
Aplastic Anemia
A Deficiency in Vitamin B12
Destruction of RBCs
Malformed Rbcs
52 of 91
Term
The nurse is caring for a patient with iron deficiency anemia, which of the following would be the most appropriate nursing intervention for this patient?
Instruct the patient to notify the HCP of nausea or constipation
Presence of pain in knees joints in the morning
Heat increases circulation by preventing vasoconstriction.
Generalized throughout the body within multiple organs
53 of 91
Term
The nurse is providing care to the patient with suspected aplastic anemia. The HCP has completed a bone marrow biopsy. Which of the following would be a description of the bone marrow that would signify a positive diagnosis of aplastic anemia?
The patient should increase intake of fluids.
The upper extremity is more specialized.
Observe the color and amount of urine.
The bone marrow is pale, fatty, and fibrous.
54 of 91
Term
The nurse is caring for the patient with hemoglobin less than 6 g/dL. Which of the following clinical manifestations would the nurse expect the patient to present?
Observe the color and amount of urine.
Orthopnea, blurred vision, and pruritus
Monitor the site for bleeding and infection.
Petechiae, ecchymosis, and restlessness
55 of 91
Term
The nurse is following the care plan risk for ineffective peripheral perfusion related to sickled cells and infarction. Which of the following would be the most appropriate intervention?
Avoid restrictive clothing and raising the knee gatch in the bed.
The spleen is the primary site for platelet destruction.
Monitor the site for bleeding and infection.
Monitoring pin and wound sites for signs of infection
56 of 91
Term
The nurse is caring for a patient with chronic episodes of hypoxia secondary to chronic obstructive pulmonary disease. The nurse will monitor the patient's laboratory results for increased RBCs due to the low oxygen levels. Which of the following blood disorders will the nurse expect to find?
Hemolytic anemia
Sickle cell anemia
Aplastic anemia
Iron deficiency anemia
57 of 91
Term
The nurse is caring for the patient who recently underwent a colectomy due to a bowel perforation and peritonitis. The nurse is preparing to administer the anticoagulant heparin to prevent which of the following blood disorders?
ANEMIA
TTP
DIC
ITP
58 of 91
Term
The nurse is caring for a patient who has CLL when the patient suddenly develops petechiae, nausea, and severe back pain. The nurse recognizes this life-threatening event as which of the following?
ITP
DIC
ANEMIA
TTP
59 of 91
Term
The nurse is caring for the patient who underwent emergency treatment for DIC. The patient voices concern over how to explain the tubes and extensive bruising to his family members. Which of the following would be an appropriate nursing intervention for disturbed body image related to physical evidence of aggressive treatment procedures?
Instruct the patient to notify the HCP of nausea or constipation
The patient keeps her dentures in at all times except for cleaning.
Enlist the aid of other members of the health care team to support the family.
Administer opioids as prescribed, avoiding IM injections.
60 of 91
Term
The nurse is caring for a patient who must undergo a splenectomy for treatment for idiopathic thrombocytopenic purpura (ITP).Which of the following statements best describes the rationale for the splenectomy?
The patient should increase intake of fluids.
There exists numbness and tingling sensations
The spleen is the primary site for platelet destruction.
The ages of adults have increased.
61 of 91
Term
The nurse is providing education to a patient with mild hemophilia on how to avoid bleeding episodes. Which one of the following would be most appropriate to include in the teaching plan?
Administer desmopressin intranasally prior to any dental procedure or sports.
Avoid restrictive clothing and raising the knee gatch in the bed.
Joint articulations are maintained by moisture from the lymph system.
Monitoring pin and wound sites for signs of infection
62 of 91
Term
The nurse is assisting in developing a plan of care for the patient with hemophilia who is experiencing severe acute pain. Which of the following would be the most appropriate intervention based on the nursing diagnosis acute pain related to bleeding into tissues?
The patient should increase intake Of fluids.
Instruct the patient on bleeding precautions and signs and symptoms of bleeding.
Monitor the site for bleeding And infection.
Administer opioids as prescribed, avoiding IM injections.
63 of 91
Term
The nurse is assessing the patient recently diagnosed with chronic myelogenous leukemia (CML). What of the following indicates a positive diagnosis for CML?
Genetic analysis of bone marrow reveals Philadelphia chromosome.
Elevated alkaline phosphatase (ALP)
Heat increases circulation by preventing vasoconstriction.
A triangular pillow is used between the legs to avoid adduction.
64 of 91
Term
The nurse is providing education to the patient with the nursing diagnosis of impaired oral membrane integrity related to chemotherapy and pancytopenia. The nurse is aware that the patient understands the teaching by which of the following actions?
Include citrus fruits while taking the medication for this disorder
The patient keeps her dentures in at all times except for cleaning.
The bone marrow is pale, fatty, and fibrous.
The ages of adults have increased.
65 of 91
Term
The nurse is caring for the patient who is 1 day status postsplenectomy. The patient complains of pain with breathing especially with inspiration. What would be the most appropriate nursing intervention for this patient?
Monitor for black tarry stools.
Avoid blood draws when possible.
Use soft toothbrush to clean the teeth.
Administer desmopressin intranasally prior to any dental procedure or sports.
Medicate with opioids for pain and assist the patient to deep breathe, cough, and ambulate.
Bone marrow that is pale, fatty, and fibrous
A CBC with all low values
Increased total iron-binding capacity (TIBC)
66 of 91
Term
The nurse is caring for a patient with a folic acid deficiency. What foods should the nurse encourage the patient to improve this deficiency? (Select all that apply.)
Administer desmopressin intranasally prior to any dental procedure or sports.
Monitor the site for bleeding and infection.
The laboratory results show presence of Reed-Sternberg cells.
The patient has painless swelling of the cervical and axillary nodes.
Split pea soup with whole grain crackers
Garden salad with green leafy vegetables
Cereals made with fortified grain and wheat germ
67 of 91
Term
The nurse is assessing a patient in a family practice clinic. The patient had extensive testing to rule out Hodgkin disease. Which of the following characteristics would indicate Hodgkin disease? (Select all that apply.)
Bone marrow that is pale, fatty, and fibrous
A CBC with all low values
Increased total iron-binding capacity (TIBC)
The laboratory results show presence of Reed-Sternberg cells.
The patient has painless swelling of the cervical and axillary nodes.
Place the patient in an examination room immediately and notify the physician of a potential bleeding crisis.
The patient keeps her dentures in at all times except for cleaning.
68 of 91
Term
The nurse is caring for a patient who has been recently diagnosed with aplastic anemia. Which of the following are indicators of this disease process? (Select all that apply.)
Place the patient in an examination room immediately and notify the physician of a potential bleeding crisis.
Generalized throughout the body within multiple organs
Tachycardia
Mental confusion
Petechiae
Bone marrow that is pale, fatty, and fibrous
A CBC with all low values
Increased total iron-binding capacity (TIBC)
69 of 91
Term
The nurse is caring for a patient with a platelet count of <20,000/mm3 . Which of the following precautions should the nurse take in providing care for this patient? (Select all that apply.)
Split pea soup with whole grain crackers
Garden salad with green leafy vegetables
Cereals made with fortified grain and wheat germ
Administer desmopressin intranasally prior to any dental procedure or sports.
Avoid restrictive clothing and raising the knee gatch in the bed.
Monitor for black tarry stools.
Avoid blood draws when possible.
Use soft toothbrush to clean the teeth.
70 of 91
Term
The nurse is providing care to the patient who has arrived at the clinic to discuss his diagnostic results. The HCP suspects multiple myeloma. Which of the following results may confirm the HCP's suspicions? (Select all that apply.)
Monitor for black tarry stools.
Avoid blood draws when possible.
Use soft toothbrush to clean the teeth.
Place the patient in an examination room immediately and notify the physician of a potential bleeding crisis.
Magnetic resonance imaging (MRI) shows diffuse osteoporosis in the bones.
Blood chemistries reveal an increase in serum calcium.
Blood and urine studies are positive for M-type globulins.
The laboratory results show presence of Reed-Sternberg cells.
The patient has painless swelling of the cervical and axillary nodes.
71 of 91
Term
The nurse is collecting data for a patient with osteoporosis. Which serum calcium result indicates the typical changes that occur in serum calcium levels with osteoporosis?
4.0 mg/dl
10.3 mg/dl
8.2 mg/dl
6.5 mg/dL
72 of 91
Term
The nurse is collecting data on a patient with manifestations of osteoarthritis. Which method of physical examination is unnecessary?
Palpating for abnormal conditions
Pallor with extremity warmth
Auscultating for joint deformity
Observing ability to perform range of motion (rom)
73 of 91
Term
The nurse is preparing material for a presentation about the musculoskeletal system. Which information is inaccurate in regard to the functioning of this system?
Monitor the site for bleeding and infection.
Monitoring pin and wound sites for signs of infection
Administer desmopressin intranasally prior to any dental procedure or sports.
Joint articulations are maintained by moisture from the lymph system.
74 of 91
Term
The nurse is helping a patient understand all of the functions of the skeleton. Which function is incorrect?
A pain level of 7 on a 0-to-10 scale
A patient with an RBC count of 2.4 million/mm3
It is the main system responsible for body movement.
It is essential to monitor all body systems for effects of the disease.
75 of 91
Term
The nurse is caring for a patient with a suspected bone tumor. Which serum laboratory result indicates to the nurse that this health problem is present?
Decreased calcium
Fresh frozen plasma (ffp)
Increased creatine kinase (ck)
Elevated alkaline phosphatase (ALP)
76 of 91
Term
The nurse is collecting data on an older adult patient. Which finding is indicative of normal changes in the musculoskeletal system of this patient?
Orthopnea, blurred vision, and pruritus
Presence of pain in knees joints in the morning
A triangular pillow is used between the legs to avoid adduction.
Generalized throughout the body within multiple organs
77 of 91
Term
The nurse is collecting data on a patient who is experiencing hip pain. Which data does the nurse consider to be subjective?
Heat increases circulation by preventing vasoconstriction.
A pain level of 7 on a 0-to-10 scale
A patient with an RBC count of 2.4 million/mm3
A complete blood count (CBC)
78 of 91
Term
The nurse is providing care for a patient scheduled for an arthrography. Which explanation about pain during the procedure does the nurse provide?
"the procedure will be uncomfortable until it is completed."
monitor the site for bleeding and infection.
"There is temporary pain during dye injection."
"there is no pain during the procedure."
79 of 91
Term
A patient diagnosed with curvature of the spine asks the nurse why breathing is so much more difficult. Which answer by the nurse best answers the question?
the upper extremity is more specialized.
"The thoracic cage has lost some flexibility."
"the thoracic cage expands with a spinal curvature."
follow the organization's verification process.
80 of 91
Term
The nurse is providing care for a patient who is diagnosed with rhabdomyolysis from a crushing injury. Laboratory results indicate elevated levels of CK, myoglobin, and serum potassium. Which nursing care is most important for the nurse implement?
Alternate heat and cold applications.
Observe the color and amount of urine.
Perform passive rom hourly.
The patient should increase intake of fluids.
81 of 91
Term
A patient arrives at a clinic with a knee joint that is noticeably swollen, warm to the touch, and painful. The HCP plans to perform an arthrocentesis. Given the patient's symptoms, which is the least likely reason for the procedure?
Extend a willingness to sit and talk with the patient.
A pain level of 8 on a 0-to-10 scale after mild analgesia
"It blocks formation of uric acid."
To mechanically inhibit the production of synovial fluid
82 of 91
Term
The nurse is reviewing the laboratory results for a patient with severe bone pain. Which condition does the nurse suspect if the ALP level is elevated?
Thyroid cancer
Bone cancer
Prostate cancer
Lung cancer
83 of 91
Term
A patient is scheduled for arthroscopic surgery on a knee. The patient is to receive light general anesthesia and will be discharged home. Which action will cause the nurse to contact the HCP or registered nurse (RN)?
Follow the organization's verification process.
To mechanically inhibit the production of synovial fluid
A pain level of 8 on a 0-to-10 scale after mild analgesia
Hematoma formation
Pain reported as 7 on a 0-to-10 scale
84 of 91
Term
The nurse is providing care for a patient before a myelography for diagnosis of a spinal column condition. Which statement regarding nursing care related to this procedure is correct?
6.5 mg/dL
Extend a willingness to sit and talk with the patient.
Hematoma formation
Pain reported as 7 on a 0-to-10 scale
"You will be head down in bed so the medium flows to the neck."
85 of 91
Term
A patient is receiving care for a torn ligament at the insertion site of an upper arm muscle. The patient asks the nurse how this condition will affect movement. Which information will the nurse correctly share?
The spleen is the primary site for platelet destruction.
The bone marrow is pale, fatty, and fibrous.
The movement of the arm will seem normal.
Observe the color and amount of urine.
86 of 91
Term
A female patient arrives at the HCP's office for a routine checkup. The nurse notes that the patient is thin, of Asian descent, and experienced a surgery-induced menopause. Which test does the nurse expect the HCP to prescribe?
A bone scan of the ankle and wrist
A complete blood count (cbc)
A test to determine blood calcium levels
A dual-energy x-ray absorptiometry (DEXA)
87 of 91
Term
A patient is prepared for a nuclear medicine scan of the skeleton, using gallium and thallium as the radioisotopes. Which nursing care will the nurse provide if the scan reveals high thallium concentrations?
To mechanically inhibit the production of synovial fluid
Extend a willingness to sit and talk with the patient.
"The thoracic cage has lost some flexibility."
Hematoma formation
Pain reported as 7 on a 0-to-10 scale
88 of 91
Term
A patient just had an arthrogram performed for pain in a synovial joint. Which nursing care is inappropriate following this procedure?
The ages of adults have increased.
Apply an elastic wrap for swelling.
Elevate the limb that was tested.
Apply ice to the affected area.
89 of 91
Term
A patient is recovering from a biopsy of the right femur and was given pain medication 1 hour ago. Which symptom does the nurse report and closely monitor in this patient? (Select all that apply.)
"Increase dairy products such as yogurt to increase your intake of vitamin B12."
Elevate the limb that was tested.
Hematoma formation
Pain reported as 7 on a 0-to-10 scale
To mechanically inhibit the production of synovial fluid
90 of 91
Term
A patient was an unrestrained passenger in a motor vehicle accident and hit the windshield. In addition, the patient's leg was fractured. Which areas should be included in this patient's neurovascular checks? (Select all that apply.)
Absent Peripheral Pulses
Notify The Rn.
Dic
Pulses
Sensation
Movement
91 of 91