Adult Health Nursing 7th Edition By Cooper Gosnell -Test Bank

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Adult Health Nursing 7th Edition By Cooper Gosnell -Test Bank

Chapter 6: Care of the Patient with a Gallbladder, Liver, Biliary Tract, or Exocrine Pancreatic Disorder

 

MULTIPLE CHOICE

 

  1. The nurse clarifies that unconjugated bilirubin, which is made up of broken-down red cells, is:
a. stored in the gallbladder  to make bile.
b. water insoluble bilirubin that must be converted by the liver.
c. a by-product which is excreted directly into the bowel for excretion.
d. necessary for digestion of fats.

 

 

ANS:  B

Unconjugated bilirubin is a water-insoluble product that must be converted in the liver to conjugated bilirubin (water soluble) so that it may be excreted through the bowel.

 

DIF:    Cognitive Level: Analysis               REF:   Page 233        OBJ:   1

TOP:   Bilirubin         KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. The patient with cirrhosis has an albumin of 2.8 g/dL. The nurse is aware that normal is 3.5 g/dL to 5 g/dL. Based on these findings, what would the nurse expect the patient to exhibit?
a. Jaundice
b. Edema
c. Copious urine output
d. Pallor

 

 

ANS:  B

Low serum albumin levels result also from excessive loss of albumin into urine or into third-space volumes, causing ascites or edema.

 

DIF:    Cognitive Level: Analysis               REF:   Page 234        OBJ:   1

TOP:   Cirrhosis        KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. What is an essential nursing measure to prevent injury to the patient who is to receive a paracentesis?
a. Have patient sign a permit
b. Pad side rails
c. Check for allergy to contrast media or to shellfish
d. Have patient void immediately before procedure

 

 

ANS:  D

To prevent the puncturing of the bladder, the patient must void immediately before the procedure. A permit is required but it is not a safety precaution for the patient. There is no contrast media used in a paracentesis.

 

DIF:    Cognitive Level: Application          REF:   Page 242        OBJ:   2

TOP:   Paracentesis   KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. What should the nurse expect of a patient with a malabsorption of vitamin K?
a. Lowered hemoglobin
b. Elevated hematocrit
c. Increased prothrombin time
d. Diminished white blood cell count

 

 

ANS:  C

Prothrombin times are increased because malabsorption of vitamin K or inability to produce the clotting factors VII, IX, and X cause the patient to have bleeding tendencies.

 

DIF:    Cognitive Level: Analysis               REF:   Page 240        OBJ:   3

TOP:   Cirrhosis        KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. A patient was scheduled for a laparoscopic cholecystectomy, but complications developed and he underwent an open cholecystectomy with a T-tube inserted into the common bile duct. What is the purpose of the T-tube?
a. To decompress the duct and relieve pain caused by stimulation of the sphincter of Oddi.
b. To improve diaphragmatic expansion and prevention of atelectasis.
c. To shorten postoperative recovery and hasten the healing process.
d. To keep the duct open and allow drainage of the bile until edema resolves.

 

 

ANS:  D

If the stones are in the common bile duct and edema is present, a biliary drainage tube, or T-tube, will be inserted to keep the duct open and allow drainage of the bile until the edema resolves.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 254, Figure 6-7

OBJ:   8                    TOP:   Cholecystectomy

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse caring for a patient who has had an open cholecystectomy with a T-Tube will:
a. open the T-tube to the air so that it will drain freely.
b. position and secure the drainage bag at the chest level.
c. Place the collection bag so the tube is not kinked.
d. Irrigate the T-tube with normal saline to ensure the free flow of bile.

 

 

ANS:  B

The T-tube is placed below the level of the common bile duct to prevent the reflux of bile. The bag must be positioned so the tube is not kinked, or bile cannot drain from the liver. Normally T-tubes are not irrigated.

 

DIF:    Cognitive Level: Application          REF:   Page 255        OBJ:   8

TOP:   Cholecystectomy                            KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. Which nursing intervention should be completed immediately after the physician has performed a needle liver biopsy?
a. Assisting to ambulate for the bathroom
b. Keeping the patient on the right side for a minimum of 2 hours
c. Taking vital signs every 4 hours
d. Keeping the patient on the left side for a minimum of 4 hours

 

 

ANS:  B

Keep the patient lying on the right side for minimum of 2 hours to splint the puncture site. It compresses the liver capsule against the chest wall to decrease the risk of hemorrhage or bile leak. Vital signs are taken every 15 minutes for 30 minutes, then every 30 minutes for 2 hours.

 

DIF:    Cognitive Level: Application          REF:   Page 236        OBJ:   2

TOP:   Liver biopsy   KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. Immediately following a liver biopsy, the patient becomes dyspneic, the pulse increases to 100, and no breath sounds can be heard on the affected side. What should the nurse suspect?
a. Peritonitis
b. Pneumothorax
c. Hemorrhage of the liver
d. Pleural effusion

 

 

ANS:  B

Pneumothorax is a possible complication of paracentesis. The patient’s head of the bed should be raised slightly, but kept on the right side. Oxygen should be administered and the assessment reported to the charge nurse and documented.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 236        OBJ:   1

TOP:   Pneumothorax                                           KEY:              Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. Which patient statement indicates that the patient requires additional teaching about an endoscopic retrograde cholangiopancreatography?
a. “Right after the test, I want breakfast with black coffee.”
b. “The instrument will be put down my throat.”
c. “I haven’t had anything to eat or drink since 9 PM last night.”
d. “My doctor said I could have medicine to relax me before the test.”

 

 

ANS:  A

After the procedure, keep the patient NPO until the gag reflex returns.

 

DIF:    Cognitive Level: Analysis               REF:   Page 239        OBJ:   1

TOP:   Diagnostic procedures                    KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse assisting in the treatment of a patient with ruptured esophageal varices who has received vasopressin IV will carefully assess for:
a. Muscular twitching/spasm
b. Hematuria
c. Macular rash on trunk and arms
d. Evidence of cardiac ischemia

 

 

ANS:  D

Vasopressin is a strong vasoconstrictor given to try to stop the hemorrhage of the varices. Unfortunately it also constricts all vessels and may cause cardiac ischemia.

 

DIF:    Cognitive Level: Application          REF:   Page 242        OBJ:   3

TOP:   Vasopressin   KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. What should the nurse point out as a significant advantage of the laparoscopic cholecystectomy?
a. Slightly more invasive, but there is less pain
b. Can be performed on all patients of any age
c. Can be performed even when there are large stones present in the bile duct
d. Less invasive procedure

 

 

ANS:  D

The laparoscopic cholecystectomy is less invasive and causes less pain and a quick recovery. If there are large stones present a sphincterotomy is done before the laparoscopic cholecystectomy. Persons with bleeding tendencies, pathologic conditions of the abdomen, stones in the bile duct, and extensive adhesions are not good candidates.

 

DIF:    Cognitive Level: Application          REF:   Page 254        OBJ:   2

TOP:   Laparoscopic cholecystectomy       KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. What should the nurse explain is the major purpose of the Sengstaken-Blakemore tube (S/B tube)?
a. Decompress the stomach
b. Control esophageal varices bleeding
c. A route for tube feedings
d. Obtain specimen for gastric analysis

 

 

ANS:  B

The major purpose of the S/B tube is to control bleeding by pressure against the vessels in the esophagus. The two balloons of the tube are inflated to put direct pressure on the esophagus and are anchored by the inflated balloon in the stomach. The tube can suction blood from the stomach as well.

 

DIF:    Cognitive Level: Analysis               REF:   Pages 242-243, Figure 6-4

OBJ:   2                    TOP:   SB tube          KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. The patient’s cirrhosis of the liver has also caused a dilation of the veins of the lower esophagus secondary to portal hypertension, resulting in the development of the complication of:
a. esophageal varices.
b. diverticulosis.
c. Crohn disease.
d. esophageal reflux (GERD).

 

 

ANS:  A

Esophageal varices (a complex of longitudinal, tortuous veins at the lower end of the esophagus) enlarge and become edematous as the result of portal hypertension.

 

DIF:    Cognitive Level: Analysis               REF:   Page 242        OBJ:   3

TOP:   Cirrhosis        KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. The patient with cirrhosis has a rising ammonia level and is becoming disoriented. The patient waves to the nurse as she enters the room. How should the nurse interpret this?
a. As an attempt to get the nurse’s attention
b. As asterixis
c. As an indication of respiratory obstruction from varices
d. As spasticity

 

 

ANS:  B

Asterixis is the “flapping tremor” seen as the patient deteriorates into ammonia intoxication or hepatic encephalopathy.

 

DIF:    Cognitive Level: Application          REF:   Page 244        OBJ:   3

TOP:   Encephalopathy                              KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. How does the administration of neomycin (Mycifradin) reduce the production of ammonia?
a. By assisting the hepatic cells to regenerate
b. By reducing ascites
c. By decreasing the bacteria in the gut
d. By helping to digest fats and proteins

 

 

ANS:  C

The buildup of ammonia can be prevented with the use of lactulose (Chronulac) and neomycin. Ammonia is produced in the gut by bacterial action. By reducing the bacteria, less ammonia is produced.

 

DIF:    Cognitive Level: Application          REF:   Page 243| Page 239, Table 6-1

OBJ:   3                    TOP:   Encephalopathy

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. What is the most common procedure for the removal of the gallbladder?
a. Laparoscopic cholecystectomy
b. Cholangiography
c. Open cholecystectomy
d. Choledochostomy

 

 

ANS:  A

The most recently developed operative procedure, which is now the most common treatment for cholecystitis and cholelithiasis, is done by way of endoscopy. It is called laparoscopic cholecystectomy and uses laser cautery to remove the gallbladder.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 254        OBJ:   8

TOP:   Laparoscopic cholecystectomy       KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity

 

  1. What should the nurse do to prepare a patient for an oral cholecystography?
a. Ensure that the patient drinks 500 mL of water before testing
b. Give 4 Oragrafin (ipodate) 5 minutes apart starting at 6 AM
c. Administer 6 Telepaque (iopanoic acid) tablets 5 minutes apart after the evening meal
d. Give a fatty meal  hour before the test is started

 

 

ANS:  C

The patient is held NPO and given 6 tablets 5 minutes apart the evening before the procedure after the evening meal. A fatty meal is given to the patient after the test is started to stimulate emptying of the gallbladder.

 

DIF:    Cognitive Level: Application          REF:   Page 234        OBJ:   1

TOP:   Oral cholecystography                    KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. Which of the following is a classic symptom of cholecystitis?
a. Substernal, radiating to the left shoulder and arm
b. Epigastric, radiating to the back
c. Right upper abdomen, radiating to the back or right scapula
d. Left upper abdomen, radiating to the jaw and neck

 

 

ANS:  C

It localizes in the right upper quadrant epigastric region. The pain radiates around the mid torso to the right scapular area.

 

DIF:    Cognitive Level: Analysis               REF:   Pages 252-253

OBJ:   2                    TOP:   Cholecystitis

KEY:  Nursing Process Step: Assessment  MSC:  NCLEX: Physiological Integrity

 

  1. What should the nurse avoid contamination from to prevent the transmission of hepatitis A?
a. Food or water
b. Blood transfusion
c. Needles
d. Sexual contact

 

 

ANS:  A

Hepatitis A virus is transmitted when a person puts something in his or her mouth that is contaminated with fecal material (called fecal-oral transmission). Teach patients the importance of good handwashing after the bathroom or changing a diaper, as well as proper food preparation, to prevent the spread of HAV.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 247 Box 6-1

OBJ:   5                    TOP:   Hepatitis        KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity

 

  1. What is the most appropriate method used by high-risk health workers to prevent hepatitis B?
a. Hepatitis B vaccine
b. Diligent handwashing
c. Wearing protective gear
d. Hb immune globulin injections

 

 

ANS:  A

The best preventative measure against the contraction of hepatitis B is HBV vaccine.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 247, Safety Precautions

OBJ:   5                    TOP:   Hepatitis B     KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Safe, Effective Care Environment

 

  1. The nurse explains that the use of cyclosporine as an immunosuppressant has been successful in the reduction of rejection of liver transplants because the drug:
a. increases the rate of the regeneration of liver cells.
b. can overcome complications presented by hepatitis C.
c. increases blood supply to transplant.
d. does not suppress bone marrow.

 

 

ANS:  D

Cyclosporine is an immunosuppressant that does not cause bone marrow suppression nor does it impede healing.

 

DIF:    Cognitive Level: Analysis               REF:   Page 249        OBJ:   7

TOP:   Liver transplant                              KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. A male patient states that he returned from a 2-week camping trip a few days ago. He complains of nausea and anorexia, and dark urine. What additional information would assist in diagnosing hepatitis A?
a. Exposure to blood
b. Recent ingestion of raw fish
c. History of intravenous drug use
d. Multiple sex partners

 

 

ANS:  B

Hepatitis A spreads by direct contact through the oral-fecal route, usually by food and water contaminated with feces.

 

DIF:    Cognitive Level: Analysis               REF:   Page 247, Box 6-1

OBJ:   5                    TOP:   Hepatitis        KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. When caring for an extremely jaundiced patient with cirrhosis, what should the nurse include provisions for in the plan of care?
a. Encouraging consumption of a high-fat  diet
b. Skin care to relieve pruritus
c. Offering foods rich in fat-soluble  vitamins
d. Meticulous foot care

 

 

ANS:  B

Jaundice causes pruritus and can lead to skin lesions and pressure ulcers.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 244        OBJ:   1

TOP:   Cirrhosis        KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse is aware that an elevated serum amylase is diagnostic of pancreatitis at an early stage as an elevation can be assessed as early as _____ after the onset of pancreatic disease.
a. 2 hours
b. 8 hours
c. 24 hours
d. 36 hours

 

 

ANS:  A

An increase in the serum amylase can be detected as early as 2 hours after the onset of pancreatic disease. In  simple acute pancreatitis, the level returns to normal in about 36 hours. In chronic disease it remains elevated.

 

DIF:    Cognitive Level: Analysis               REF:   Page 237        OBJ:   1

TOP:   Serum amylase                               KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. The 100 lb patient who has been exposed to hepatitis A is to receive an injection of immune serum globulin. What should the dose (.02 mL/kg) be?
a. 0.9 mL
b. 1.4 mL
c. 1.6 mL
d. 1.8 mL

 

 

ANS:  A

100 lb/2.2 = 45.4. 45.4 ´ 0.02 = 0.90

 

DIF:    Cognitive Level: Application          REF:   Page 248        OBJ:   2

TOP:   Immune serum globulin                  KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. A family member of a patient asks the nurse about the protein-restricted diet ordered because of advanced liver disease with hepatic encephalopathy. What statement by the nurse would best explain the purpose of the diet?
a. “The liver cannot rid the body of ammonia that is made by the breakdown of protein in the digestive system.”
b. “The liver heals better with a high-carbohydrate diet rather than with a diet high in protein.”
c. “Most people have too much protein in their diets. The amount in this diet is better for liver healing.”
d. “Because of portal hypertension, the blood flows around the liver, and ammonia made from protein collects in the brain, causing hallucinations.”

 

 

ANS:  A

The patient with hepatic encephalopathy is on a very low-protein to no-protein diet. The goal of management of hepatic encephalopathy is the reduction of ammonia formation in the intestines.

 

DIF:    Cognitive Level: Analysis               REF:   Page 236        OBJ:   3

TOP:   Cirrhosis        KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse would make provisions in the plan of care for a person who has had a liver transplant to prevent:
a. fluid congestion.
b. fatigue.
c. infection.
d. urinary retention.

 

 

ANS:  C

A critical aspect of nursing care following liver transplantation is monitoring for infection.

The major postoperative complications of a liver transplant are rejection and infection.

 

DIF:    Cognitive Level: Analysis               REF:   Page 249        OBJ:   1

TOP:   Liver transplant                              KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse is aware that the hepatitis A immunization provides immunity in:
a. 5 days.
b. 10 days.
c. 15 days.
d. 30 days.

 

 

ANS:  D

Primary immunization with hepatitis A vaccine provides immunity within 30 days.

 

DIF:    Cognitive Level: Application          REF:   Page 248        OBJ:   8

TOP:   Hepatitis A     KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity

 

  1. What is the challenge in encouraging coughing and deep breathing for a postoperative patient who had an open cholecystectomy?
a. High placement of incision
b. Excessive nausea
c. Weakened abdominal muscles
d. Poor oxygenation

 

 

ANS:  A

The high placement of the incision of the cholecystectomy makes the patient reluctant to cough. Splinting the incision is beneficial.

 

DIF:    Cognitive Level: Application          REF:   Page 255        OBJ:   2

TOP:   Cholecystectomy                            KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. Why is it advantageous for a live person to be a liver donor?
a. Because the donor is not at risk for any complication
b. Because the recipient is more likely to avoid rejection
c. Because the donor donates only a part of the liver
d. Because the blood supply is more dependable in the donated liver

 

 

ANS:  C

A live donor may donate only a portion of their liver and within weeks the donor’s liver has grown to the size to meet the body’s needs. The same is true for the recipient.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 249        OBJ:   7

TOP:   Liver transplant                              KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. Which factors are most commonly associated with pancreatitis?
a. Coronary artery disease
b. Alcoholism and biliary tract disease
c. Cirrhosis
d. History of myocardial infarction

 

 

ANS:  B

Alcoholism and biliary tract disease are the two factors most commonly associated with pancreatitis.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 257        OBJ:   2

TOP:   Pancreatitis     KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. A patient with pancreatitis is NPO. The patient asks the nurse why he is unable to have anything by mouth. Which of the following is the best response?
a. “Diagnostic tests depend on you not eating anything.”
b. “The pancreas is stimulated whenever you eat or drink, and causes pain.”
c. “Eating causes the need for a bowel movement, which excretes your medication too rapidly.”
d. “Resting your GI tract will cure your pancreatitis.”

 

 

ANS:  B

Food and fluids are withheld to avoid stimulating pancreatic activity, and IV fluids are administered.

 

DIF:    Cognitive Level: Analysis               REF:   Page 257        OBJ:   2

TOP:   Pancreatitis     KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. Why is morphine contraindicated in the patient with pancreatitis?
a. Demerol (meperidine) is less expensive.
b. Tylenol is more effective at managing this type of pain.
c. Morphine may cause spasms of the sphincter of Oddi.
d. These patients do not experience pain.

 

 

ANS:  C

A common complaint is constant, severe pain; in such cases, meperidine (Demerol) PCA is often administered. Morphine may cause spasms of the sphincter of Oddi.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 253        OBJ:   2

TOP:   Pancreatitis     KEY:  Nursing Process Step: Intervention

MSC:  NCLEX: Physiological Integrity

 

  1. Which factors may increase a patient’s risk of developing cancer of the pancreas?
a. Diet high in carbohydrates and dairy products
b. Cardiovascular disease and glaucoma
c. Tea and cola consumption
d. Cigarette smokers and people with diabetes mellitus

 

 

ANS:  D

The cause of cancer of the pancreas is unknown, but it is diagnosed more often in cigarette smokers, people exposed to chemical carcinogens, and people with diabetes mellitus and pancreatitis.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 259        OBJ:   2

TOP:   Cancer of the pancreas                   KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. Which assessment would indicate possible gallbladder disease in an older adult?
a. Dull pain in the right upper quadrant region
b. Changes in color of urine or stool
c. Distention of veins in upper part of body
d. Aching muscles and tenderness in the liver

 

 

ANS:  B

The incidence of cholelithiasis increases with aging. Assess older adults for history of changes in stool or urine color. Cirrhosis of the liver may cause distention in veins in the upper part of the body.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 257, Life Span Considerations

OBJ:   2                    TOP:   Age-related changes

KEY:  Nursing Process Step: Assessment  MSC:  NCLEX: Physiological Integrity

 

  1. What should the nurse monitor in caring for the patient undergoing a paracentesis?
a. The urinary output
b. Hypervolemia
c. Fluid removal over at least 30 minutes
d. Seizure

 

 

ANS:  C

The fluid removed during a paracentesis is removed over a period of 30 to 90 minutes to prevent sudden changes in blood pressure leading to syncope. The bed should be in a high Fowler position. Food and fluid restriction is usually not necessary.

 

DIF:    Cognitive Level: Analysis               REF:   Page 242        OBJ:   1

TOP:   Paracentesis   KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity

 

  1. A patient with a T-tube for an open cholecystectomy has resumed oral intake. The T-tube is clamped 2 hours before meals and unclamped 2 hours after meals to aid in the digestion of fat. During the time the tube is clamped the patient complains of abdominal pain and nausea. Which intervention is most appropriate?
a. Notify the physician
b. Unclamp the tube immediately
c. Increase the IV fluids
d. Change the T-tube dressing

 

 

ANS:  B

While the tube is clamped, the patient may show signs of abdominal pain, nausea, vomiting, etc. Unclamp the tube immediately to allow for drainage and relief of both nausea and pain.

 

DIF:    Cognitive Level: Analysis               REF:   Page 255        OBJ:   8

TOP:   Cancer of the pancreas                   KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

MULTIPLE RESPONSE

 

  1. What are the indications for a liver transplant? (Select all that apply.)
a. Congenital biliary abnormalities
b. Hepatic malignancy
c. Chronic hepatitis
d. Cirrhosis due to alcoholism
e. Gallbladder disease

 

 

ANS:  A, B, C

Indications for liver transplantation include congenital biliary abnormalities, inborn errors of metabolism, hepatic malignancy (confined to the liver), sclerosing cholangitis, and chronic end-stage liver disease.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 249        OBJ:   7

TOP:   Liver transplant                              KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. Which medical interventions and management systems control the bleeding of esophageal varices? (Select all that apply.)
a. Transfusions
b. Sengstaken-Blakemore tube
c. Band ligation
d. Cryotherapy
e. Portocaval shunt
f. Large doses of vitamin B12

 

 

ANS:  B, C, E

Band ligation, insertion of the S/B tube, and various shunting surgeries are helpful in stopping the hemorrhage. Transfusions and water-soluble vitamins are not beneficial.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 242        OBJ:   3

TOP:   Esophageal varices                         KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. Dietary teaching for a patient who is treated conservatively for cholecystitis is necessary to keep the patient comfortable. Which foods should be avoided? (Select all that apply.)
a. Peanut butter
b. Grilled chicken
c. Rice and pasta
d. Bananas, apples, oranges
e. Whole milk
f. Glazed chocolate doughnuts

 

 

ANS:  A, E, F

Peanut butter, nuts, chocolate, whole milk, fried foods, and cream and other fatty foods should be avoided.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 256        OBJ:   2

TOP:   Cholecystitis and cholelithiasis       KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. Viral hepatitis may be treated at home. What should be taught to the patient’s family? (Select all that apply.)
a. Clothes should be laundered separately with hot water.
b. Personal items and drinking glasses should not be shared.
c. Articles soiled with feces do not require extra care.
d. Hands need to be thoroughly washed after toileting.
e. Contaminated items may be disposed of with regular trash.

 

 

ANS:  A, B, D

For the patient with viral hepatitis being cared for in the home, the family needs to be taught necessary precautions. Clothes should be laundered separately with hot water. Personal items used by the patient should not be shared. Articles soiled with feces must be disinfected. Any contaminated items should be disposed of properly.

 

DIF:    Cognitive Level: Analysis               REF:   Page 248        OBJ:   5

TOP:   Hepatitis         KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse is aware that the liver synthesizes products essential to health. Which products are synthesized by the liver? (Select all that apply.)
a. Intrinsic factor
b. Protein
c. Vitamin K
d. Red blood cells
e. Albumin

 

 

ANS:  B, E

The liver synthesizes protein and albumin.

 

DIF:    Cognitive Level: Analysis               REF:   Page 234        OBJ:   N/A

TOP:   Products synthesized by liver         KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity

 

  1. What should the nurse do as part of the preparation for an endoscopic retrograde cholangiopancreatography (ERCP)? (Select all that apply.)
a. Confirm that a recent chest x-ray is on file
b. Confirm the presence of a consent form
c. Warn patient that the procedure will take about 3 hours
d. Confirm the presence of a prothrombin time/INR
e. Withhold food and drink for 4 hours

 

 

ANS:  B, D

Before the ERCP the patient will be held NPO for 8 hours. It is necessary that a consent form be signed as well as evidence of a prothrombin time INR.

 

DIF:    Cognitive Level: Application          REF:   Page 238        OBJ:   1

TOP:   ERCP             KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Safe, Effective Care Environment

 

COMPLETION

 

  1. ___________ is a condition characterized by yellowing of the sclera and the skin.

 

ANS:

Jaundice

 

Jaundice is the discoloration of body tissues caused by abnormally high blood levels of bilirubin.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 241        OBJ:   4

TOP:   Jaundice         KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. The disease that is on the increase because of the growing obesity population and is associated with coronary artery disease and use of corticosteroids is_______________.

 

ANS:

nonalcoholic fatty liver disease (NAFLD)

nonalcoholic fatty liver disease

NAFLD

 

NAFLD is a disease that is on the rise due to the increasing population of obese persons. The disease is also associated with CAD and the use of corticosteroids.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 240        OBJ:   2

TOP:   NAFLD          KEY:  Nursing Process Step: N/A

MSC:  NCLEX: Physiological Integrity

 

  1. The tumor marker that is elevated in patients with pancreatic cancer is______.

 

ANS:

CA19-9

 

The tumor marker CA19-9 is elevated in the presence of pancreatic cancer.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 259        OBJ:   1

TOP:   CA19-9          KEY:  Nursing Process Step: N/A

MSC:  NCLEX: Physiological Integrity

 

  1. Hepatitis D is usually seen as a co-infection with __________.

 

ANS:

hepatitis B

 

Hepatitis D is usually seen as a coinfection with hepatitis B.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 247, Box 6-1

OBJ:   6                    TOP:   Hepatitis        KEY:  Nursing Process Step: N/A

MSC:  NCLEX: Physiological Integrity

 

  1. A ___________occurs when the body encapsulates the autodigestive debris in the pancreatic tissue, frequently becoming an abscess.

 

ANS:

pseudocyst

 

A pseudocyst occurs when the body encapsulates the autodigestive debris in the pancreatic tissue.

 

DIF:    Cognitive Level: Comprehension   REF:   Page: 6-63      OBJ:   2

TOP:   Pseudocyst     KEY:  Nursing Process Step: N/A

MSC:  NCLEX: Physiological Integrity

 

OTHER

 

  1. The nurse clarifies that deterioration progresses through stages before presenting with liver disease. Place the stages in order. (Separate letters by a comma and space as follows: A, B, C, D)

 

  1. Liver disease
  2. Inflammation
  3. Hepatic insufficiency
  4. Destruction
  5. Fibrotic regeneration

 

ANS:

D, B, E, C, A

 

Liver deterioration follows a pattern of stages: destruction, inflammation, fibrotic regeneration; hepatic insufficiency then presents as  liver disease.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 257        OBJ:   2

TOP:   Pseudocyst     KEY:  Nursing Process Step: N/A

MSC:  NCLEX: Physiological Integrity

 

  1. Arrange the normal process of protein metabolism. (Separate letters by a comma and space as follows: A, B, C, D)

 

  1. Protein enters the blood stream
  2. Excreted by kidney
  3. Portal vein delivers blood to the liver
  4. Conversion to urea
  5. Ammonia produced in the bowel

 

ANS:

A, E, C, D, B

 

Protein products enter the blood stream and are changed in the bowel to ammonia; the products then pass through the portal vein to the liver where the ammonia is converted to urea, which is then excreted by the kidneys.

 

DIF:    Cognitive Level: Analysis               REF:   Page 240        OBJ:   2

TOP:   Liver destruction                            KEY:  Nursing Process Step: Implementation.

MSC:  NCLEX: Physiological Integrity

 

Chapter 7: Care of the Patient with a Blood or Lymphatic Disorder

 

MULTIPLE CHOICE

 

  1. What is the process by which certain cells engulf and digest microorganisms and cellular debris?
a. Erythrocytosis
b. Hematocrit
c. Phagocytosis
d. Hemostasis

 

 

ANS:  C

Phagocytosis is the process by which bacteria, cellular debris, and solid particles are destroyed and removed.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 267        OBJ:   3

TOP:   Diagnostic procedures                    KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse explains that because it is a reliable and predictable indicator of the body’s level of infection or recovery the _____________________ is a common diagnostic tool.
a. Hemoglobin
b. Hematocrit
c. Mean cell volume (MCV)
d. Differential

 

 

ANS:  D

A differential white blood cell count is an examination in which the different kinds of WBCs are counted and reported as percentages of the total examined. It is a common diagnostic tool because of its reliability and the predictability of the body’s response to infection or its progress in recovery.

 

DIF:    Cognitive Level: Analysis               REF:   Page 267        OBJ:   4

TOP:   Differential    KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse assessing a differential sees an increase in immature neutrophils (bands) and is aware that this indicates:
a. a significant hemorrhage.
b. aplastic anemia.
c. an overwhelming bacterial infection.
d. beginning recovery from an infection.

 

 

ANS:  C

An increase in immature neutrophils (bands) is called bandemia, and it indicates an overwhelming bacterial infection.

 

DIF:    Cognitive Level: Application          REF:   Page 267        OBJ:   1

TOP:   Bandemia       KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. B cells and T cells fit under which classification?
a. Erythrocytes
b. Basophils
c. Lymphocytes
d. Monocytes

 

 

ANS:  C

B cells and T cells, the major players in the antigen/antibody conflict, are both lymphocytes.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 267        OBJ:   1

TOP:   Lymphocytes                                  KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse explains that in the event of an invasion of an allergen, the basophils release a strong vasodilator, which is:
a. lysozyme.
b. prothrombin.
c. hematocrit.
d. histamine.

 

 

ANS:  D

Histamine is released by the basophils during the invasion of an allergen.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 267        OBJ:   1

TOP:   Leukocytes    KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. The presence of excess bands in the peripheral blood that indicate severe infection is called:
a. shift to the left.
b. shift to the right.
c. bone marrow aspiration.
d. thrombocytosis.

 

 

ANS:  A

The presence of excess bands in the peripheral blood is called a shift to the left (i.e., a shift toward immature cells) and indicates severe infection.

 

DIF:    Cognitive Level: Analysis               REF:   Page 267        OBJ:   8

TOP:   Diagnostic procedures                    KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. A patient who had a Schilling test shows a 20% excretion of the radioactive vitamin B12. What would this indicate?
a. The patient has a low reserve of iron and has iron deficiency anemia.
b. The patient has a normal finding and does not have pernicious anemia.
c. The patient has a deficiency of thrombocytes and has a clotting disorder.
d. The patient has an excess of RBCs and has polycythemia.

 

 

ANS:  B

The Schilling test is a laboratory blood test for diagnosing pernicious anemia. The normal reading 24 hours after the administration of radioactive vitamin B12 is 8% to 40%. The test measures the absorption of radioactive vitamin B12.

 

DIF:    Cognitive Level: Analysis               REF:   Page 271        OBJ:   8

TOP:   Schilling test                                   KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. In an adult, where are erythrocytes continuously produced?
a. Yellow bone marrow
b. Lymphatic system
c. Spleen
d. Red bone marrow

 

 

ANS:  D

Erythrocytes are continuously produced in the red bone marrow, principally in the vertebrae, ribs, and sternum.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 265        OBJ:   9

TOP:   Diagnostic procedures                    KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity

 

  1. What does the elevation in the eosinophil count to 10% indicate?
a. Anemia
b. Allergy
c. Infection
d. Hypoxia

 

 

ANS:  B

Normal values of eosinophils are 1% to 4%. An elevation to 10% would indicate the presence of an allergic reaction.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 267        OBJ:   1

TOP:   Eosinophils    KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. What would a nurse include in a teaching plan for a home health patient with a hemoglobin of 8.4 mg?
a. Exercising for periods of 30 minutes daily
b. Limiting fluid intake
c. Alternating activity with rest periods
d. Avoiding the use of oxygen

 

 

ANS:  C

Severely anemic persons need to conserve their energy. Observing a rest period after a period of activity will reduce hypoxia. Oxygen may be used as necessary.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 273        OBJ:   1

TOP:   Anemia          KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity

 

  1. Approximately how much blood is stored in the spleen that can be released in a hypovolemic emergency?
a. 100 mL
b. 300 mL
c. 500 mL
d. 1000 mL

 

 

ANS:  C

The spleen stores 1 pint of blood, approximately 500 mL, which can be released during emergencies.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 274        OBJ:   11

TOP:   Spleen            KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse caring for a patient with pernicious anemia should make provisions for:
a. frequent iced drinks.
b. lightweight blanket.
c. a fan to circulate the air.
d. reverse isolation.

 

 

ANS:  B

Persons with pernicious anemia are especially sensitive to cold. The provision of a light blanket is beneficial.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 276        OBJ:   11

TOP:   Pernicious anemia                          KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity

 

  1. When instructing the patient taking an oral liquid iron preparation, what should the nurse include?
a. Information relative to taking the iron with milk
b. Information relative to the bowel movement color changing to dark red
c. Information relative to taking preparation through a straw to prevent staining of teeth
d. Information relative to taking a drug with meals or a snack

 

 

ANS:  C

Liquid iron preparations should be drunk through a straw to prevent tooth staining. All oral iron preparations should be taken before meals. Dairy products interfere with the absorption of iron.

 

DIF:    Cognitive Level: Application          REF:   Page 250, Health Promotion

OBJ:   9                    TOP:   Oral iron administration

KEY:  Nursing Process Step: Planning       MSC:  NCLEX: Physiological Integrity

 

  1. When the 14-year-old African American boy comes into the emergency room in sickle cell crisis, what should be the primary focus of care?
a. Instruct patient about transfusion procedure
b. Starting of IV fluids
c. Pain control
d. Relief of dyspnea

 

 

ANS:  C

Pain control during the crisis is the focus. Continuous opioids are the mainstay of pain management. Certainly IV fluids to reduce viscosity of blood and oxygen for relief of dyspnea are important, but pain control is paramount in the acute phase.

 

DIF:    Cognitive Level: Analysis               REF:   Page 282        OBJ:   9

TOP:   Leukemia       KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Psychosocial Integrity

 

  1. The mother of a 4-year-old child with leukemia says to the nurse, “I don’t understand why he is crying about his legs hurting.” The nurse’s most informative response would be based on the information that bone pain is related to:
a. Elevated WBCs in differential
b. Long periods of inactivity
c. Splenomegaly
d. Bone marrow congested with white cells

 

 

ANS:  D

Long bone pain is the result of bone marrow that is congested with immature white cells.

 

DIF:    Cognitive Level: Application          REF:   Page 286        OBJ:   9

TOP:   Leukemia       KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. What must a patient undergo before a bone marrow transplant?
a. A thorough nutritional plan to support new marrow
b. Total body irradiation to kill all the marrow cells
c. A physical therapy program to strengthen the body
d. Inhalation therapy to reduce possible pathogens in the lungs

 

 

ANS:  B

Before the actual marrow transplant, the patient must undergo total body irradiation or chemotherapy to kill all the marrow cells and the leukemic cells. The patient is at a major risk for infection at this time.

 

DIF:    Cognitive Level: Application          REF:   Page 287        OBJ:   12

TOP:   Marrow transplant                          KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity

 

  1. The 9-year-old child with leukemia who is on palliative care has drawn a picture of a boy under a huge black cloud that has lightning coming out of it. Which of the following would be an appropriate intervention for the nurse?
a. “What is this picture about?”
b. “Are you afraid of lightning?”
c. “I bet this is a picture of you, isn’t it?”
d. “Is it about to rain in your picture?”

 

 

ANS:  A

Asking what the child has drawn is a neutral and nonthreatening question. Drawings can give a clue to perceptions and emotions that a young child may not be able to verbalize. The nurse should not try to interpret the drawing.

 

DIF:    Cognitive Level: Application          REF:   Page 288        OBJ:   12

TOP:   Leukemia       KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. The home health nurse recommends to the mother of a 12-year-old child with leukemia that the child should have:
a. the series for prevention of hepatitis B.
b. an annual influenza vaccine.
c. an annual pneumococcal vaccine.
d. vitamin B12 shots.

 

 

ANS:  B

Children with leukemia should have an annual influenza vaccine and a pneumococcal vaccine every 5 years.

 

DIF:    Cognitive Level: Application          REF:   Page 288        OBJ:   9

TOP:   Pneumococcal vaccine                   KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. Which patient statement from a 15-year-old girl with thrombocytopenia would require more assessment to report to the charge nurse?
a. “I think these red spots on my skin are going away.”
b. “I am so bored lying in bed I could scream.”
c. “My bowel movement is brown and stinks.”
d. “I have this really weird Coke-colored urine.”

 

 

ANS:  D

Coke-colored urine is hematuria that should be documented and reported to the charge nurse. The purpura will fade as they are absorbed. Boredom and smelly stools are normal for a 14-year-old.

 

DIF:    Cognitive Level: Analysis               REF:   Page 291        OBJ:   16

TOP:   Thrombocytopenia                         KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. A 23-year-old male patient with hemophilia A says, “How can I keep my children from having hemophilia A?” Which of the following is the most informative response?
a. “You need to select a very dependable mode of birth control.”
b. “You can only pass hemophilia B to your sons.”
c. “Your daughter may be a carrier and her children may have hemophilia A. Your son is not at risk.”
d. “Your sons should have coagulation studies.”

 

 

ANS:  C

Hemophilia A is an X-linked trait. Females are carriers; therefore, the patient’s daughter could pass the disease to her sons. The patient’s sons are not at risk for hemophilia A.

 

DIF:    Cognitive Level: Analysis               REF:   Page 291        OBJ:   13

TOP:   Hemophilia A                                           KEY:              Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse caring for a child with hemophilia who is hospitalized with hemarthrosis should include which of the following in the plan of care?
a. Splint the affected leg to maintain anatomic alignment
b. Apply warm compresses to reduce hemorrhage in the joint
c. Use analgesia sparingly
d. Encourage vigorous ROM exercises several times a day to keep knee flexible

 

 

ANS:  A

Splinting the affected knee is necessary to retain anatomic alignment while the pain is severe. Analgesia should be given as needed. Physical therapy and ROM are appropriate after pain has subsided.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 293        OBJ:   13

TOP:   Hemarthrosis                                  KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity

 

  1. In caring for a patient with multiple myeloma, what should the nurse include in the daily care?
a. Provisions for limiting fluid intake to less than 1000 mL/day
b. Provisions for close supervision and assistance when ambulating
c. Provisions for straining all urine
d. Provisions for limiting use of an analgesic

 

 

ANS:  B

Because of the constant threat of pathologic fractures, ambulation should be carefully supervised and assisted. Uric acid is increased and may crystalize in the kidney, but straining is not necessary. Analgesia is necessary for relief of bone pain.

 

DIF:    Cognitive Level: Application          REF:   Page 297        OBJ:   15

TOP:   Multiple myeloma                          KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse is aware that a person with Hodgkin disease, who has two or more abnormal lymph nodes on the same side of the diaphragm and involvement of extranodal involvement on the same side of the diaphragm, would be in:
a. stage I
b. stage II
c. stage III
d. stage IV

 

 

ANS:  B

Stage II indicates that there are two or more abnormal lymph nodes on the same side of the diaphragm and extranodal involvement on the same side of the diaphragm.

 

DIF:    Cognitive Level: Analysis               REF:   Page 299, Box 7-7

OBJ:   15                  TOP:   Hodgkin disease

KEY:  Nursing Process Step: Assessment  MSC:  NCLEX: Physiological Integrity

 

  1. The nurse explains that a positron emission tomography (PET) has been ordered to:
a. assess bone marrow depression.
b. measure bone density.
c. radiate and destroy diseased lymph nodes.
d. measure lymph node response to therapy.

 

 

ANS:  D

The PET can measure the effect of therapy on diseased nodes.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 300        OBJ:   15

TOP:   PET                KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity

 

  1. Which of the following foods would the nurse recommend to a person with iron deficiency anemia as an excellent meat source for erythropoiesis?
a. Dark meat of chicken
b. Cured ham
c. Pork chops
d. Processed meat

 

 

ANS:  A

The dark meat of poultry is a good meat source for erythropoiesis.

 

DIF:    Cognitive Level: Analysis               REF:   Page 280, Box 7-3

OBJ:   9                    TOP:   Iron deficiency anemia

KEY:  Nursing Process Step: Planning       MSC:  NCLEX: Physiological Integrity

 

  1. The peripheral smear is a diagnostic test that:
a. assesses the level of hemoglobin.
b. measures antibody production.
c. examines the shape and structure of RBCs.
d. identifies infection.

 

 

ANS:  C

The peripheral smear allows the study of the size, structure, and shape of RBCs.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 271        OBJ:   8

TOP:   Peripheral smear                             KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. The typical medical treatment of polycythemia vera involves repeated phlebotomies and medications such as busulfan (Myleran) in order to:
a. stimulate bone marrow.
b. inhibit bone marrow activity.
c. increase hemoglobin.
d. reduce gout.

 

 

ANS:  B

Repeated phlebotomy decreases blood viscosity, and myelosuppressive agents such as busulfan (Myleran) are often given to inhibit bone marrow activity.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 283        OBJ:   N/A

TOP:   Polycythemia vera                          KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity

 

  1. Which of the following would the nurse explain as the most common type of leukemia that affects children?
a. Chronic lymphocytic leukemia ( CLL)
b. Acute myeloid leukemia (AML)
c. Acute lymphocytic leukemia (ALL)
d. Chronic myeloid leukemia (CML)

 

 

ANS:  C

The most common type of leukemia that affects children is the fast-advancing ALL. This leukemia can also affect adults.

 

DIF:    Cognitive Level: Analysis               REF:   Page 286        OBJ:   12

TOP:   Leukemia       KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse is aware that persons of the Jehovah’s Witness faith accept which types of blood transfusions?
a. No type of blood transfusion
b. Blood that has been blessed by their religious leader
c. Transfusions only for persons who have not yet been baptized
d. Autologous blood transfusions

 

 

ANS:  D

Jehovah’s Witness followers are accepting of autologous blood transfusions and some will accept volume expanders such as colloids.

 

DIF:    Cognitive Level: Application          REF:   Page 273, Cultural Considerations

OBJ:   9                    TOP:   Jehovah’s Witness

KEY:  Nursing Process Step: Assessment  MSC:  NCLEX: Physiological Integrity

 

  1. Which mandatory practice is the most effective and significant nursing practice to prevent the spread of infection?
a. Strict and frequent handwashing by all people having contact with the patient
b. Placement of patients in private rooms with high-efficiency particulate air (HEPA) filtration
c. Administration of combinations of prophylactic antibiotics
d. Creation of a “sterile” environment for the patient with the use of laminar airflow rooms

 

 

ANS:  A

Meticulous handwashing by medical and nursing personnel and strict asepsis are mandatory.

 

DIF:    Cognitive Level: Application          REF:   Page 285, Nursing Care Plan

OBJ:   12                  TOP:   Handwashing

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Safe, Effective Care Environment

 

  1. What is the average life span of an erythrocyte?
a. 7 days
b. 60 days
c. 120 days
d. Up to several years

 

 

ANS:  C

The life span of an RBC is 120 days. A WBC’s life span is days to several years. Platelets live 5 to 9 days.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 265        OBJ:   2

TOP:   Anatomy and physiology of blood cells

KEY:  Nursing Process Step: Assessment  MSC:  NCLEX: Health Promotion and Maintenance

 

  1. Because older adults suffer from conditions such as colonic diverticula, hiatal hernia, and ulcerations that can cause occult bleeding, the nurse should assess for symptoms of:
a. leukemia.
b. iron deficiency anemia.
c. sickle cell anemia.
d. polycythemia.

 

 

ANS:  B

Blood loss is a major cause of iron deficiency in adults. The major sources of chronic blood loss are from the GI and genitourinary systems.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 303, Life Span Considerations

OBJ:   9                    TOP:   Anatomy and physiology of blood cells

KEY:  Nursing Process Step: Assessment  MSC:  NCLEX: Health Promotion and Maintenance

 

  1. The nurse explains that the treatment of hemophilia A has been revolutionized with the advent of the use of:
a. corticosteroids.
b. large doses of testosterone.
c. recombinant factor VIII.
d. transfusion with packed red cells.

 

 

ANS:  C

Recombinant factor VIII has been a major forward step in the treatment of hemophilia A.

 

DIF:    Cognitive Level: Analysis               REF:   Page 271        OBJ:   13

TOP:   Hemophilia A                                           KEY:              Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. From which location would the bone marrow sample come in the aspiration of a 25-year-old patient?
a. Sternum
b. Posterior superior iliac crest
c. Posterior iliac crest
d. Femur

 

 

ANS:  C

The preferred site for bone marrow aspiration puncture in adults is the posterior iliac crest.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 271        OBJ:   8

TOP:   Bone marrow aspiration                 KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

MULTIPLE RESPONSE

 

  1. What are the most likely matches for a bone marrow transplant to a 10-year-old with leukemia? (Select all that apply.)
a. Uncle
b. Self
c. Mother
d. Brother
e. Sister
f. Father

 

 

ANS:  B, D, E

Specimens from twins, siblings, or self (autologous) while in remission are preferred.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 277        OBJ:   12

TOP:   Bone marrow transplant                 KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity

 

  1. The spleen is a highly vascularized organ located in the left upper quadrant of the abdominal cavity. What are the main functions of the spleen? (Select all that apply.)
a. Serve as reservoir for blood
b. Destroy worn-out RBCs
c. Promote phagocytosis
d. Responsible for development of T lymphocytes
e. Continuously produce RBCs during lifetime

 

 

ANS:  A, B, C

The spleen stores 1 pint of blood, which can be released during emergencies, such as hemorrhage, in less than 60 seconds. The main functions of the spleen are (1) to serve as a reservoir for blood; (2) to form lymphocytes, monocytes, and plasma cells; (3) to destroy worn-out RBCs; (4) to remove bacteria by phagocytosis (engulfing and digesting); and (5) to produce RBCs before birth (the spleen is believed to produce RBCs after birth only in cases of extreme hemolytic anemia).

 

DIF:    Cognitive Level: Knowledge          REF:   Page 274        OBJ:   2

TOP:   Anatomy and Physiology of the Hematological and Lymphatic System

KEY:  Nursing Process Step: Assessment  MSC:  NCLEX: Physiological Integrity

 

  1. The nurse examines the complete blood count (CBC) to assess (select all that apply):
a. hematocrit.
b. red cell count.
c. differential white cell count.
d. plasma level.
e. blood type.
f. hemoglobin.

 

 

ANS:  A, B, C, F

The CBC gives information relative to RBC, WBC, hematocrit, hemoglobin, erythrocyte indexes, WBC differential, and examination of the peripheral blood cells.

 

DIF:    Cognitive Level: Application          REF:   Page 271        OBJ:   8

TOP:   CBC               KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. Which of the following are necessary factors that support healthy erythropoiesis? (Select all that apply.)
a. Dietary magnesium
b. Healthy bone marrow
c. Adequate oxygen source
d. Vitamin B12
e. Amino acids
f. Vitamin B2

 

 

ANS:  B, D, E, F

Erythropoiesis, red blood cell production, is dependent on the availability of healthy bone marrow, dietary supply of copper and iron, amino acids, vitamins B12 and B2, folic acid, and pyridoxine.

 

DIF:    Cognitive Level: Analysis               REF:   Page 265        OBJ:   2

TOP:   Erythropoiesis                                           KEY:              Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse caring for a patient in the emergency room with suspected internal injuries will assess for hypovolemic shock, which is evidenced by (select all that apply):
a. irritability.
b. restlessness.
c. slow bounding pulse.
d. decreased respirations.
e. pallor.
f. hypotension.

 

 

ANS:  A, B, E, F

Indicators of hypovolemia are restlessness, irritability, rapid thready pulse, increasing respirations, pale, cool moist skin, and hypotension, Should the blood loss continue, the patient could go into hypovolemic shock.

 

DIF:    Cognitive Level: Application          REF:   Page 274, Box 7-1

OBJ:   10                  TOP:   Hypovolemia

KEY:  Nursing Process Step: Assessment  MSC:  NCLEX: Physiological Integrity

 

  1. Which of the following are “B” symptoms of a patient with Hodgkin disease? (Select all that apply.)
a. Hematuria
b. Night sweats
c. Severe diarrhea
d. Weight gain from edema
e. Fever
f. Persistent dry cough

 

 

ANS:  B, E

The “B” symptoms of Hodgkin disease are night sweats, fever, and weight loss. These symptoms are associated with a poor prognosis.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 299        OBJ:   15

TOP:   “B” symptoms                                          KEY:              Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

COMPLETION

 

  1. _____________ are leukocytes that destroy and remove cellular waste, bacteria, and solid particles.

 

ANS:

Neutrophils

 

Neutrophils (granular circulating leukocytes essential for phagocytosis, the process by which bacteria, cellular debris, and solid particles are destroyed and removed) ingest bacteria and dispose of dead tissue.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 267        OBJ:   1

TOP:   Leukocytes    KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. The person with aplastic anemia is said to be _________________ because all three major blood elements (RBCs, WBCs, and platelets) are diminished or absent.

 

ANS:

pancytopenic

 

Persons with aplastic anemia are deficient in all three of the major blood elements, a condition known as pancytopenia.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 277        OBJ:   9

TOP:   Aplastic anemia                              KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse clarifies that ____________ _______________ replaces iron stores needed for red blood cell production.

 

ANS:

ferrous sulfate

 

Ferrous sulfate replaces iron stores needed for red blood cell production.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 287        OBJ:   9

TOP:   Ferrous sulfate                                KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. Neutrophils release ______________, an enzyme that destroys certain bacteria.

 

ANS:

lysozyme

 

Lysozyme is an enzyme released by the neutrophils that kills certain bacteria when the bacteria is recognized in the body.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 267        OBJ:   1

TOP:   Lysozyme      KEY:  Nursing Process Step: N/A

MSC:  NCLEX: Physiological Integrity

 

  1. The Reed-Sternberg cell is the hallmark diagnostic indicator for _______________ __________.

 

ANS:

Hodgkin disease

 

The Reed-Sternberg cell, large abnormal multinucleated cells in the lymph nodes, is diagnostic of Hodgkin disease.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 299        OBJ:   15

TOP:   Reed-Sternberg cells                       KEY:  Nursing Process Step: N/A

MSC:  NCLEX: Physiological Integrity

 

OTHER

 

  1. Arrange the process of hemostasis in sequence. (Separate letters by a comma and space as follows: A, B, C, D)

 

  1. Release of clotting factor from injured tissue
  2. Formation of thrombin
  3. Formation of fibrin
  4. Trapping of RBC and platelets
  5. Clot
  6. Release of thromboplastin

 

ANS:

A, F, B, C, D, E

 

Clotting factors are released from the injured tissue causing the release of thromboplastin, which acts with calcium to form thrombin; fibrin is formed, which traps red cells and platelets to make the clot.

 

DIF:    Cognitive Level: Analysis               REF:   Page 268, Figure 7-3

OBJ:   5                    TOP:   Clot formation                                          KEY:   Nursing Process Step: N/A

MSC:  NCLEX: Physiological Integrity

 

  1. Outline the sequence of the process that stimulates the increase in the production of red blood cells. (Separate letters by a comma and space as follows: A, B, C, D)

 

  1. Kidneys release erythropoietic factor
  2. Increase in red blood cell production
  3. Enzyme stimulates red bone marrow
  4. Oxygen delivery increased to the tissues
  5. Oxygen delivery decreased to the tissues

f, Decrease in red blood cell production

 

ANS:

E, A, C, B, D, F

 

When the tissues of the body register a decrease of oxygen, the kidneys release the erythropoietic factor that stimulates the bone marrow to produce more RBCs, which increases the oxygen delivery to the tissues which then signals the bone marrow to decrease the RBC production.

 

DIF:    Cognitive Level: Analysis               REF:   Page 265        OBJ:   2

TOP:   Erythropoiesis                                           KEY:              Nursing Process Step: N/A

MSC:  NCLEX: Physiological Integrity