Medical Surgical Nursing  Concepts & Practice 3rd Edition by Susan C. DeWit, Candice K. Kumagai – Test Bank

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Medical Surgical Nursing  Concepts & Practice 3rd Edition by Susan C. DeWit, Candice K. Kumagai – Test Bank

 

Sample  Questions

 

Chapter 06: Infection Prevention and Control

deWit: Medical-Surgical Nursing: Concepts & Practice, 3rd Edition

 

MULTIPLE CHOICE

 

  1. The nurse is teaching a patient about infection prevention. The nurse points out that covering the mouth and nose with a tissue for a sneeze reduces the probability of infection spreading by which route?
a. Droplet
b. Airborne
c. Direct contact
d. Indirect contact

 

 

ANS:  A

Infection from the droplet route requires the pathogens be expelled in droplets from the host and inhaled by another host.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension   REF:   101

OBJ:   1 (theory)       TOP:   Disease-Producing Pathogens

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Safe, Effective Care Environment: Safety and Infection Control

 

  1. The nurse is providing infection control teaching to a patient. Which patient statement warrants additional patient teaching?
a. “It is important that I get my whooping cough vaccination as directed by my health care provider.”
b. “Getting plenty of sleep each night will help my immune system.”
c. “I should wash my hands before preparing my food.”
d. “It is important that I take my antibiotic until my symptoms have completely resolved.”

 

 

ANS:  D

Antibiotics must be completed in entirety. Partial completion of a protocol of prescribed antimicrobial medication can cause a pathogen to become resistant to that particular drug. Vaccinations, adequate rest, and proper hand hygiene are important infection control measures.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   101, 113, Table 6-7

OBJ:   1 (theory)       TOP:   Infection Control Measures

KEY:  Nursing Process Step: Evaluation

MSC:  NCLEX: Safe, Effective Care Environment: Safety and Infection Control

 

  1. When the patient complains, “If this viral infection I have right now can’t be helped by antibiotics, why am I taking this expensive acyclovir?” How should the nurse respond?
a. “Acyclovir is an antiviral drug that kills viruses.”
b. “Acyclovir is given to many patients with viral infections.”
c. “Acyclovir is an antiviral drug that prevents your infection from becoming worse.”
d. “Acyclovir helps strengthen your immune system.”

 

 

ANS:  C

The patient currently has a viral infection; acyclovir is an antiviral drug that will decrease the virulence of the infection if started in the early phase of the infection. The drug may not kill the virus and is not given frequently to patients with viruses. Acyclovir will not strengthen the immune system.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   101

OBJ:   8 (theory)       TOP:   Viruses          KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Safe, Effective Care Environment: Safety and Infection Control

 

  1. The clinic nurse offers suggestions to a patient who is planning a trip to Mexico that will help prevent a protozoan infection. Which suggestion is most helpful?
a. “Ask the doctor for a prophylactic prescription for an antiviral drug.”
b. “Broad-spectrum antibiotics will be most helpful if you contract a protozoan infection.”
c. “Be sure to practice good hand hygiene while on your vacation.”
d. “It would be best if you drank bottled water while on your trip.”

 

 

ANS:  D

Protozoa frequently live in the water and soil and cause infection by ingestion of the parasite. Water in many foreign countries contains protozoa, so drinking bottled water is the best suggestion.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   101

OBJ:   1 (theory)       TOP:   Protozoa        KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Reduction of Risk Potential

 

  1. While assessing an obese resident in a long-term care facility, the nurse finds a red, moist rash under the patient’s breasts, in the axilla, and in the inguinal fold. Based on this assessment, the nurse reports to the charge nurse that the resident probably has which type of infection?
a. A fungal infection
b. A bacterial infection
c. An allergic reaction
d. Contact dermatitis

 

 

ANS:  A

Fungal infections thrive in warm, moist environments and most frequently affect the skin.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension   REF:   102

OBJ:   1 (theory)       TOP:   Fungi             KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Safe, Effective Care Environment: Safety and Infection Control

 

  1. A frustrated patient with a fungal infection complains, “Why is the infection taking so long to heal?” Which response is most appropriate?
a. “Fungal infections are essentially incurable.”
b. “Fungi form spores, which make them difficult to kill.”
c. “Fungi can be considered natural flora and are protected by the body.”
d. “Fungi can alter the patient’s DNA and RNA.”

 

 

ANS:  B

Fungi are capable of forming spores, which makes them resistant to antifungal agents.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension   REF:   102

OBJ:   1 (theory)       TOP:   Fungi             KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Safe, Effective Care Environment: Safety and Infection Control

 

  1. The nurse explains to the patient who is using Prilosec (a proton pump inhibitor) that the drug reduces the amount of which natural protector in the stomach lining?
a. Lactic acid
b. Lysozyme
c. Cilia
d. Fatty acids

 

 

ANS:  B

Lysozyme is found in the lining of the stomach and in the stomach acids.

 

PTS:   1                    DIF:    Cognitive Level: Knowledge          REF:   102

OBJ:   2 (theory)       TOP:   Chemical Barrier

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Pharmacological Therapies

 

  1. How should the home health nurse advise the patient to treat a fever of 100° F?
a. Take aspirin as needed.
b. Take Tylenol every 4 to 6 hours.
c. Bathe in cool water before bed.
d. Do nothing at all.

 

 

ANS:  D

Allowing reasonable levels of fever allows the body’s natural defenses to make a hostile environment to the pathogen through heat.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   103

OBJ:   3 (theory)       TOP:   Fever             KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. The home health nurse is providing dietary recommendations to keep the immune system healthy. The patient demonstrates understanding by increasing intake of which foods?
a. Eggs and beans
b. Celery and water
c. Pasta and bread
d. Olive oil and peanuts

 

 

ANS:  A

Protein stores must be kept at an adequate level in order to produce antibodies, thus boosting the immune system. Eggs and beans are a good source of protein. Increasing intake of celery and water increases fluid. Pasta and bread are carbohydrate-rich foods. Olive oil and peanuts feature unsaturated fats. Fluids, carbohydrates, and unsaturated fats will not enhance the immune system.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   103

OBJ:   8 (theory)       TOP:   Nutrition        KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

 

  1. The nurse is caring for several patients and determines which patient to be most at risk for developing an infection related to a decreased anti-inflammatory response?
a. A patient who has been experiencing high levels of stress for the last 3 months.
b. A patient with a glycosylated Hgb level of 6.7%.
c. A patient with osteoarthritis who was recently diagnosed.
d. A patient who is scheduled for laparoscopic cholecystectomy in 2 weeks related to gallstones.

 

 

ANS:  A

The presence of increased levels of cortisol resulting from ongoing stress inhibits the anti-inflammatory response, thus making this patient most susceptible to developing an infection. A glycosylated Hgb level of 6.7% is normal; osteoarthritis and gallstones would not significantly increase a patient’s likelihood of developing an infection.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   100, Box 6-1, 103

OBJ:   10 (clinical)    TOP:   Cortisol          KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. To which entity should the home health nurse make a referral in order to supply a home-bound older adult with a daily meal?
a. A community food bank
b. The Salvation Army
c. An agency supplying food stamps
d. Meals on Wheels

 

 

ANS:  D

Meals on Wheels provides a large, nutritious meal to home-bound people. A community food bank, the Salvation Army, and food stamps would not adequately assist a home-bound individual.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension

REF:   103, Older Adult Care Points          OBJ:   1 (clinical)      TOP:   Nutrition

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. The nurse uses a visual aid to demonstrate how which antibody attaches to the antigen to clear the pathogen from the body?
a. IgA
b. IgD
c. IgG
d. IgM

 

 

ANS:  D

Immunoglobulin M (IgM) is the antibody that recognizes the foreign protein and attaches itself to it in order to clear the pathogen from the body.

 

PTS:   1                    DIF:    Cognitive Level: Knowledge          REF:   104, Table 6-2

OBJ:   2 (theory)       TOP:   Antibodies     KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. The nurse explains that exposure to a pathogen stimulates the macrophages to migrate to the area of infection to ingest and destroy the pathogen. This statement describes which process?
a. Pathogen neutralization
b. Immune response
c. Antibody action
d. Phagocytosis

 

 

ANS:  D

Phagocytosis is the process of the ingestion of a pathogen by macrophages.

 

PTS:   1                    DIF:    Cognitive Level: Knowledge          REF:   104

OBJ:   2 (theory)       TOP:   Phagocytosis

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. The patient complains of the unsightly swelling of her lip at the site of an infection. The nurse explains that the swelling is part of the inflammatory response and performs which action?
a. Stores blood
b. Acts as a compression wall
c. Provides an antibody reservoir
d. Produces leukocytes

 

 

ANS:  B

The swelling of the inflammatory response acts as a compression wall to delay the spread of harmful agents to the rest of the body.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension   REF:   106

OBJ:   2 (theory)       TOP:   Inflammatory Response

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. The nurse is providing infection control teaching to a group of patients. Which statement demonstrates that the patient understands the nurse’s teaching?
a. “I should take an antibiotic at the first sign of an infection.”
b. “Hand hygiene is one of the most effective ways I can prevent the spread of infection.”
c. “Vaccinations only prevent a disease from becoming severe.”
d. “If I eat a nutritious diet, it will be difficult for me to get an infection.”

 

 

ANS:  B

Hand hygiene is the most effective single act that can reduce the spread of disease. Antibiotics should not be taken at the first sign of infection, especially if the infection is caused by a virus; vaccinations can also prevent diseases from occurring; a nutritious diet is only one component in the prevention of infection.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   107

OBJ:   2 (theory)       TOP:   Hand Hygiene

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

 

  1. The nurse discusses and demonstrates proper hand hygiene to an immunocompromised patient and his wife. Which statement indicates a need for additional teaching?
a. “It is okay for my wife to wear artificial nails as long as she washes her hands properly.”
b. “I should always wash my hands before I eat.”
c. “Hand gels work as well as handwashing under most circumstances.”
d. “I should use friction and wash my hands for about 20 seconds if I am using soap and water.”

 

 

ANS:  A

Artificial nails harbor microorganisms regardless of good hand hygiene. Washing hands prior to eating is good practice, as well as using friction and washing for 15 to 30 seconds with soap and water. Hand gels are effective in most circumstances except for certain infections such as C. difficile and C. albicans.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   107-108

OBJ:   2 (clinical)      TOP:   Hand Hygiene

KEY:  Nursing Process Step: Evaluation

MSC:  NCLEX: Safe, Effective Care Environment: Safety and Infection Control

 

  1. The nurse explains that a vaccination provides defense against infection via which type of immunity?
a. Innate immunity
b. The inflammatory response
c. Antibody-mediated immunity
d. Cell-mediated immunity

 

 

ANS:  C

Vaccinations produce an antibody-mediated immunity by stimulating the host to develop specific antibodies against specific diseases.

 

PTS:   1                    DIF:    Cognitive Level: Knowledge          REF:   105, Table 6-3

OBJ:   2 (theory)       TOP:   Immune Response

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. The nurse is planning care for a patient and determines that Expanded Precautions are warranted when performing care for a patient with which infection?
a. Active tuberculosis (TB)
b. Bacterial pneumonia
c. A urinary tract infection (UTI) caused by E. coli
d. A fungal infection of the groin and axilla

 

 

ANS:  A

Active TB can be spread by airborne pathogens. Masks and gowns, in addition to gloves, should be worn while caring for such patients. Standard Precautions would be used for patients with bacterial pneumonia, a UTI caused by E. coli, and a fungal infection of the groin and axilla.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   109, Table 6-5

OBJ:   5 (theory)       TOP:   Expanded Precautions

KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Safe, Effective Care Environment: Safety and Infection Control

 

  1. The nurse is caring for a patient with C. difficile infection. Which action is most important for the nurse to take?
a. Only use alcohol-based hand cleanser for hand hygiene.
b. Always wear an impervious mask.
c. Don proper eye protection before providing care.
d. Notify housekeeping to use appropriate cleaning agents.

 

 

ANS:  D

Notification of housekeeping to use alcohol-free cleaners is necessary in order to eradicate the pathogen. Soap and water must be used after contact with this organism because alcohol-based hand sanitizers do not adequately kill the microorganism. A mask and eye protection are not necessary.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   113

OBJ:   9 (clinical)      TOP:   Prevention of Health Care–Associated Infections

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Safe, Effective Care Environment: Safety and Infection Control

 

  1. The nurse is caring for a patient with general sepsis. Which finding should first alert the nurse to a potential complication that warrants immediate attention?
a. Increased lethargy
b. Sudden coughing
c. Elevated blood pressure
d. Cloudy urine

 

 

ANS:  A

Increasing lethargy is an indicator of impending septic shock. Coughing and cloudy urine are not signs of impending septic shock. Decreased rather than increased blood pressure would indicate impending septic shock.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   115

OBJ:   1 (theory)       TOP:   Septic Shock

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

 

  1. The nurse who suffers an accidental needle stick following administration of an intramuscular injection to a patient anticipates that facility protocol will suggest immediate treatment with which type of immunotherapy?
a. IgM
b. IgD
c. Ig A
d. IgG

 

 

ANS:  D

IgG is frequently given to provide passive immunity until the body’s own immune system can defend itself; therefore, it would most likely be a component of a health care facility’s initial treatment protocol for accidental needle sticks. IgM, IgD, and IgA would not be indicated.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension   REF:   104, Table 6-2

OBJ:   1 (theory)       TOP:   Immunoglobulins

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

 

  1. The nurse provides discharge teaching about antibiotic therapy. Which statement indicates that the patient requires additional teaching?
a. “I should wait 3 days after my symptoms resolve before stopping my antibiotic.”
b. “I should try to take my medication as evenly spaced apart as possible.”
c. “If I start feeling worse, I should call my health care provider.”
d. “I should not share my medication with anyone.”

 

 

ANS:  A

The antibiotic should be taken until it is completely gone in order to ensure the infection has been adequately treated. Antibiotics are more effective if spaced evenly apart when taken. The patient should continue to improve if therapy is effective, so the health care provider should be notified if symptoms are not improving. Patients should never share any type of prescribed medication.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   113, Table 6-7

OBJ:   8 (theory)       TOP:   Antimicrobial Therapy

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

 

MULTIPLE RESPONSE

 

  1. The nurse instructs the nursing assistant in a long-term care facility regarding infection control measures. Which action(s) demonstrate(s) that the nursing assistant understands the nurse’s teaching? (Select all that apply.)
a. Assisting residents with hand hygiene before meals.
b. Cleaning incontinent residents as soon as possible.
c. Administering prescribed antibiotics during meals to residents who require assistance with feeding.
d. Inspecting residents’ skin for open areas during bathing.
e. Assisting residents with hand hygiene after participating in group activities.

 

 

ANS:  A, B, D, E

It is important for the nursing assistant to assist residents with hand hygiene prior to meals and after participating in group activities in order to help prevent the spread of infection. Cleaning incontinent residents as soon as possible prevents skin breakdown, which may lead to infection. While bathing residents, the nursing assistant should monitor for signs of skin breakdown and report any areas to the nurse. Nursing assistants are not permitted to administer medications.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   121

OBJ:   10 (clinical)    TOP:   Infection Control Measures

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

 

  1. Which areas of the body is/are protected by normal flora? (Select all that apply.)
a. Skin
b. Bladder
c. Lower gastrointestinal (GI) tract
d. Nose and throat
e. Eye

 

 

ANS:  A, C, D, E

Normal flora inhabit and protect the skin, lower GI tract, nose and throat, and eyes. The bladder does not have any natural flora for protection.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension   REF:   100, Table 6-1

OBJ:   2 (theory)       TOP:   Natural Flora

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. The nurse is obtaining a health history on a newly admitted patient. Which information alerts the nurse that the patient is at increased risk for developing an infection? (Select all that apply.)
a. The patient reports having unprotected heterosexual sex in three previous relationships.
b. The patient is employed as a biochemist in a hospital.
c. The patient’s income is considered middle-class level.
d. The patient reports getting 4 to 5 hours of sleep per night.
e. The patient is 21% over the suggested normal weight.

 

 

ANS:  A, D, E

This patient’s lifestyle habits, insufficient sleep, and being obese increase the chance of developing an infection by the strain placed on the immune system. This patient’s occupation and income level would not increase the risk for infection.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   100, Box 6-1

OBJ:   10 (clinical)    TOP:   Risk Factors   KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

COMPLETION

 

  1. The nurse explains that an infection occurring in the body represents an interrelationship between the __________, __________, and __________.

 

ANS:

host, agent, environment

host, environment, agent

agent, host, environment

agent, environment, host

environment, host, agent

environment, agent, host

 

A pathologic agent, upon entering the body, must attach to a host in order to multiply in a supportive environment.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   100, Box 6-1

OBJ:   1 (theory)       TOP:   Infection Process

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. The bacteria that are rod-shaped are classified as _________.

 

ANS:

bacilli

 

Bacilli are rod-shaped bacteria.

 

PTS:   1                    DIF:    Cognitive Level: Knowledge          REF:   101

OBJ:   1 (theory)       TOP:   Bacteria         KEY:  Nursing Process Step: N/A

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. The nurse explains that the four lines of defense the body employs to combat infection are inflammatory response, immune response, __________, and __________.

 

ANS:

skin, normal flora

normal flora, skin

 

The body is defended against infection by the skin, normal flora, and inflammatory and immune responses.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension   REF:   102

OBJ:   2 (theory)       TOP:   Defense Against Infection

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

Chapter 07: Care of Patients with Pain

deWit: Medical-Surgical Nursing: Concepts & Practice, 3rd Edition

 

MULTIPLE CHOICE

 

  1. In order to provide the optimum nursing care, it is important for the nurse to know that the standard of pain and pain control is best determined by which person?
a. Physician
b. Nurse
c. Patient’s family
d. Patient

 

 

ANS:  D

Only the patient knows when pain occurs and what remedy relieves it.

 

PTS:   1                    DIF:    Cognitive Level: Knowledge          REF:   127

OBJ:   1 (theory)       TOP:   Pain Theory   KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. The nurse clarifies the basics of the gate theory of pain control. Which information should the nurse include?
a. Pain is perceived as opening a “gate” to pain symptoms.
b. The “gate” can be closed to pain by the use of nonpainful stimuli.
c. The “gate” swings back and forth, first allowing pain, then blocking it.
d. The patient can be trained to close the “gate” to pain.

 

 

ANS:  B

The sensorineural “gate” can be closed by applying a number of nonpharmacologic stimuli so that the pain is not perceived.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension   REF:   124

OBJ:   1 (theory)       TOP:   Gate Theory   KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. When giving care to a 30-year-old Hispanic male, which action can most likely be attributed to the patient’s cultural beliefs about pain?
a. The patient maintains a stoic affect about pain.
b. The patient prefers a pill to an injection.
c. The patient ignores somatic interventions such as heat and massage.
d. The patient confesses to pain but refuses pain medication.

 

 

ANS:  A

Hispanic males are frequently stoic regarding pain. They prefer injections to pills but may elect to use prayer, heat, or herbal remedies for pain relief.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   131, Cultural Considerations

OBJ:   4 (theory)       TOP:   Cultural Considerations

KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. The nurse is caring for a patient who is having constant nociceptor pain. Which intervention best addresses the patient’s pain during the perception phase of pain?
a. Administer nonsteroidal anti-inflammatory drugs (NSAIDs) for moderate pain.
b. Ask the physician if an opioid could be ordered to treat the patient’s pain when severe.
c. Engage the patient in conversation regarding his family, hobbies, and plans following discharge from the facility.
d. Determine if the patient typically takes a neurotransmitter uptake blocker medication for pain control.

 

 

ANS:  C

Nonpharmacologic interventions such as distraction and guided imagery are effective for pain relief during the perception phase. NSAIDs are most effective during the transduction phase of pain, opioids are most effective during the transmission phase, and drugs that block neurotransmitter uptake work best during the modulation phase.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   125

OBJ:   3 (theory)       TOP:   Pain Perception

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. The patient is experiencing phantom pain following the amputation of her foot. Which type of pain is most associated with phantom pain?
a. Nociceptive
b. Mild
c. Uncontrollable
d. Neuropathic

 

 

ANS:  D

Neuropathic pain is associated with a dysfunction of the nervous system that involves an abnormality in the processing of sensations such as phantom pain. Nociceptive pain is associated with pain stimuli from either somatic (body tissue) or visceral (organs) structures. Mild and uncontrollable refer to severity rather than classifications of pain.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension   REF:   126, Table 7-1

OBJ:   1 (theory)       TOP:   Neuropathic Pain

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. The nurse explains that the pain threshold and pain tolerance are different. Which statement about the pain threshold is true?
a. Pain threshold is the point at which pain is perceived.
b. Pain threshold is the point at which the person responds to pain.
c. Pain threshold is the point at which pharmacologic intervention is required.
d. Pain threshold is the point at which signs such as grimacing or groaning are observed.

 

 

ANS:  A

The pain threshold is the point at which the pain is perceived.

 

PTS:   1                    DIF:    Cognitive Level: Knowledge          REF:   127

OBJ:   1 (theory)       TOP:   Pain Threshold

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. The patient who had abdominal surgery this morning refuses the opioid pain medication for fear of addiction. How should the nurse respond?
a. “Opioids are addictive, whereas nonsteroidal anti-inflammatory drugs (NSAIDs) are not.”
b. “Addiction is mainly a matter of attitude.”
c. “Fewer than 3% of people become addicted to drugs used for pain relief.”
d. “Although addiction does occur, it is quickly reversed.”

 

 

ANS:  C

Pain from abdominal surgery is acute pain. This patient is not experiencing chronic pain that will require ongoing pain medication, and addiction occurs in fewer than 3% of people who take pain medication. Any medication can be addictive. Addiction is often not merely a matter of attitude. Finally, addictions typically require long-term therapy.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   134, Table 7-4

OBJ:   5 (theory)       TOP:   False Perception About Pain

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Pharmacological Therapies

 

  1. Which student nurse’s note in the patient’s record features proper documentation of a pain assessment?
a. Pt. complains of local sharp pain (4/5) in lower abdomen upon standing.
b. Pt. complains of stomach pain after eating (3/5).
c. Pt. reports standing makes his stomach hurt.
d. Pt. reports sharp pain in stomach.

 

 

ANS:  A

The recorded assessment should include location, characteristics, quantity, severity based on a pain scale, and pattern.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension   REF:   134

OBJ:   8 (clinical)      TOP:   Pain Assessment

KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. The nurse is educating the home health patient about indications for acetaminophen. Which information should the nurse include in the teaching plan?
a. Take acetaminophen as frequently as needed.
b. Take acetaminophen before pain becomes severe.
c. Take acetaminophen when pain becomes unbearable.
d. Take acetaminophen sparingly and with caution.

 

 

ANS:  B

Taking medication before pain becomes severe controls pain best. Once taken, the medication should be taken on the prescribed schedule until pain is well controlled. Taking acetaminophen too frequently could lead to toxicity and liver problems. Waiting until the pain becomes unbearable will require larger amounts of analgesics to control the pain. Acetaminophen may be used as needed.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   134, Patient Teaching

OBJ:   6 (theory)       TOP:   Pain Medication

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Pharmacological Therapies

 

  1. While bathing a patient, the nurse notes that a transdermal patch that was meant to be on the patient for 3 days is now gone on the second day. What action should the nurse take?
a. Document the loss and apply a fresh patch to be replaced in 3 days.
b. Report the loss to the charge nurse.
c. Document the loss, replace the patch, and continue with the original schedule for replacement.
d. Remind the patient that oral pain relief will be available until the patch is replaced in 24 hours.

 

 

ANS:  A

The patch should be replaced after the loss is documented, and the schedule should be changed. There is no need for the patient to wait for a new patch to be applied in 24 hours.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   136

OBJ:   6 (theory)       TOP:   Transdermal Patches

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. The patient on frequent doses of meperidine (Demerol) complains of constipation. Which initial intervention is best?
a. Offer fruit such as prunes or apricots.
b. Request an order for an enema.
c. Report the condition to the charge nurse.
d. Increase oral fluid intake.

 

 

ANS:  D

Increasing fluid intake is the best initial approach because additional fluid allows the body to correct the problem naturally. Fruits can be offered, but increasing the fluid intake is the most effective and priority intervention. An enema is invasive and is not an early intervention for constipation. The nurse should be able to implement proper care without reporting the constipation to the charge nurse.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   137

OBJ:   10 (clinical)    TOP:   Common Side Effects

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. Because of the threat of lowering the seizure threshold, the home health nurse would suggest that the 85-year-old patient limit the use of which pain medication?
a. Ibuprofen (Motrin)
b. Naproxen (Aleve)
c. Tramadol (Ultram)
d. Acetaminophen (Tylenol)

 

 

ANS:  C

Tramadol (Ultram) is associated with a lowered seizure threshold in the older adult.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension

REF:   138, Older Adult Care Points          OBJ:   7 (theory)       TOP:   Common Side Effects

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Pharmacological Therapies

 

  1. The home health nurse educates the 75-year-old patient about the warm compresses he is using on his swollen elbow. Which information is most important to include in the teaching plan?
a. Apply the warm compress directly on the skin.
b. Allow the compress to remain in place for 15 to 20 minutes.
c. Take aspirin 30 minutes prior to applying the compress.
d. Alternate the warm compress with an ice pack every 10 minutes.

 

 

ANS:  B

Applications of heat should only be left in place for 15 to 20 minutes. The warm compress should not be applied directly on the skin. The warm compress does not need to be combined with pharmacologic therapy, and aspirin therapy may not be indicated. The nurse should consult with the health care provider before suggesting any medication. The compress works to offer mild pain relief by vasodilation; these effects would be negated by alternating the warm compress with ice.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   138

OBJ:   10 (clinical)    TOP:   Nonpharmacologic Approaches

KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. The hospitalized postsurgical patient is reluctant to take the opioid pain medication because of drowsiness. Which response is most informative for the nurse to make?
a. “Mental stimulation after the medication will keep you more alert.”
b. “Sleep and pain relief promote healing.”
c. “Drowsiness is an undesirable side effect.”
d. “The medication should be taken only before bedtime.”

 

 

ANS:  B

Effective analgesia and adequate rest and sleep promote healing. Mental stimulation after taking an opioid will most likely not be effective for keeping the patient alert. Drowsiness is an expected effect. The medication should be taken as prescribed, not just before bedtime.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   138

OBJ:   9 (clinical)      TOP:   Nonpharmacologic Approaches

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. To help with pain control, how should the nurse time the distraction activities for a patient?
a. To coincide with mealtimes
b. To bridge the time between administration and onset
c. To occur just before bedtime
d. To awaken the patient in the morning

 

 

ANS:  B

Distraction is helpful with pain control between administration of the analgesia and its onset. Mealtimes, bedtime, and sleep should not be interrupted with distraction activities.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension   REF:   139

OBJ:   10 (clinical)    TOP:   Nonpharmacologic Approaches

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. A patient reports pain relief after having received a placebo. Which conclusion is most accurate for the nurse to determine?
a. The patient was not actually experiencing pain.
b. The patient was relieved of the anxiety that there is no ready source of pain remedy.
c. The patient was demonstrating “attention-seeking” behavior.
d. The patient was being manipulative.

 

 

ANS:  B

Much pain is associated with anxiety that there will be no pain remedy available. The delivery of a placebo relieves pain as it relieves the anxiety.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension   REF:   134, Table 7-4

OBJ:   6 (theory)       TOP:   False Perception about Pain

KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. The nurse is caring for a 45-year-old male Arab patient who is in pain. Which action can most likely be attributed to the patient’s cultural belief about pain?
a. The patient never requests pain medication.
b. The patient asks for pain relief to control pain.
c. The patient becomes irritable and demanding when in pain.
d. The patient hides pain from his family.

 

 

ANS:  B

Individuals of Arab descent generally view pain as something to be controlled and will probably call for pain remedy frequently and expect prompt response. Arabs will express pain to their family.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   131, Cultural Considerations

OBJ:   4 (theory)       TOP:   Cultural Beliefs about Pain

KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. The nurse is caring for a patient that is receiving intravenous morphine sulfate. The patient breaks out in hives and begins to itch. What should the nurse do first?
a. Obtain the patient’s vital signs.
b. Stop the infusion.
c. Report the patient’s condition to the charge nurse.
d. Give the prescribed antihistamine.

 

 

ANS:  B

The drug should be stopped immediately so that the patient does not receive any more of the medication. After completing this priority intervention, the nurse should then obtain the patient’s vital signs, report all findings to the charge nurse, and administer the prescribed antihistamine.

 

PTS:   1                    DIF:    Cognitive Level: Analysis               REF:   137

OBJ:   9 (clinical)      TOP:   Allergy           KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Reduction of Risk Potential

 

  1. The nurse is planning to teach a family member about effective massage techniques. Which information is most important to include in the teaching plan?
a. Use heat and a mild menthol cream for comfort.
b. Pound painful areas with the sides of the hands.
c. Gently and firmly massage of areas of inflammation.
d. Use long, firm strokes while avoiding areas of inflammation.

 

 

ANS:  D

Long, firm, and smooth strokes on areas that are not inflamed will direct the patient’s attention away from the painful area. Heat and menthol cream used together may cause a burn.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   139

OBJ:   10 (clinical)    TOP:   Massage         KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. The nurse explains that acupressure and acupuncture are effective pain relief modalities that focus on specific body areas. Which term best describes these therapies?
a. Triangulation
b. Hot spots
c. Meridians
d. Zones

 

 

ANS:  C

The Asian therapies of acupuncture and acupressure use body areas called meridians.

 

PTS:   1                    DIF:    Cognitive Level: Knowledge          REF:   139

OBJ:   7 (theory)       TOP:   Acupuncture and Acupressure

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. The nurse is caring for a patient who is 1-day postoperative following a colon resection. The patient has degenerative joint disease and uses a pain medication patch to control this chronic pain. Which consideration is most important when planning care for this patient?
a. Understand that the pain medication patch will control the postoperative pain.
b. Realize that this patient will most likely require more pain medication than most patients undergoing a colon resection.
c. Recognize that the patient will be afraid to ask for additional pain medication for fear of being viewed as addicted to pain medicine.
d. Expect the patient to forget about the pain caused from the degenerative joint disease.

 

 

ANS:  B

Patients who are being treated for chronic pain often require higher doses of pain medication to treat postoperative pain. The patient’s pain medication patch will not likely treat the postoperative pain. There is no indication that the patient will be afraid to ask for additional pain medication, and the patient is not likely to forget about the postoperative pain.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   127, Clinical Cues

OBJ:   6 (theory)       TOP:   Acute vs. Chronic Pain Management

KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. The nurse is planning care plans for multiple patients. Which patient does the nurse anticipate will experience the highest level of pain?
a. 28-year-old experiencing pain related to a metatarsal fracture
b. 45-year-old experiencing pain following a laparoscopic cholecystectomy
c. 67-year-old experiencing chronic back pain
d. 79-year-old experiencing pain related to osteoarthritis

 

 

ANS:  D

While pain is always dependent on the individual patient’s perception, the older adult tends to be less tolerant to pain due to factors such as having more than one chronic ailment and having fewer resources for tolerating pain.

 

PTS:   1                    DIF:    Cognitive Level: Application

REF:   127, Older Adult Care Points          OBJ:   4 (theory)       TOP:   Pain in Older Adults

KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort

 

MULTIPLE RESPONSE

 

  1. The nurse is using the gate theory as a guide to pain management. Which intervention(s) should the nurse plan to offer? (Select all that apply.)
a. Massage
b. Social activities
c. Music
d. Interactive distraction
e. A quiet environment

 

 

ANS:  A, B, D

Music is not effective as a gate closer. High levels of sensory stimulation are more effective for decreasing pain according to the gate theory.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension   REF:   124

OBJ:   1 (theory)       TOP:   Gate Control Theory

KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. What is/are the functions of endorphins? (Select all that apply.)
a. Inhibition of unpleasant stimuli
b. Diminished anxiety
c. Relief of pain
d. Feeling of euphoria
e. Increased blood pressure

 

 

ANS:  A, B, C, D

Endorphins are thought to diminish unpleasant stimuli and pain, reduce anxiety, and give feelings of euphoria.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension   REF:   125

OBJ:   3 (theory)       TOP:   Endorphins    KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. The nurse is caring for the patient with neuropathic pain. Which agents will most effectively control this patient’s pain? (Select all that apply.)
a. Analgesics
b. Opioids
c. Antidepressants
d. Anti-inflammatory agents
e. Anticonvulsants

 

 

ANS:  C, D, E

Neuropathic pain is best relieved by antidepressants, anti-inflammatory agents, and anticonvulsants. Analgesics and opioids generally do not alleviate neuropathic pain.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension   REF:   126-127

OBJ:   3 (theory)       TOP:   Neuropathic Pain

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Pharmacological Therapies

 

  1. Although the patient with a kidney stone denies pain, the nurse assesses cues that indicate that pain is perceived. Which assessments indicate that pain may be present? (Select all that apply.)
a. Increased pulse rate
b. Decreased respiratory rate
c. Diaphoresis
d. Muscle tension
e. Nausea

 

 

ANS:  A, C, D, E

The respiratory rate increases in patients in acute pain.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension   REF:   128-129

OBJ:   8 (clinical)      TOP:   Assessment of Acute Pain

KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort

 

COMPLETION

 

  1. Pain receptors in the skin, connective tissue, bone, joints, and muscles are classified as __________.

 

ANS:

nociceptors

 

Pain receptors in the skin, connective tissue, bone, joints, and muscles are nociceptors.

 

PTS:   1                    DIF:    Cognitive Level: Knowledge          REF:   125

OBJ:   3 (theory)       TOP:   Nociceptor Receptors                                KEY:   Nursing Process Step: N/A

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

MATCHING

 

Arrange the sequence of nociceptive pain in the order in which the process occurs.

a. Transmission
b. Modulation
c. Transduction
d. Perception

 

 

  1. Step 1

 

  1. Step 2

 

  1. Step 3

 

  1. Step 4

 

  1. ANS:  C                    PTS:   1                    DIF:    Cognitive Level: Comprehension

REF:   125, 126, Figure 7-2                       OBJ:   3 (theory)       TOP:   Nociceptive Pain Perception

KEY:  Nursing Process Step: N/A

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. ANS:  A                    PTS:   1                    DIF:    Cognitive Level: Comprehension

REF:   125, 126, Figure 7-2                       OBJ:   3 (theory)       TOP:   Nociceptive Pain Perception

KEY:  Nursing Process Step: N/A

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. ANS:  D                    PTS:   1                    DIF:    Cognitive Level: Comprehension

REF:   125, 126, Figure 7-2                       OBJ:   3 (theory)       TOP:   Nociceptive Pain Perception

KEY:  Nursing Process Step: N/A

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. ANS:  B                    PTS:   1                    DIF:    Cognitive Level: Comprehension

REF:   125, 126, Figure 7-2                       OBJ:   3 (theory)       TOP:   Nociceptive Pain Perception

KEY:  Nursing Process Step: N/A

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

Chapter 11: Care of Patients with Immune and Lymphatic Disorders (with HIV and AIDS)

deWit: Medical-Surgical Nursing: Concepts & Practice, 3rd Edition

 

MULTIPLE CHOICE

 

  1. The nurse is caring for a pediatric patient recently diagnosed with severe combined immunodeficiency (SCID) disease. The nurse determines that teaching has been effective after the parent makes which statement?
a. “This disease is like a pediatric version of AIDS.”
b. “My child must be careful not to fall to avoid bleeding.”
c. “My child should not attend day care.”
d. “This problem happened because of chemotherapy treatments.”

 

 

ANS:  C

There are two forms of immune deficiency: primary and acquired. In primary immune deficiency disorders (PIDD), the cause is an inherited genetic mutation and some of PIDD are detected during infancy or early childhood. Patients with this type of disorder experience repeated infections that clearly increase their risk of morbidity and mortality as well as the cost of health care. AIDS is an example of acquired immune deficiency and affects pediatric patients as well as adults. Hemophilia is a disorder in which patients can suffer life-threatening bleeds from a fall. Chemotherapy recipients may develop an acquired immune disorder, but chemotherapy would not cause any type of immune disorder in the child.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   217, Box 11-1

OBJ:   1                    TOP:   Primary Immune Deficiency

KEY:  Nursing Process Step: Evaluation

MSC:  NCLEX: Physiological Integrity: Reduction of Risk Potential

 

  1. After an influenza immunization, the patient complains of shortness of breath, breaks out in hives, and begins to twitch. Which ordered medication should the nurse give first?
a. Epinephrine injection
b. Oxygen via mask at 5 L/min
c. Corticosteroid injection
d. Bronchodilators per nebulization

 

 

ANS:  A

Epinephrine is the initial line of defense to reverse anaphylaxis, followed by high-flow oxygen, bronchodilators, and corticosteroid injection as necessary.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   249

OBJ:   6 (clinical)      TOP:   Anaphylaxis  KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

 

  1. The nurse is educating a patient with systemic lupus erythematosus (SLE). Which information is most important for the nurse to include in the teaching plan?
a. Train with weights to increase strength.
b. Avoid glycerin-based soaps.
c. Use an SPF 15 sunblock when outdoors.
d. Apply fragrance-free lotions to dry areas twice daily.

 

 

ANS:  D

Skin protection for patients with SLE is a top priority. The patient should be advised to liberally apply fragrance-free lotions to dry areas at least twice daily. Weight training could cause joint strain. SLE patients should choose a mild soap with a glycerin base and select sunscreen that features SPF of 30 or higher.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   233, 237, Patient Teaching

OBJ:   7                    TOP:   SLE Teaching

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

 

  1. The nurse is educating a patient about his diagnosis of stage II Hodgkin disease. Which statement indicates that the nurse’s teaching has been successful?
a. “The cancer has spread throughout my entire body.”
b. “There is only one lymph node involved.”
c. “The lymph nodes in both of my arms are affected.”
d. “Two nodes in my left arm area are affected.”

 

 

ANS:  D

Stage II indicates that there are two or more involved lymph nodes on the same side of the diaphragm (or body). The lymph nodes affected could be in any part of the lymphatic system. The disease spreading outside of the lymph system indicates stage IV. Single node involvement is stage I, and lymph involvement on both sides of the diaphragm or body is considered stage III.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   238, Figure 11-5

OBJ:   8                    TOP:   Hodgkin Disease Node Staging

KEY:  Nursing Process Step: Evaluation

MSC:  NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

 

  1. MOPP and ABVD therapy for the treatment of Hodgkin disease are treatment protocols that use which combination of factors?
a. Multiple medications given concurrently
b. Heat, exercise, and chemotherapy
c. Alternating radiation and chemotherapy
d. Chemotherapy and alternative herbal remedies

 

 

ANS:  A

MOPP and ABVD are chemotherapy treatment protocols using a combination of four drugs given concurrently. MOPP is the acronym for the drugs mechlorethamine, vincristine (Oncovin), procarbazine, and prednisone. ABVD is the acronym for the drugs doxorubicin (Adriamycin), bleomycin, vinblastine, and dacarbazine. This treatment protocol is usually used for stages III and IV of the disease.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   238

OBJ:   8                    TOP:   Treatment: Hodgkin Disease

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

 

  1. The nurse caring for a patient with advanced AIDS. While collecting data, the nurse notes a weight loss of several pounds, poor food consumption, and complaint of no appetite. Based on these findings, the nurse should carefully monitor the patient for development of which problem?
a. Lymphedema
b. Hyperglycemia
c. Hypertension
d. Anasarca

 

 

ANS:  D

Anasarca is generalized edema in the trunk, extremities, and around the eyes. It results in patients with advanced AIDS from a severe depletion of albumin when the patient has an insufficient nutritional intake, as is evident with this patient. Lymphedema is an abnormal collection of lymph fluid accumulated in the peripheral and periorbital areas, sometimes seen in AIDS patients. Hypoglycemia and hypotension are typically seen in patients with advanced AIDS who have poor nutritional and fluid intake.

 

PTS:   1                    DIF:    Cognitive Level: Analysis               REF:   226

OBJ:   3 (clinical)      TOP:   Advanced AIDS: Symptoms

KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. The nurse is caring for an immune compromised patient. The patient displays a low-grade fever and complains of a burning and shooting pain, along with itching and tingling, that progresses from the clavicle to the scapula. The nurse suspects that the patient will undergo evaluation for which infection?
a. Hepatitis C
b. Shingles
c. Candidiasis
d. Cryptococcosis

 

 

ANS:  B

The immune compromised patient may experience opportunistic infections. Hepatitis C, bacterial infections, and cryptococcosis are all opportunistic infections, but the symptoms this patient is experiencing are consistent with shingles.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   226, Table 11-5

OBJ:   6 (theory)       TOP:   Opportunistic Infection

KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. The patient scheduled for a computed tomography (CT) scan with contrast medium questions the nurse why the technologist asked her if she had any food allergies. Which response by the nurse is correct?
a. “The dye used for a CT scan is egg based, so egg allergies would prevent you from having the test.”
b. “People who are allergic to dairy products are likely to be allergic to CT scan dye.”
c. “Allergies to shellfish can be a problem because shellfish and CT scan dye are iodine based.”
d. “Wheat is the preservative used in CT scan dye, so allergies to wheat may cause allergies to the dye.”

 

 

ANS:  C

Allergies to seafood indicate intolerance to iodine. This means there is potential for an allergic reaction to iodine-based contrast agents used in radiologic imaging studies such as CT scans with contrast medium.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   247, Clinical Cues

OBJ:   10 (theory)     TOP:   Allergies        KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Reduction of Risk Potential

 

  1. The nurse is performing an assessment on a patient admitted for diagnostic testing to rule out fibromyalgia. Which assessment finding indicates that the patient actually may have the disorder?
a. A decreased response to painful stimuli
b. A pain response to nonpainful stimuli
c. Absent response to painful stimuli
d. Numbness and tingling in response to painful stimuli

 

 

ANS:  B

Allodynia, pain response to nonpainful stimuli, is one of the signs typically seen in the patient with fibromyalgia. Patients with fibromyalgia often experience hyperalgesia, which is a heightened response to painful stimuli.

 

PTS:   1                    DIF:    Cognitive Level: Knowledge          REF:   240

OBJ:   9 (theory)       TOP:   Fibromyalgia

KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Safe, Effective Care Environment: Management of Care

 

  1. The nurse is working in a trauma unit and is accidentally stuck with an IV needle following venipuncture of the patient. What is the nurse’s first action?
a. Immediately begin taking the two- or three-drug regimen.
b. Report the stick to the charge nurse immediately so follow-up can be initiated.
c. Wash the punctured area with soap and water.
d. Complete an incident report so immediate testing of the patient and nurse can begin.

 

 

ANS:  C

The area should first be cleansed in an attempt to flush any pathogenic organisms from the site, followed by reporting the incident to the charge nurse and completing an incident report. Appropriate treatment regimen will then be started.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   231, Safety Alert

OBJ:   9 (theory)       TOP:   HIV Exposure

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Safe, Effective Care Environment: Safety and Infection Control

 

  1. The nurse has just administered a new antibiotic to a patient. Which manifestation is the best early indicator that the patient may be experiencing an anaphylactic reaction?
a. Wheezing
b. Shortness of breath
c. Difficulty swallowing
d. Angioedema

 

 

ANS:  D

The appearance of hives (urticaria) or swelling beneath the skin (angioedema) may signal the onset of an anaphylactic episode. Wheezing, shortness of breath, and difficulty swallowing are later signs of anaphylaxis.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   247

OBJ:   10 (theory)     TOP:   Anaphylaxis  KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Safe, Effective Care Environment: Management of Care

 

  1. A patient with an immune deficiency disorder has been admitted to the medical unit due to a current infection and weight loss of 12% of his body weight. Which nutritional intervention is most appropriate for this patient?
a. Fat
b. Vitamin C
c. Vitamin B12
d. Protein

 

 

ANS:  D

Foods high in protein will not only help with increasing weight but will aid in synthesizing needed antibodies for this condition. Fats, vitamin C, and vitamin B12 will not address either the need for weight gain or antibody synthesis.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   219

OBJ:   4 (theory)       TOP:   Immune Deficiency

KEY:  Nursing Process Step: Intervention

MSC:  NCLEX: Safe, Effective Care Environment: Management of Care

 

  1. The nurse is caring for a patient who reports feeling very stressed about her new diagnosis of fibromyalgia. Which response is most beneficial in addressing the patient’s stress?
a. “I can’t imagine how it must feel to have this disorder.”
b. “What worries you the most about your fibromyalgia?”
c. “Light exercise and relaxation techniques may really help alleviate your stress.”
d. “You can talk to your doctor about your stress and ask him to prescribe some antianxiety medication.”

 

 

ANS:  B

Although light exercise and relaxation techniques may be helpful in reducing stress, the nurse should first address concerns and provide information about the disorder. Providing necessary information is a major stress reducer. Stating only that the nurse “can’t imagine how you feel” provides no therapeutic value, and medications are not a first-line treatment for stress.

 

PTS:   1                    DIF:    Cognitive Level: Analysis               REF:   240

OBJ:   9 | 5 (clinical)                                 TOP:   Fibromyalgia

KEY:  Nursing Process Step: Intervention MSC:  NCLEX: Psychosocial Integrity

 

  1. The home care nurse is caring for a patient with a severe immune deficiency disorder. What information about infection prevention is most important for the nurse to include in the teaching plan?
a. Check your temperature daily.
b. Wash your hands frequently.
c. Check daily for signs of infection.
d. Seek medical advice at the first sign of infection.

 

 

ANS:  B

In order to prevent infection, meticulous hand hygiene must be practiced. Monitoring the temperature, monitoring for signs of infection, and reporting signs of infection to the physician are not preventative measures but early intervention if infection occurs.

 

PTS:   1                    DIF:    Cognitive Level: Analysis               REF:   219, Patient Teaching

OBJ:   2 (clinical)      TOP:   Immune Deficiency

KEY:  Nursing Process Step: Intervention

MSC:  NCLEX: Safe, Effective Care Environment: Safety and Infection Control

 

  1. The nurse is educating a patient with lymphoma. Which statement indicates that the patient correctly differentiates Hodgkin lymphoma (HL) and non-Hodgkin lymphoma (NHL)?
a. “Non-Hodgkin lymphoma is less predictable and can spread faster.”
b. “The first sign of Hodgkin lymphoma is that a single lymph node on one side of the body gets bigger.”
c. “People who are older than 60 years are at a bigger risk than younger people.”
d. “I will have to have a lot of blood work drawn.”

 

 

ANS:  A

NHL is less predictable and can spread faster than HL. Additionally, this statement features a comparison. NHL usually begins with unilateral, painless enlargement of a single lymph node. Expressing an understanding about implication of age as a risk factor or need for blood work does not differentiate specific details about either type of lymphoma.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   239

OBJ:   8 (theory)       TOP:   Lymphoma: Diagnosis

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

 

  1. The nurse is caring for a patient with suspected Hodgkin’s lymphoma (HL). For confirmation of this diagnosis, the nurse understands that the patient’s blood work would reveal which type of abnormal cell?
a. Abnormal B cells
b. Abnormal T cells
c. Cytotoxic T cells
d. Reed-Sternberg (R-S) cells

 

 

ANS:  D

If Reed-Sternberg (R-S) cells are present, the patient has Hodgkin’s lymphoma (HL). If the R-S cells are not present, the patient is diagnosed as having non-Hodgkin’s lymphoma (NHL). NHL is then identified as either B-cell or T-cell lymphoma.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension   REF:   237

OBJ:   8 (theory)       TOP:   Lymphoma: Diagnosis

KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. The nurse is assessing a patient’s lymph nodes. Which finding would alert the nurse to the possibility of the patient having non-Hodgkin’s lymphoma (NHL)?
a. Enlarged lymph nodes that form an adjacent line of enlargement.
b. Painful widespread enlarged lymph nodes.
c. Noncontiguous enlarged lymph nodes.
d. Enlarged lymph nodes primarily in the neck and axillary region.

 

 

ANS:  C

NHL typically manifests as enlargement in one node, then one or more nodes are skipped, and then another node is affected (noncontiguous). These enlarged nodes are usually painless with NHL.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension   REF:   239

OBJ:   8 (theory)       TOP:   Lymphoma: Assessment

KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. The nurse is preparing to write a care plan for the patient with fibromyalgia. Which problem/nursing diagnosis best addresses this disorder?
a. Fatigue
b. Pain, Chronic
c. Impaired Physical Mobility
d. Activity Intolerance

 

 

ANS:  B

Pain is the predominant symptom with fibromyalgia. The pain can lead to other problems, such as fatigue, impaired mobility, and activity intolerance; however, if the pain can be controlled, other health problems may be reduced.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   240

OBJ:   16 (clinical)    TOP:   Fibromyalgia

KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Safe, Effective Care Environment: Management of Care

 

  1. The nurse is providing teaching to a patient who has undergone a liver transplant. Which statement by the patient demonstrates the need for further patient teaching?
a. “I will need to take medications to boost my immune system for the next year.”
b. “I will need to be sure to avoid people that have infections.”
c. “I will need to take immune suppression medications the rest of my life.”
d. “I will need to be monitored to determine if my medications need adjusted.”

 

 

ANS:  A

Immune suppression medications will need to be taken for the rest of the patient’s life in order to increase the chances of avoiding organ rejection. Boosting the patient’s immune system would lead to organ rejection. Individuals with infections should be avoided since the immune system is depressed. Doses of medications must be evaluated for necessary adjustments throughout the patient’s lifetime.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   217

OBJ:   2 (theory)       TOP:   Preventing Transplant Rejection

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Reduction of Risk Potential

 

  1. The home health nurse is teaching the HIV-positive patient and his family members about infection control in the home. Which action indicates that the nurse’s teaching has been successful?
a. Using only regular household cleaners to clean the bathroom
b. Placing soiled laundry directly into a hamper
c. Refusing visitors during certain months of the year
d. Wearing gloves during household chores

 

 

ANS:  D

The nurse should encourage always donning protective gloves when performing household tasks. After cleaning the bathrooms with a regular household cleaner, disinfect with a 1:10 bleach solution. Soiled laundry should be placed into a closed plastic bag before laundering, not left in an open hamper. It is not necessary to refuse visitors based on certain months of the year; infection control involves proper hand hygiene, avoiding actively ill individuals, and adequately disinfecting surfaces and substances that may have come into contact with contaminated body fluids.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   219

OBJ:   2 (clinical)      TOP:   Infection Control in

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. A patient has been exposed to an allergen resulting in a hypersensitivity reaction. The nurse correctly recognizes that which immunoglobulin has been triggered?
a. IgA
b. IgB
c. IgD
d. IgE

 

 

ANS:  D

On first contact with the allergen, the body’s immune system is triggered to produce immunoglobulin E (IgE) antibody to recognize the specific antigen.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension   REF:   241

OBJ:   10 (theory)     TOP:   Allergy and Hypersensitivity

KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

MULTIPLE RESPONSE

 

  1. Which condition(s) that can cause acquired immune deficiency? (Select all that apply.)
a. Chemotherapy
b. Viral infections
c. Smoking
d. Malnutrition
e. Bacterial infections

 

 

ANS:  A, B, C, D

Bacterial infections do not cause immune deficiency.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension   REF:   217

OBJ:   1 (theory)       TOP:   Conditions Causing Immune Deficiency

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

 

  1. During assessment of the patient diagnosed with systemic lupus erythematosus (SLE), which sign(s) and symptom(s) would the nurse expect to find? (Select all that apply.)
a. Hair loss
b. Enlarged cervical lymph nodes
c. Mouth sores
d. Fatigue
e. Rashes

 

 

ANS:  A, C, D, E

The patient with SLE does not typically have enlarged lymph nodes. Hair loss, mouth sores, fatigue, and rashes are just a few of the symptoms present in a patient with SLE.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension   REF:   233-234

OBJ:   7 (theory)       TOP:   SLE                KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. The nurse is caring for a patient with systemic lupus erythematosus (SLE). The patient complains of severe fatigue, a butterfly rash, and joint pain. Which nursing intervention(s) is/are most appropriate for this patient? (Select all that apply.)
a. Encourage the use of a sun lamp to help with the rash.
b. Assess pain control measures that have helped the patient in the past.
c. Assist the patient with planning rest periods throughout the day.
d. Remind the patient to avoid contact with people who have an infection.
e. Ensure the patient understands the importance of her medication regimen.

 

 

ANS:  B, C, D, E

Any type of sunlight tends to worsen the rash of a patient with SLE and can cause a generalized flare-up of the disease. Pain control measures that have previously been effective should be continued; intense fatigue is a common problem with SLE, so planned rest periods are necessary; infections often exacerbate the disease, so it is important to decrease the chance of the patient with SLE from being exposed to others with infections; and the medication regimen for the SLE patient should be maintained in order to prevent flare-ups of the disease or other body systems from being affected by SLE.

 

PTS:   1                    DIF:    Cognitive Level: Application

REF:   233, 236, Nursing Care Plan 11-1  OBJ:   7 (theory)       TOP:   SLE

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Safe, Effective Care Environment: Management of Care

 

  1. The school nurse is instructing a group of high school sophomores in safe sex practices. Which practice(s) should the nurse include in her teaching? (Select all that apply.)
a. Use a condom.
b. Use a spermicide.
c. Practice abstinence.
d. Get vaccinated against HIV.
e. Avoid unprotected orogenital sex.

 

 

ANS:  A, C, E

HIV can be transmitted by sexual practices of not using a condom and through orogenital sex. Abstinence is the only way to ensure that HIV is not transmitted through sexual intercourse. Spermicides do not prevent HIV transmission, and there is no vaccination against HIV.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   222-223

OBJ:   4 (theory)       TOP:   Safe Sex        KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. When collecting data from a patient suspected of having an immune deficiency, which factor(s) should be included? (Select all that apply.)
a. Family history of immune disorders
b. Age
c. Weight gain
d. Alcohol use
e. Exposure to HIV

 

 

ANS:  A, B, D, E

When an immune deficiency is suspected, information is gathered about the current physical status of the patient, such as her general state of health, infections she may have had recently, how the infections affected her, and how frequently they occur. It is also important to assess for risk behaviors such as intravenous drug use, multiple sexual partners, exposure to HIV, immunosuppressive drug therapy, alcohol consumption, and family history of genetic immune disorders.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension   REF:   218-219

OBJ:   14 (clinical)    TOP:   Nursing Management Immune Deficiency

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

COMPLETION

 

  1. The nurse stresses that the primary emphasis on controlling HIV is __________.

 

ANS:

prevention

 

Prevention of HIV infections is the major key to controlling HIV infections.

 

PTS:   1                    DIF:    Cognitive Level: Knowledge          REF:   223

OBJ:   1 (theory)       TOP:   HIV Infection

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. The patient with AIDS voices concern over the amount of money it will cost to manage his disease. The nurse is aware that the estimated medications and laboratory testing cost is an average of $______ per year for the patient with AIDS.

 

ANS:

25000

25,000

 

It is estimated that medications and laboratory testing for a patient with AIDS will cost at least $25,000.

 

PTS:   1                    DIF:    Cognitive Level: Knowledge          REF:   224

OBJ:   2 (theory)       TOP:   Diagnosis of AIDS

KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Safe, Effective Care Environment: Management of Care

 

MATCHING

 

Arrange the process of HIV invasion in the proper sequence.

a. HIV attaches to CD4 receptor sites on T-helper cells.
b. Opportunistic infection occurs.
c. Infected cell replicates itself millions of times.
d. T-helper cells fail to activate phagocytes.
e. Immune system is unable to respond effectively.

 

 

  1. Step 1

 

  1. Step 2

 

  1. Step 3

 

  1. Step 4

 

  1. Step 5

 

  1. ANS:  A                    PTS:   1                    DIF:    Cognitive Level: Analysis

REF:   220                OBJ:   3 (theory)       TOP:   HIV Infection

KEY:  Nursing Process Step: N/A

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. ANS:  C                    PTS:   1                    DIF:    Cognitive Level: Analysis

REF:   220                OBJ:   3 (theory)       TOP:   HIV Infection

KEY:  Nursing Process Step: N/A

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. ANS:  D                    PTS:   1                    DIF:    Cognitive Level: Analysis

REF:   220                OBJ:   3 (theory)       TOP:   HIV Infection

KEY:  Nursing Process Step: N/A

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. ANS:  E                    PTS:   1                    DIF:    Cognitive Level: Analysis

REF:   220                OBJ:   3 (theory)       TOP:   HIV Infection

KEY:  Nursing Process Step: N/A

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. ANS:  B                    PTS:   1                    DIF:    Cognitive Level: Analysis

REF:   220                OBJ:   3 (theory)       TOP:   HIV Infection

KEY:  Nursing Process Step: N/A

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

Chapter 15: The Hematologic System

deWit: Medical-Surgical Nursing: Concepts & Practice, 3rd Edition

 

MULTIPLE CHOICE

 

  1. Which organ releases the erythropoietin-stimulating factor that directs stem cells in the bone marrow to make blood cells?
a. Brain
b. Lung
c. Kidney
d. Liver

 

 

ANS:  C

The kidney secretes the erythropoietin-stimulating factor to stimulate the stem cells to make blood cells.

 

PTS:   1                    DIF:    Cognitive Level: Knowledge          REF:   328

OBJ:   2 (theory)       TOP:   Erythropoiesis                                           KEY:   Nursing Process Step: N/A

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. What is the average life span of a red blood cell (RBC)?
a. 30 days
b. 90 days
c. 100 days
d. 120 days

 

 

ANS:  D

RBCs live approximately 120 days.

 

PTS:   1                    DIF:    Cognitive Level: Knowledge          REF:   328

OBJ:   1 (theory)       TOP:   Life of RBCs

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

 

  1. Which organ can help the body compensate in the event of a massive hemorrhagic episode by contracting and adding blood to the circulating volume?
a. Spleen
b. Liver
c. Pancreas
d. Bone marrow

 

 

ANS:  A

The spleen has the ability to contract and add blood to the circulating volume in the event of massive hemorrhage.

 

PTS:   1                    DIF:    Cognitive Level: Knowledge          REF:   330

OBJ:   1 (clinical)      TOP:   Spleen            KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. The nurse is reviewing laboratory reports for multiple patients. Which patient’s laboratory values require the nurse’s immediate attention?
a. Hemoglobin (Hgb) of 7.1 g/dL; white blood cell (WBC) count of 4500 mL/mm3
b. Potassium of 5.5 mEq/L; WBC count of 7000 mL/mm3
c. Sodium of 129 mEq/L; WBC of 6000 mL/mm3; 13.2 g/dL
d. Calcium of 8.8 mg/dL; WBC count of 8000 mL/mm3

 

 

ANS:  A

All of the WBC counts are normal. The nurse must then decide which other laboratory value requires the most urgent attention. The Hgb is critically low and requires immediate intervention (likely a transfusion). The low Hgb suggests possible anemia or blood loss. The normal Hgb range for adults is: females, 12.0 to 16.7 g/dL; males, 13.0 to 18.0 g/dL. The potassium of 5.5 mEq/L is at the top of the normal range and requires close monitoring for potential cardiac complications but is less urgent than the critical value. The sodium of 129 mEq/L is at the low end of the normal range and requires close monitoring but is less urgent than the critical value. The calcium level of 8.8 mg/dL is a normal value.

 

PTS:   1                    DIF:    Cognitive Level: Analysis               REF:   333, Table 15-1

OBJ:   5 (theory)       TOP:   Blood Counts

KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity: Reduction of Risk Potential

 

  1. When the nurse notes a rise in the eosinophil count, which problem does she suspect?
a. Bacterial infection
b. Allergy
c. Viral infection
d. Blood dyscrasia

 

 

ANS:  B

In the event of an allergy or the infestation of pinworms, the eosinophil count will rise. Bacterial infection stimulates the production of neutrophils and segmented neutrophils; lymphocytes are increased with viral infections. Blood dyscrasia refers to an imbalance in the numbers of types of cells or other pathologic conditions of the blood.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension   REF:   329

OBJ:   5 (theory)       TOP:   Eosinophil Count

KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity: Reduction of Risk Potential

 

  1. The nurse uses a visual aid to depict the several kinds of hemoglobin. Which hemoglobin changes the shape of the red blood cell RBC on which it resides?
a. hemoglobin A
b. hemoglobin A1c
c. hemoglobin F
d. hemoglobin S

 

 

ANS:  D

Hemoglobin S is the abnormal hemoglobin seen in people with sickle cell anemia. The hemoglobin changes the shape of the RBC to a sickle shape.

 

PTS:   1                    DIF:    Cognitive Level: Knowledge          REF:   332

OBJ:   1 (theory)       TOP:   Hgb S             KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Reduction of Risk Potential

 

  1. The nurse is caring for an 80-year-old African American patient. On assessment, the nurse observes yellow sclera. Which other finding would support the nurse’s suspicion that hemolysis is occurring?
a. Koilonychia
b. Circumoral cyanosis
c. Tea colored urine
d. Hemangioma

 

 

ANS:  C

Jaundice, or a yellowing discoloration of the skin and sclera of the eyes, can occur as a result of excessive destruction of red blood cells (hemolysis). When red blood cells are ruptured, bilirubin is released. The pigment eventually finds its way into the bloodstream, where it causes jaundice. If hemolysis is occurring, the urine will often contain bilirubin, giving urine a brown tea color. Koilonychia are ridges in the fingernails associated with iron deficiency anemia. Circumoral cyanosis is a bluish tinge around the mouth that indicates respiratory deficiency. A hemangioma is a benign, strawberry-colored birthmark common in children.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   336

OBJ:   7 (theory)       TOP:   Hemolysis      KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. Jaundice results from excessive release of which substance into the bloodstream?
a. Histamine
b. Bilirubin
c. Plasma
d. Platelets

 

 

ANS:  B

Excessive levels of bilirubin in the blood (hyperbilirubinemia) from the increased hemolysis of red blood cells are responsible for jaundice.

 

PTS:   1                    DIF:    Cognitive Level: Knowledge          REF:   336

OBJ:   7 (theory)       TOP:   Jaundice: Hyperbilirubinemia

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. The nurse is caring for a patient with pernicious anemia. The patient asks the nurse why she experiences constant fatigue. Which response most accurately answers the patient’s question?
a. “Your anemia causes inadequate oxygen delivery to your cells, which causes you to feel fatigue.”
b. “Your anemia causes an enlarged spleen, which makes breathing difficult and leads to fatigue.”
c. “Your anemia causes proliferation of white cells, which leads to fatigue.”
d. “Your anemia causes excessive manufacture of red blood cells, which overworks your body and leads to fatigue.”

 

 

ANS:  A

The fatigue experienced by people with anemia is related to the lack of oxygenation due to the lack of RBCs to carry the oxygen.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension   REF:   337

OBJ:   3 (clinical)      TOP:   Fatigue Associated With Anemia

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. If melena appears, a minimum of what amount of blood has been deposited into the gastrointestinal (GI) tract?
a. 35 mL
b. 50 mL
c. 80 mL
d. 100 mL

 

 

ANS:  B

For the symptom of melena (dark, tarry stools) to appear, a minimum of 50 to 75 mL of blood must have entered the GI tract.

 

PTS:   1                    DIF:    Cognitive Level: Knowledge          REF:   339, Clinical Cues

OBJ:   2 (clinical)      TOP:   Melena           KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. The nurse is caring for a patient whose complete blood count reports an abnormal amount of “bands,” or immature granulocytes. Based on this finding, which problem does the nurse suspect?
a. An ongoing bacterial infection
b. An allergic reaction
c. Impending anemia
d. An overwhelming viral infection

 

 

ANS:  A

Immature white blood cells are released when the more mature circulating cells have not been able to combat an ongoing bacterial infection. Eosinophils increase in response to allergic reactions, and red blood cells are associated with anemia. An increase in lymphocytes is seen with a viral infection.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension   REF:   332, Clinical Cues

OBJ:   5 (theory)       TOP:   Significance of Bands: Bacterial Infection

KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. The nurse is caring for an older adult patient who is confused and irritable. The nurse reviews the patient’s history and notes that it is negative for dementia. Which potential underlying problem should the nurse suspect?
a. Leukopenia
b. Hypokalemia
c. Hypoxia
d. Hyperbilirubinemia

 

 

ANS:  C

Confusion and irritability caused by hypoxia is often mistaken for Alzheimer’s dementia. Confusion and irritability are not common features of low white blood cell count, low potassium levels, or high bilirubin levels.

 

PTS:   1                    DIF:    Cognitive Level: Application

REF:   336, Older Adult Care Points          OBJ:   5 (theory)       TOP:   Hypoxia versus Dementia

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. The nurse is reviewing a patient’s assessment data upon admission to the acute care facility. Which finding best indicates iron deficiency anemia?
a. Pulse of 90 beats/min
b. Yellow sclera
c. Tea-colored urine
d. Pale conjunctivae

 

 

ANS:  D

Pale conjunctivae are an indication of anemia. A pulse rate of 90 beats/min is within the higher limits of normal. Yellow sclera is indicative of jaundice. Tea-colored urine may indicate the presence of bilirubin or blood in the urine.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   332

OBJ:   7 (theory)       TOP:   Signs of Anemia

KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. The nurse is caring for a patient with pernicious anemia immediately following a bone marrow biopsy of the left posterior iliac crest. Which action should the nurse perform first?
a. Inform the patient that he may feel pressure and sharp, brief pain.
b. Check the pulses in the leg and foot distal to the puncture.
c. Administer an ordered analgesic.
d. Apply pressure to the site for 5 minutes with an ice pack.

 

 

ANS:  D

The most immediate priority concern for this patient is bleeding. The nurse should apply pressure to the site to prevent a hematoma. The patient would feel pressure and sharp brief pain during the aspiration, not afterward. The nurse can assess pulses in the leg and foot, although this assessment would be most appropriate if the procedure involved an arterial stick. The nurse should administer the ordered analgesic after hemostasis is obtained.

 

PTS:   1                    DIF:    Cognitive Level: Analysis               REF:   335, Table 15-1

OBJ:   7 (clinical)      TOP:   Post-marrow Aspiration Care

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Reduction of Risk Potential

 

  1. The nurse is caring for a patient who is taking radiation treatments. The patient has a platelet count of 100,000/mm3. Which action is most important for the nurse to add to the patient’s care plan?
a. Instruct the patient to change positions slowly.
b. Remove the clutter from the patient’s room.
c. Remove the fresh orange from the patient’s meal tray.
d. Limit the number of visitors in the room at a time.

 

 

ANS:  B

This patient is thrombocytopenic (low platelet count) and is at an increased risk for bleeding. A cluttered room increases the risk for falls, and a fall could be particularly dangerous for this patient. Changing positions slowly is indicated in the patient with orthostatic hypotension. Removing the fresh orange from the patient’s tray and limiting visitors are infection control measures for the patient on neutropenic precautions.

 

PTS:   1                    DIF:    Cognitive Level: Analysis               REF:   331

OBJ:   2 (theory)       TOP:   Thrombocytopenia

KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity: Reduction of Risk Potential

 

  1. What is the average life span of a platelet cell?
a. 10 days
b. 14 days
c. 30 days
d. 45 days

 

 

ANS:  A

Platelets live only about 10 days.

 

PTS:   1                    DIF:    Cognitive Level: Knowledge          REF:   330

OBJ:   2 (theory)       TOP:   Platelets: Life Span

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. The nurse is caring for an older adult patient. A family member of the patient seems to frequently catch colds. Which response is best?
a. “After the age of 60, the plasma volume decreases so there is less infection fighting ability.”
b. “Bone marrow activity decreases by about 50% with aging, which lowers the immune response to infection.”
c. “The older adult’s blood is more prone to clotting, so infection-fighting cells don’t get to the source of infection quickly.”
d. “His antibody response to vaccines is overactive.”

 

 

ANS:  B

The older adult patient is more prone to infection due to the decrease in bone marrow activity, which in turn reduces the immune response. Plasma volume does decrease after age of 60, but the concern is decreased blood reserve volume in case of blood loss, not infection. The older adult’s blood is more prone to clotting due to platelet aggregation and alterations in clotting activity; this increases the risk for problems related to thrombosis, not infection. Lastly, the older adult’s antibody response to vaccines is decreased.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   330

OBJ:   3 (theory)       TOP:   Effects of Aging

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. Which statement about the hematologic system is accurate?
a. “African Americans have the highest incidence of sickle cell disease.”
b. “Iatrogenic blood disorders are congenital in origin.”
c. “Folic acid is directly related to synthesis of hemoglobin.”
d. “Bruising in the older adult patient is of great concern.”

 

 

ANS:  A

African Americans do have the highest incidence of sickle cell disease. Iatrogenic blood disorders are brought on by medical treatment, such as bone marrow suppression. Iron, rather than folic acid, is directly related to hemoglobin synthesis; folic acid is related to RBC maturation. The older adult tends to bruise more due to the thinning of the skin and the increased fragility of the vessels; therefore, it is expected to see some bruising with these patients. Excessive bruising, however, in the older adult patient should be investigated.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension   REF:   330, Cultural Considerations

OBJ:   3 (theory)       TOP:   Hematologic System Characteristics

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

MULTIPLE RESPONSE

 

  1. Which statement(s) describe functions of blood? (Select all that apply.)
a. To absorb nutrients
b. To transport blood gases
c. To regulate pH by buffering
d. To regulate fluid distribution
e. To regulate body temperature

 

 

ANS:  B, C, D, E

Blood transports blood gases, regulates pH through buffering, regulates fluid distribution, and regulates body temperature. Blood transports nutrients but does not absorb them.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension   REF:   327

OBJ:   1 (theory)       TOP:   Blood: Function

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. Which organ(s) compose the lymphatic system? (Select all that apply.)
a. Thymus
b. Lymph nodes
c. Kidneys
d. Spleen
e. Tonsils

 

 

ANS:  A, B, D

The lymphatic system consists of the thymus gland, lymph nodes, lymph channels, the spleen, and the thymus gland (see Chapter 10). The tonsils and kidneys are not considered a part of the lymphatic system.

 

PTS:   1                    DIF:    Cognitive Level: Knowledge          REF:   330

OBJ:   2 (theory)       TOP:   Lymphatic System                          KEY:  Nursing Process Step: N/A

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. Which age-related changes occur in the hematologic system? (Select all that apply.)
a. Decreased blood volume
b. Decreased bone marrow production
c. Decreased rate of blood cell production
d. Increased immune response
e. Increased clotting time

 

 

ANS:  A, B, C, E

Age-related changes of the hematologic system include decreasing blood volume, bone marrow production, and blood cell production rate, along with increasing clotting time. The immune response decreases with age.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension   REF:   330

OBJ:   3 (theory)       TOP:   Blood: Age-Related Changes

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. Which assessment technique assures accuracy in daily abdominal girth measurement? (Select all that apply.)
a. Place marks on the lateral sides of the abdomen where the tape is placed.
b. Use the same tape every day.
c. Measure girth with the tape placed 1 inch above the umbilicus.
d. Measure the same area every day.
e. Measure girth at the same time every day.

 

 

ANS:  A, B, D, E

Place marks on the lateral aspects of the abdomen where the measuring tape is placed and measure at the umbilicus. Put the measuring tape in the same place each day at the same time. Girth is measured at the level of the umbilicus.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension   REF:   336, Clinical Cues

OBJ:   2 (clinical)      TOP:   Measurement of Girth

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. The nurse is assessing a patient with a dark complexion for cyanosis. To ensure the most accurate assessment, which locations should the nurse inspect? (Select all that apply.)
a. Conjunctiva
b. Gums
c. Roof of the mouth
d. Nail beds
e. Palms of the hands

 

 

ANS:  B, C

A person with a dark complexion can be assessed for cyanosis by examining the gums and the roof of the mouth. Cyanosis is not usually apparent in the conjunctiva or palms of the hands. The nail beds tend to be darker in dark-skinned individuals so this would not render an accurate assessment of cyanosis.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   335, Focused Assessment

OBJ:   2 (clinical)      TOP:   Assessment: Cyanosis

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

 

  1. Which actions should the nurse take to help the severely anemic patient conserve energy? (Select all that apply.)
a. Manage care to include frequent rest periods.
b. Assist with activities of daily living (ADLs).
c. Place personal care items close at hand.
d. Arrange for small meals with between-meal snacks.
e. Ensure that exercise sessions are planned during the morning.

 

 

ANS:  A, B, C, D

Managing care and planning for rest, assisting with ADLs, placing personal care items nearby, and arranging for small meals are all actions that will spare the patient fatigue. Exercise sessions should not be implemented until the severe anemia improves.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension   REF:   337, Table 15-2

OBJ:   3 (clinical)      TOP:   Fatigue           KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort

 

COMPLETION

 

  1. The normal range of hemoglobin is from _____ g/dL to _____ g/dL.

 

ANS:

12.0; 18.0

 

The normal range for hemoglobin is from 12.0 to 18.0 g/dL.

 

PTS:   1                    DIF:    Cognitive Level: Knowledge          REF:   328

OBJ:   2 (theory)       TOP:   Hgb: Normal Range                        KEY:  Nursing Process Step: N/A

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. In making an assessment of a patient with a bleeding disorder who has a dark complexion, the nurse should check the palms of the hands and the soles of the feet for _____________.

 

ANS:

petechiae

 

The small hemorrhages, petechiae, can be better assessed on people with a dark complexion by examining the palms of the hands and the soles of the feet.

 

PTS:   1                    DIF:    Cognitive Level: Comprehension   REF:   336

OBJ:   7 (theory)       TOP:   Assessment for Petechiae

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

 

  1. A female patient being seen in an outpatient clinic states she is having excessive menstruation and reports saturating four peri-pads per day. The nurse estimates the blood loss for this patient as ______ mL per day.

 

ANS:

200

 

The average amount of blood loss via menstruation is less than 80 mL. Each saturated pad or tampon is equal to about 50 mL of blood loss. Therefore, this patient is losing approximately 200 mL of blood per day.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   331, Clinical Cues

OBJ:   4 (theory)       TOP:   Menstruation Blood Loss

KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity: Reduction of Risk Potential

 

MATCHING

 

The student nurse is drawing a diagram of the phases of the monocyte cell to present to the nursing class. The student correctly diagrams the phases in which order of occurrence?

a. Becomes a phagocyte
b. Becomes a macrophage
c. Engulfs bacteria
d. Migrates into tissues
e. Becomes a monocyte
f. Becomes a leukocyte

 

 

  1. Step 1

 

  1. Step 2

 

  1. Step 3

 

  1. Step 4

 

  1. Step 5

 

  1. Step 6

 

  1. ANS:  F                    PTS:   1                    DIF:    Cognitive Level: Analysis

REF:   328-329         OBJ:   1 (theory)       TOP:   Monocyte Phases

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. ANS:  E                    PTS:   1                    DIF:    Cognitive Level: Analysis

REF:   328-329         OBJ:   1 (theory)       TOP:   Monocyte Phases

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. ANS:  B                    PTS:   1                    DIF:    Cognitive Level: Analysis

REF:   328-329         OBJ:   1 (theory)       TOP:   Monocyte Phases

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. ANS:  D                    PTS:   1                    DIF:    Cognitive Level: Analysis

REF:   328-329         OBJ:   1 (theory)       TOP:   Monocyte Phases

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. ANS:  A                    PTS:   1                    DIF:    Cognitive Level: Analysis

REF:   328-329         OBJ:   1 (theory)       TOP:   Monocyte Phases

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. ANS:  C                    PTS:   1                    DIF:    Cognitive Level: Analysis

REF:   328-329         OBJ:   1 (theory)       TOP:   Monocyte Phases

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance