Medical Surgical Nursing - NCLEX type model questions part 4
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1. A patient with a history of iron-deficiency anemia
who has not taken iron supplements for several years is experiencing increased
fatigue and dizziness. What would the nurse expect the patient’s laboratory
findings to include?
a. Hematocrit 0.38 (38%)
b. Red blood cell (RBC) count 4,500,000/µL
c. Hemoglobin (Hb) 86 g/L
d. Normal RBC indices
ANS: C
The patient’s clinical manifestations indicate
moderate anemia, which is consistent with an Hb of 60 to 100 g/L.
2. When the nurse discusses foods high in iron with a
patient who has iron-deficiency anemia, the patient tells the nurse that she
prepares low-cholesterol foods for her family and probably does not eat enough
meat to meet her iron requirements. It is an appropriate goal for the patient
to increase dietary intake of which of the following?
a. Eggs and fish
b. Nuts and cornmeal
c. Milk and milk products
d. Legumes and dried fruit
ANS: D
Legumes and dried fruits are high in iron and low in
fat and cholesterol
3. Which one of the following groups of people is at
an increased risk for developing iron-deficiency anemia?
a. Postmenopausal women
b. Middle-class people
c. Pregnant women
d. School-aged males
ANS: C
Those at risk for the development of iron-deficiency
anemia are premenopausal and pregnant women, people from low socioeconomic
backgrounds, older adults, and individuals experiencing blood loss.
4. A 52-year-old patient has pernicious anemia with
long-standing weakness and paraesthesia of the feet and hands. The nurse
determines that expected outcomes related to knowledge of the therapeutic
regimen have been met when the patient states which of the following?
a. “I will need to have cobalamin (B12) injections
regularly for the rest of my life.”
b. “I will increase sources of cobalamin (B12), such
as muscle meats and liver, in my diet.”
c. “The feeling in my hands and feet will return when
my hemoglobin level returns to normal.”
d. “I should plan for only part-time employment
because of the chronic fatigue that pernicious anemia causes.”
ANS: A
Pernicious anemia prevents the absorption of vitamin
B12, and the patient requires injections or intranasal administration of
cobalamin.
5. A patient with chronic lymphocytic leukemia is
hospitalized for treatment of severe hemolytic anemia. What is an appropriate
nursing intervention for the patient?
a. Provide a diet high in vitamin K and folic acid.
b. Plan care to alternate periods of rest and
activity.
c. Isolate the patient from visitors and other
patients.
d. Encourage increased intake of fluid and fibre in
the diet.
ANS: B
Nursing care for patients with anemia should alternate
periods of rest and activity to maintain patient mobility without causing undue
fatigue.
6. After teaching the patient about taking oral iron
preparations for a moderate iron-deficiency anemia, which of the following
patient statements indicates to the nurse that additional instruction is
needed?
a. “I will contact my doctor if my stools start to
turn black.”
b. “I will call the doctor if the tablets cause a lot
of stomach upset.”
c. “I will increase my fluid intake if the iron
tablets make me constipated.”
d. “I should take the iron tablets with orange juice
about an hour before meals.”
ANS: A
It is normal for the stools to appear black when a
patient is taking iron, and the patient should not call the doctor about this.
7. A 42-year-old patient is admitted to the hospital
with idiopathic aplastic anemia. What is an appropriate collaborative problem
for the nurse to identify for the patient?
a. Potential complication: seizures
b. Potential complication: hemorrhage
c. Potential complication: neurogenic shock
d. Potential complication: pulmonary edema
ANS: B
Because the patient with aplastic anemia has
pancytopenia, the patient is at risk for bleeding and infection
8. A patient with sickle cell anemia is admitted to
the hospital in crisis with severe abdominal pain. While caring for the
patient, what is it most important for the nurse to do?
a. Limit the patient’s intake of oral fluids.
b. Evaluate the effectiveness of narcotic analgesics.
c. Encourage the patient to ambulate as much as
tolerated.
d. Teach the patient about high-protein, high-calorie
foods.
ANS: B
Pain is the most common clinical manifestation of a
crisis and usually requires large doses of continuous opioids for control.
9. A 21-year-old patient is having a sickle cell
crisis for the first time in many years. He asks the nurse why the sickling
causes such pain. The nurse should explain that the pain of sickling is caused
by which of the following?
a. Spasms of the blood cells as they change shape
b. Deposition of sickled red cells in the bone marrow
c. Tissue hypoxia caused by small blood vessel
occlusion
d. Bacterial or viral infections of organs that caused
the sickling
ANS: C
The pain associated with a sickle cell crisis is
caused by ischemia, as the sickled cells occlude small blood vessels and
capillaries.
10. During discharge teaching for the patient with
neutropenia, which of the following issues should the nurse include?
a. Caffeine and alcohol intake
b. Excessive dietary iron intake
c. Limiting fluids to 2 L per day
d. Exposure to crowds
ANS: D
Patients with neutropenia should be instructed to
avoid crowds and people who have colds, flu, or infections. If they are in a public
area, they should be taught to wear a mask.
11. A patient who has experienced an acute blood loss
exhibits a normal supine blood pressure and pulse at rest but complains of
postural hypotension and has a pulse of 110 beats/min when exercising. The nurse
knows that these signs and symptoms are manifestations of what percentage of
blood loss?
a. 10%
b. 20%
c. 30%
d. 40%
ANS: C
A patient who has experienced an acute blood loss and
exhibits a normal supine blood pressure and pulse at rest but complains of
postural hypotension and has a pulse of 110 beats/min when exercising has lost
approximately 30% of their total blood volume.
12. During the admission assessment of a patient who
has an Hb of 4.7 mmol/L (7.6 g/dL) and jaundice of the sclera, what laboratory
results would the nurse assess?
a. Stool occult blood
b. Bilirubin level
c. Schilling test
d. Gastric analysis testing
ANS: B
Jaundice is caused by the elevation of bilirubin level
associated with RBC hemolysis. The presence of jaundice suggests a hemolytic
anemia, rather than gastrointestinal bleeding or cobalamin deficiency, as the
cause of the anemia.
13. The physician orders transfusion with packed RBCs
for a patient who has severe anemia resulting from a bleeding peptic ulcer.
What is the most important nursing action to prevent a transfusion reaction
when administering the blood?
a. Verify and document patient identification.
b. Keep the blood chilled during administration.
c. Administer the blood at a rate of no more than 2
mL/min.
d. Stay with the patient during the first 15 minutes
of the transfusion.
ANS: A
Improper identification is responsible for 90% of
hemolytic transfusion reactions.
14. A patient receiving a transfusion of whole blood
develops chills and fever, headache, and anxiety 30 minutes after the
transfusion is started. Which of the following does the nurse implement after
stopping the transfusion?
a. Send a urine specimen to the laboratory.
b. Administer acetaminophen (Tylenol).
c. Give diphenhydramine (Benadryl).
d. Draw blood for a new crossmatch.
ANS: B
The patient’s clinical manifestations are consistent
with a febrile, nonhemolytic transfusion reaction. The transfusion should be
stopped and antipyretics administered for the fever as ordered
15. Fifteen minutes after a transfusion of packed RBCs
is started, a patient develops tachycardia and tachypnea, and complains of back
pain and feeling warm. What is the nurse’s priority action?
a. Discontinue transfusion, and infuse normal saline.
b. Administer oxygen therapy at a high flow rate.
c. Slow the transfusion rate, and reassess the patient
in 15 minutes.
d. Stop the blood, and discard the used bag and tubing
in a biohazard container.
ANS: A
The first action should be to disconnect the
transfusion and infuse normal saline to keep the line open and maintain the
patient’s blood pressure. The other actions are also needed but are not the
highest priority
16. A patient who has been receiving a heparin
infusion and warfarin (Coumadin) for a deep-vein thrombosis is diagnosed with
heparin-induced thrombocytopenia and thrombosis syndrome (HITTS). What does the
nurse anticipate that the physician will order?
a. Use saline for flushing intravenous (IV) lines.
b. Give low–molecular weight (LMW) heparin.
c. Discontinue the warfarin.
d. Administer platelet transfusions.
ANS: A
All heparin is discontinued when the HITTS is
diagnosed. The patient should be instructed never to receive heparin or LMW
heparin; therefore, saline will be ordered for flushing IV lines
17. During treatment of the patient with an acute
exacerbation of polycythemia vera, what is a critical nursing intervention?
a. Administer oxygen.
b. Evaluate fluid balance.
c. Administer anticoagulants.
d. Administer parenteral iron.
ANS: B
Monitoring hydration status is important during an
acute exacerbation because the patient is at risk for fluid overload or
underhydration.
18. For which one of the following lab results would
the nurse expect to see abnormal results in a patient who has hemophilia?
a. Thrombin time
b. Platelet count
c. Prothrombin time
d. Partial thromboplastin time
ANS: D
Partial thromboplastin time is prolonged in patients
with hemophilia because of a deficiency in any intrinsic clotting system
factor. Prothrombin time, thrombin time, and platelet count are expected to be
normal in a patient with hemophilia
19. Of the following patients waiting to be admitted
by the emergency department nurse, which one requires the most rapid assessment
and care by the nurse?
a. The patient with a history of sickle cell anemia
who has had nausea and diarrhea for 24 hours
b. The patient who has chemotherapy-induced
neutropenia and a temperature of 38°C
c. The patient with thrombocytopenia who has oozing
after having a tooth extracted
d. The patient with hemophilia A who has ankle
swelling after twisting the ankle
ANS: B
A neutropenic patient with a fever is assumed to have
an infection and is at risk for rapidly developing sepsis. Rapid assessment,
cultures, and initiation of antibiotic therapy are needed.
20. While a patient with severe acquired
thrombocytopenia is receiving platelet transfusions, the nurse recognizes that
a platelet transfusion reaction may be present when the patient experiences
which of the following signs?
a. Flushing, itching, and urticaria
b. Sudden onset of chills and fever
c. Urticaria, wheezing, and hypotension
d. Tachycardia, tachypnea, and hemoglobinuria
ANS: B
Sudden onset of both chills and fever indicates a
transfusion reaction.
21. The nurse identifies a nursing diagnosis of risk
for injury related to medical interventions for a patient with immune
thrombocytopenic purpura. What is an appropriate nursing intervention that
addresses the etiology of this nursing diagnosis?
a. Use a soft-bristled toothbrush and cotton swabs for
mouth care.
b. Limit the number of venipunctures by using an
intermittent-infusion device.
c. Assess the patient during the platelet transfusion
for symptoms of transfusion reactions.
d. Assess the patient’s mucous membranes and skin each
shift to detect the presence of bleeding.
ANS: B
Limit the number of venipunctures; intramuscular or
subcutaneous injections should be avoided because of the risk for bleeding.
22. When preparing a patient for a blood transfusion,
the nurse will prepare the blood. Which IV solution would the nurse prepare to
administer in a Y-type tubing adjacent to the blood?
a. Dextrose 5%
b. Lactated Ringer’s
c. Normal saline
d. Dextrose 10%
ANS: C
When preparing a patient for a blood transfusion, the
nurse will prepare the blood and attach normal saline to Y-type tubing adjacent
to the blood for administration.
23. A patient with type A hemophilia has been admitted
to the hospital with severe pain and swelling in his right knee. To prevent
joint deformity during the initial care of the patient, what should the nurse
do?
a. Immobilize the knee.
b. Elevate the right lower limb on pillows.
c. Perform passive range of motion to the knee.
d. Have the patient perform isometric exercises of the
affected leg against a footboard.
ANS: A
The initial action should be total rest of the knee to
minimize bleeding.
24. Laboratory studies related to coagulation are
performed on a patient with a bleeding disorder. The nurse explains to the
patient that von Willebrand’s disease can be differentiated from other types of
hemophilia by evaluating which of the following laboratory results?
a. Bleeding time
b. Platelet count
c. Prothrombin time
d. Partial thromboplastin time
ANS: A
The bleeding time is affected by von Willebrand’s
disease. Platelet count, prothrombin time, and partial thromboplastin time are
normal in von Willebrand’s disease.
25. When caring for a patient with hemophilia, the
nurse teaches the patient to seek immediate medical attention on experiencing
which of the following signs?
a. Fever
b. A sore throat
c. Bleeding gums
d. Dark, tarry stools (melena)
ANS: D
Melena is a sign of gastrointestinal bleeding and
requires further assessment.
26. A patient’s family member asks the nurse what
caused the patient to develop disseminated intravascular coagulation (DIC).
What does the nurse tell the family member about DIC?
a. It is caused by an abnormal activation of clotting.
b. It occurs when the immune system attacks platelets.
c. It is a complication of cancer chemotherapy.
d. It is caused when hemolytic processes destroy
erythrocytes.
ANS: A
DIC is an abnormal response of the clotting cascade
stimulated by a variety of diseases or disorders
27. During treatment of the patient who has
sepsis-induced DIC with moderate bleeding, on what would the nurse expect the
initial collaborative care will focus?
a. Administration of heparin to reduce intravascular
clotting
b. Treatment of the infectious process with IV
antibiotics
c. Infusion of whole blood to replace clotting factors
and RBCs
d. Supportive management of symptoms until the DIC is
resolved
ANS: B
Treatment of the acute sepsis is essential to
resolving the DIC and will be the major focus of collaborative care. Heparin
administration is controversial in DIC, although it may be used if the DIC does
not resolve and clotting factors continue to decrease.
28. A patient with myelodysplastic syndrome has
laboratory values that indicate total bone marrow suppression. The nurse
identifies a nursing diagnosis of risk for infection based on which of the
following findings?
a. Basophils 120 cells/mL
b. Monocytes 360 cells/mL
c. Neutrophils 4000 cells/mL
d. White blood cell (WBC) count 2.8 × 109 cells/L
(2800 cells/microlitre)
ANS: D
The low WBC count indicates a risk for infection. The
nurse should notify the physician and expect an order to check the differential
WBC count.
29. What is the most appropriate nursing intervention
to assess for the presence of infection in a patient with neutropenia?
a. Monitor WBCs daily.
b. Monitor temperature every 4 hours.
c. Monitor the skin for temperature and diaphoresis.
d. Monitor the mouth and perianal area every shift for
signs of redness and swelling.
ANS: B
The earliest sign of infection in a neutropenic
patient is an elevation in temperature. Patients with neutropenia (low
neutrophil count) are susceptible to infection and may be febrile.
30. A patient receiving chemotherapy for acute
lymphocytic leukemia has pancytopenia, and filgrastim (Neupogen) is prescribed.
The nurse teaches the patient that the reason for the use of the medication is
which of the following?
a. Remission of the leukemia
b. Improvement in the number and function of
neutrophils
c. Replacement of abnormal stem cells in the bone
marrow with normal cells
d. Prevention of hemorrhage complications in patients
with thrombocytopenia
ANS: B
Filgrastim increases the neutrophil count and function
in neutropenic patients.
31. A 64-year-old patient with newly diagnosed acute
myelogenous leukemia (AML) is undergoing induction therapy with
chemotherapeutic agents. He tells the nurse that he is so sick from the induction
therapy that he wonders if it is worth it. What is the best response to this
patient?
a. “I know you feel really ill right now, but after
this therapy, your disease will go into a remission, and you will feel normal
again.”
b. “Induction therapy is very aggressive and causes
the most side effects, so when this phase is completed, you won’t feel so ill.”
c. “Your type of leukemia has a survival rate of up to
10 years if aggressive therapy is started, so the effects of treatment should
be worth it to you.”
d. “I know that this phase is very difficult for you,
but the treatment is necessary to achieve control of your disease so that you
will have some time to make choices about your life.”
ANS: D
AML is very aggressive, and survival after diagnosis
is short without treatment.
32. A patient with chemotherapy-induced neutropenia is
placed in a private room, and protective isolation is instituted. The care plan
the nurse develops with the patient is based on the knowledge that which of the
following sources of infection is the most common in patients with neutropenia?
a. Normally nonpathogenic microorganisms of the
patient’s own flora
b. Microorganisms that are not sensitive to
broad-spectrum antibiotics
c. Microorganisms transmitted to the patient by the
hands of health care providers
d. Microorganisms transmitted to the patient by health
care providers with transmissible infections
ANS: A
An important consideration in the care of a
neutropenic patient is the determination of the best means to protect the
patient whose own defences against infection are compromised. To accomplish
this goal, the following principles must be kept in mind: (1) the patient’s
normal flora are the most common source of microbial colonization and infection;
(2) transmission of organisms from humans most commonly occurs by direct
contact with the hands; (3) air, food, water, and equipment provide additional
opportunities for infection transmission; and (4) health care providers with
transmissible illnesses and other patients with infections can also be sources
of infection transmission under certain conditions.
33. A patient with neutropenia has a nursing diagnosis
of risk for infection. What is the most important nursing intervention in the
prevention of transmission of harmful pathogens to the patient?
a. Prohibiting the oral intake of fresh fruits and
vegetables
b. Maintaining strict administration schedules of
prophylactic antibiotics
c. Strict and frequent handwashing by all persons
having contact with the patient
d. Creating a “sterile” environment for the patient
with the use of laminar airflow rooms
ANS: C
Infection control measures such as handwashing are
necessary for the patient with neutropenia
34. A 45-year-old woman with chronic myelogenous
leukemia is considering the possibility of treatment with a bone marrow
transplant from a human leukocyte antigen–matched sibling. To assist the
patient with treatment decisions, what is the best approach for the nurse to
use?
a. Emphasize the positive outcomes of a bone marrow
transplant.
b. Ensure that the patient understands the risks of
treatment-related death or treatment failure.
c. Explain that a cure is not possible with any other
type of treatment except a bone marrow transplant.
d. Encourage the patient to ask the physician about
new, experimental treatments for leukemia that do not involve total body
irradiation.
ANS: B
Offering the patient an opportunity to ask questions
or discuss concerns about hematopoietic stem cell transplantation will
encourage the patient to voice concerns about this treatment and will also
allow the nurse to assess whether the patient needs more information about the
procedure
35. During care of the patient with multiple myeloma,
what is an important nursing intervention?
a. Limiting activity to prevent pathological fractures
b. Maintaining a fluid intake of 3 to 4 L/day to
dilute calcium load
c. Assessing for changes in size and characteristics
of lymph nodes
d. Administering narcotic analgesics continuously to
control bone pain
ANS: B
A high fluid intake and urinary output help prevent
the complications of kidney stones arising from hypercalcemia and renal failure
caused by deposition of Bence-Jones protein in the renal tubules.
36. A patient with non-Hodgkin’s lymphoma develops a
platelet count of 10,000 cells/microlitre during chemotherapy. Based on this
finding, what is an appropriate nursing intervention for the patient?
a. Provide oral hygiene every 2 hours.
b. Check the temperature every 4 hours.
c. Check all stools for occult blood.
d. Encourage fluids to 3000 mL/day.
ANS: C
Because the patient is at risk for spontaneous
bleeding, the nurse should check stools for occult blood.
37. A 26-year-old patient with stage II Hodgkin’s
disease asks the nurse how long he probably has to live. What is the best
response to the patient?
a. “No one can predict when someone will die, so try
to focus on the present.”
b. “It will depend on how your disease responds to
chemotherapy, but most patients do well.”
c. “If your initiation chemotherapy is effective, it
is possible to have at least a 5-year remission.”
d. “Most patients with your stage of Hodgkin’s disease
are treated successfully.”
ANS: D
The survival rate is almost 90% in patients with the
early stages of Hodgkin’s lymphoma.
38. Which nutrient plays a role in helping mature RBCs
in erythropoiesis?
a. Iron
b. Folic acid
c. Pyridoxine
d. Ascorbic acid
ANS: B
Folic acid’s role in erythropoiesis is to cause RBC
maturation.
39. While monitoring a patient’s cardiac activity, the
nurse recognizes that stimulation of which of the following is a normal
physiological mechanism responsible for an increase in heart rate (HR) and
force of cardiac contractions?
a. The vagus nerve
b. Baroreceptors in the aortic arch and carotid sinus
c. α-Adrenergic receptors in the vascular system
d. Chemoreceptors in the aortic arch and carotid body
ANS: D
Chemoreceptors located in the aortic arch and carotid
body are capable of initiating changes in HR and arterial pressure in response
to decreased arterial O2 pressure, increased arterial carbon dioxide pressure,
and decreased plasma pH.
40. While assessing a patient who has just arrived in
the emergency department, the nurse notes a pulse deficit. Which of the
following does the nurse anticipate that the patient may require?
a. Hourly blood pressure (BP) checks
b. A coronary arteriogram
c. Electrocardiographic (ECG) monitoring
d. A two-dimensional echocardiogram
ANS: C
Pulse deficit is a difference between simultaneously
obtained apical and radial pulses and indicates that dysrhythmias might be
detected with ECG monitoring
41. A patient has a BP of 142/84 mm Hg. The nurse will
calculate and document the patient’s mean arterial pressure (MAP) as being
which following amount?
a. 103 mm Hg
b. 113 mm Hg
c. 123 mm Hg
d. 131 mm Hg
ANS: A
MAP = Diastolic BP + 1/3 Pulse pressure.
42. The nurse is monitoring a patient with possible
coronary artery disease who is undergoing exercise (stress) testing on a
treadmill. Which symptom has the most immediate implications for the patient’s
care during the exercise testing?
a. BP rising from 134/68 to 150/80 mm Hg
b. HR increasing from 80 to 96 beats/min
c. Patient complaining of feeling short of breath
d. ECG indicating the presence of coronary ischemia
ANS: D
ECG changes associated with coronary ischemia (such as
T-wave inversions and ST-segment depression) indicate that the myocardium is
not getting adequate oxygen delivery and that the exercise test should be
terminated immediately
43. During physical examination of a 56-year-old man,
the nurse palpates the point of maximal impulse (PMI) in the sixth intercostal
space lateral to the midclavicular line. What is the most appropriate
interpretation of this finding?
a. The PMI is in the normal location.
b. The patient may have left ventricular hypertrophy.
c. The patient has age-related downward displacement
of the heart.
d. The patient should be observed for signs of left
atrial enlargement.
ANS: B
The PMI should be felt at the intersection of the
fifth intercostal space and the midclavicular line. A PMI located outside these
landmarks indicates possible cardiac enlargement, such as with left ventricular
hypertrophy.
44. To auscultate for extra heart sounds in the mitral
area, with what part of the stethoscope will the nurse listen?
a. The bell of the stethoscope with the patient in the
left lateral position
b. The diaphragm of the stethoscope with the patient
in a reclining position
c. The diaphragm of the stethoscope with the patient
lying flat on the left side
d. The bell of the stethoscope with the patient
sitting and leaning to the right side
ANS: A
Gallop rhythms generate low-pitched sounds and are
most easily heard with the bell of the stethoscope. Sounds associated with the
mitral valve are accentuated by turning the patient to the left side, which
brings the heart closer to the chest wall.
45. The standard orders on the cardiac unit state,
“Notify the physician for MAP less than 70 mm Hg.” For which patient would the
nurse call the physician?
a. The patient with left ventricular failure who has a
BP of 110/70 mm Hg
b. The patient with a myocardial infarction who has a
BP of 114/50 mm Hg
c. The postoperative patient with a BP of 116/42 mm Hg
d. The newly admitted patient with a BP of 122/60 mm
Hg
ANS: C
The MAP is calculated using the formula MAP =
(Diastolic BP + 1/3 Pulse Pressure). The MAP for the postoperative patient in C
is 67 mm Hg. The MAP in the other three patients is higher than 70 mm Hg.
46. During physical examination of a 72-year-old
patient, the nurse observes pulsation of the abdominal aorta in the epigastric
area just below the xiphoid process. How will the nurse interpret this finding?
a. Normal assessment data in a thin person
b. Sclerosis and inelasticity of the aorta
c. A possible abdominal aortic aneurysm
d. Evidence of elevated systemic arterial pressure
ANS: A
Visible pulsation of the abdominal aorta is commonly
observed in the epigastric area for thin individuals.
47. A patient is scheduled for cardiac catheterization
with coronary angiography. Before the test, about which of the following should
the nurse inform the patient?
a. A catheter will be inserted into a vein in the arm
or leg and advanced to the heart.
b. ECG monitoring will be required for 24 hours
following the test to detect any dysrhythmias.
c. A feeling of warmth and a fluttering sensation may
be experienced as the catheter is advanced.
d. Complications of the test include breaking of the
catheter, air or blood embolism, and puncture of the ventricles.
ANS: C
A sensation of warmth or flushing is common when the
iodine-based contrast material is injected, which can produce anxiety unless it
has been discussed with the patient.
48. Which of the following is a normal cardiac index
(CI) assessment finding?
a. 2 L/min
b. 3 L/min/m2
c. 6 L/min
d. 8 L/min/m2
ANS: B
The normal range for a CI reading is 2.8 to 4.2
L/min/m2.
49. What should the nurse teach the patient being
evaluated for rhythm disturbances with a Holter monitor to do?
a. Remove the electrodes to shower or bathe.
b. Exercise as much as possible while his monitor is
in place.
c. Keep a diary of his activities as long as he wears
the monitor.
d. Attach the recorder, and call the assigned number
if an episode of irregular heartbeats occurs.
ANS: C
The patient is instructed to keep a diary describing
daily activities while Holter monitoring is being accomplished to help
correlate any rhythm disturbances with patient activities.
50. When auscultating over the patient’s abdominal
aorta, the nurse hears a humming sound. How will the nurse document this finding?
a. Bruit
b. Thrill
c. Heave
d. Arterial obstruction
ANS: A
A bruit is the sound created by turbulent blood flow
in an artery.
51. The physician orders serum troponin levels in a
patient with a possible myocardial infarction. What will the nurse explain to
the patient about this test?
a. It is the most specific indicator for myocardial
damage available.
b. It measures the amount of myoglobin released from
damaged myocardial cells.
c. It can provide evidence of myocardial damage more
quickly than can enzyme tests.
d. It is diagnostic for myocardial damage only when
used in combination with creatinine kinase-MB isoenzymes.
ANS: C
Cardiac troponins start to elevate 1 hour after myocardial
injury and are specific to myocardium.
52. Which of the following is a normal age-related
change in the heart?
a. Increased elastin
b. Decreased collagen
c. Decreased cardiac output
d. Increased stroke volume
ANS: C
A normal age-related change in the heart is a decrease
in cardiac output. Elastin and stroke volume are decreased, and collagen is
increased.
53. The nurse hears a murmur between the S1 and S2
heart sounds at the patient’s left fifth intercostal space and midclavicular
line. What is the best way to record this information?
a. “Systolic murmur heard at mitral area.”
b. “Diastolic murmur heard at aortic area.”
c. “Systolic murmur heard at Erb’s point.”
d. “Diastolic murmur heard at tricuspid area.”
ANS: A
The S1 sound is created by closure of the mitral and
tricuspid valves and signifies the onset of ventricular systole. S2 is caused
by the closure of the aortic and pulmonic valves and signifies the onset of
diastole. A murmur occurring between these two sounds is a systolic murmur.
54. What should the nurse expect as a possible
etiology in a patient who exhibits a positive Homans sign?
a. Thyrotoxicosis
b. Thrombophlebitis
c. Incompetent valves
d. Intermittent claudication
ANS: B
The nurse should suspect thrombophlebitis in a patient
who exhibits a positive Homans sign.
55. Upon auscultation, the nurse identifies an
arterial bruit. What is a possible cause?
a. Cardiac dysrhythmias
b. Aneurysm
c. Pericarditis
d. Cardiac valve disorder
ANS: B
An arterial bruit is suggestive of wither an aneurysm
or an arterial obstruction.
56. The registered nurse (RN) is observing a student
nurse who is doing a physical assessment on a patient. The RN will need to
intervene immediately if the student does which of the following?
a. Presses on the skin over the tibia for 10 seconds
to check for edema
b. Palpates both carotid arteries simultaneously to
compare pulse quality
c. Places the patient in the left lateral position to
check for the PMI
d. Uses the palm of the hand to assess extremity skin
temperature
ANS: B
The carotid pulses should never be palpated at the
same time to avoid vagal stimulation, dysrhythmias, and decreased cerebral
blood flow. The other assessment techniques also need to be corrected; however,
they are not dangerous to the patient.
57. A patient with syncope is scheduled for Holter
monitoring. When teaching the patient about the purpose of the procedure, the
nurse explains that Holter monitoring provides information about which of the
following?
a. Ventricular ejection fraction during usual daily
activities
b. Cardiovascular response to high-intensity exercise
c. Changes in cardiac output when the patient is
resting
d. HR and rhythm during normal patient activities
ANS: D
Holter monitoring is used to assess for possible
changes in HR or rhythm over a 24- to 48-hour period. The patient is usually
instructed to continue with usual daily activities rather than changing
exercise or activity level.
58. A transesophageal echocardiogram (TEE) is ordered
for a patient with possible endocarditis. Which of these actions included in
the standard TEE orders will the nurse need to accomplish first?
a. Make the patient nothing by mouth (NPO) status.
b. Start a large-gauge IV line.
c. Administer O2 per mask.
d. Give lorazepam (Ativan) 1 mg IV.
ANS: A
The patient will need to be NPO status for 6 hours
preceding the TEE, so the nurse should place the patient on NPO status as soon
as the order is received.
59. Which one of the following central venous pressure
(CVP) readings would the nurse report to the physician as being abnormal?
a. 3 mm Hg
b. 6 mm Hg
c. 9 mm Hg
d. 12 mm Hg
ANS: D
The normal CVP reading is 2 to 9 mm Hg.
60. For how long may blood preserved with CPD be
stored (unfrozen) before use?
a. 21 days
b. 35 days
c. 42 days
d. 3 months
ANS: A
When preserved with citrate, phosphate, and dextrose a
unit of blood has a shelf life of 21 days (unfrozen).
61. The nurse is caring for a patient who needs a
blood transfusion. The patient has been tested and was found to have blood type
O. The nurse knows this means that which antigen is present on the surface of
the red blood cells?
a. The type A antigen is present.
b. The type B antigen is present.
c. Neither type A nor type B antigens are present.
d. Both type A and type B antigens are present.
ANS: C
When neither A nor B antigens are present, the blood
group is type O. When the type A antigen is present, the blood group is type A.
When the type B antigen is present, the blood group is type B. When both A and
B antigens are present, the blood group is type AB.
62. A nurse is concerned about the type of blood that
a patient is to receive. A patient with an O blood type may safely receive
which type of blood?
a. Type A blood
b. Type B blood
c. Type AB blood
d. Type O blood
ANS: D
People with type O blood have both A and B antibodies
and therefore can receive only type O blood. People with type A blood have anti-B
antibodies and therefore can receive only type A blood. People with type B
blood have anti-A antibodies and therefore can receive only type B blood.
People with type AB blood have neither antibody and therefore can receive all
blood types.
63. The patient is scheduled to receive a blood
transfusion. Preadministration laboratory tests are run to assess the level of
which component in the patient’s blood?
a. Sodium (Na)
b. Calcium (Ca)
c. Potassium (K)
d. Iron (Fe)
ANS: C
When blood is stored, there is continual destruction
of RBCs, which releases potassium from the cells into the plasma. If blood is
transfused rapidly, transient elevated potassium levels may occur before the
potassium is reabsorbed and put the patient at risk
64. The patient has received a total of 7 units of
blood over the past 8 hours. The nurse assesses the patient’s laboratory test
results. Which of the following would be an expected complication?
a. Hypokalemia
b. Hyperkalemia
c. Hypercalcemia
d. Iron deficiency
ANS: B
When blood is stored, there is continual destruction
of RBCs, which releases potassium from the cells into the plasma. If blood is
transfused rapidly, transient hyperkalemia may occur before the potassium is
reabsorbed. Blood that is preserved with citrate phosphate dextrose (CPD)
contains a high concentration of citrate ions. The excess citrate may combine
with the ionized calcium in the recipient’s blood, resulting in transient low
ionized calcium levels. Patients receiving multiple transfusions should be
assessed for iron overload.
65. The patient is to receive 2 units of packed RBCs.
The units are cold, and the nurse is concerned that this could lead to
dysrhythmias and/or a reduction in core temperature. What action may the nurse
take to prevent this?
a. Warm the blood in a microwave.
b. Warm the blood using hot water.
c. Warm the blood using a blood warmer.
d. Allow the blood to warm to room temperature before
administering.
ANS: C
In emergency situations, rapid transfusion of cold
blood may lead to dysrhythmias and a reduction in core temperature. Sometimes a
blood warmer machine is used for large transfusions of greater than 50 mL/kg/hr
or in patients with cold agglutinins. Heating blood products in a microwave or
with hot water is dangerous and may destroy blood cells. Blood must be given
within a prescribed time frame. Allowing the blood to come to room temperature
before administration would decrease the time available for administration.
66. The patient is scheduled to receive 1 unit of
packed RBCs. She has small, fragile veins, and a 22-gauge intravenous (IV)
patent catheter is in place. What should the nurse do?
a. Cancel the blood transfusion.
b. Insert a 16-gauge IV catheter into the antecubital
fossa.
c. Use the IV catheter that is in place.
d. Transfuse the blood over 6 hours.
ANS: C
In emergency situations that require rapid
transfusions, a large-gauge cannula is preferred; however, transfusions for
therapeutic indications may be infused with cannulas ranging from 20 to 24
gauge. Large-gauge cannulas (18 or 20 gauge) promote rapid flow of blood
components. 16-Gauge catheters are used frequently in surgery, but not usually
on acute care units. Blood must be transfused within 4 hours. Use of
smaller-gauge cannulas, such as 24 gauge, often requires the blood bank to
divide the unit so that each half can be infused within the allotted time or
requires the use of pressure-assisted devices.
67. What primary intervention should a nurse who is
preparing a blood transfusion perform?
a. Set up the Y tubing.
b. Obtain 0.9% saline.
c. Verify the blood product and the patient.
d. Have the patient void or empty the urine drainage
container.
ANS: C
Correctly verify the product and identify the patient
with a person considered qualified by your agency. Strict adherence to
verification procedures before administration of blood or blood components
reduces the risk of administering the wrong blood to the patient. Clerical
errors are the cause of most hemolytic transfusion reactions. Y tubing is used
to facilitate maintenance of IV access in case a patient will need more than 1
unit of blood. However, the focus here is on prevention of possible blood reactions.
Use of Y tubing will not prevent a blood reaction. Normal saline is compatible
with blood products, unlike solutions that contain dextrose, which causes
coagulation of donor blood. However, strict adherence to verification
procedures before administration of blood or blood components reduces the risk
of administering the wrong blood to the patient. Empty the urine drainage
collection container or have the patient void. If a transfusion reaction
occurs, a urine specimen containing urine produced after initiation of the
transfusion will be sent to the laboratory.
68. The patient is to receive 1 unit of packed RBCs.
The nurse obtains the blood from the blood bank and returns to the unit to find
that the patient has been taken to radiology for a CT scan and is expected to
return in about an hour. What should the nurse do?
a. Go to radiology and administer the blood.
b. Keep the blood refrigerated until the patient
returns.
c. Return the blood to the blood bank.
d. Hang the blood in the patient’s room and start it
when the patient returns.
ANS: C
Initiate the blood transfusion within 30 minutes of
the time of release from the blood bank. If you cannot do this because the
patient is in the bathroom or the physician has to be notified of an elevated
temperature, immediately return the blood to the blood bank, and retrieve it
when you can administer it.
69. The nurse is preparing to administer a unit of
blood to a patient using blood tubing. On the blood product side of the Y
tubing, she will hang blood. What will she hang on the other side of the Y
tubing?
a. Dextrose 5%
b. Normal saline
c. Dextrose 10%
d. Dextrose 5%/normal saline
ANS: B
Normal saline is compatible with blood products,
unlike solutions that contain dextrose, which causes coagulation of donor
blood.
70. The nurse is administering blood. What should the
nurse do to detect a blood reaction as quickly as possible?
a. Remain with the patient during the first 15
minutes.
b. Transfuse the blood at 10 mL/min.
c. Monitor vital signs q 1 hour.
d. Transfuse blood at 50 gtt/min.
ANS: A
Remain with the patient during the first 15 minutes of
a transfusion. Most transfusion reactions occur within the first 15 minutes of
a transfusion. The initial flow rate during this time should be 2 mL/min, or 20
gtt/min. Initially infusing a small amount of blood component minimizes the
volume of blood to which the patient is exposed, thereby minimizing the
severity of a reaction. Monitor the patient’s vital signs at 5 minutes, at 15
minutes, and every 30 minutes until 1 hour after transfusion or per agency
policy. Frequent monitoring of vital signs will help to quickly alert the nurse
to a transfusion reaction
71. An appropriate technique for the nurse to
implement for a blood transfusion is to:
a. provide medication through the IV line with the
blood.
b. regulate the flow of blood so that it infuses over
8 hours.
c. clear the IV tubing with normal saline after the
blood infuses.
d. administer a blood product with clots through a
filter line.
ANS: C
After the blood has infused, clear the IV line with
0.9% normal saline and discard the blood bag according to agency policy.
Medication should never be injected into the same IV line as a blood component
because of the risk of contaminating the blood product with pathogens and the
possibility of incompatibility. A separate IV line must be maintained if the
patient requires IV infusion (total parenteral nutrition, pain control) during
the transfusion. A unit of blood should not hang for longer than 4 hours
because of the danger of bacterial growth. Check the appearance of blood
product for leaks, bubbles, clots, or a purplish color. Do not transfuse blood
if its integrity is compromised. Blood serves as a medium for bacteria.
72. When a patient’s adverse reaction to a blood
transfusion is differentiated, which of the following signs/symptoms indicates
the presence of an anaphylactic response?
a. Wheezing and chest pain
b. Headache and muscle pain
c. Hypotension and tingling of the extremities
d. Crackles in the lungs and increased central venous
pressure
ANS: A
Observe the patient for wheezing, chest pain, and
possible cardiac arrest. All of these are indications of an anaphylactic
reaction. Be alert to patient complaints of headache or muscle pain in the
presence of a fever. Both may be indicative of a febrile nonhemolytic reaction.
Observe patients receiving massive transfusions for mild hypothermia, cardiac
dysrhythmias, hypotension, and hypocalcemia. Cold blood products can affect the
cardiac conduction system, resulting in ventricular dysrhythmias. Other cardiac
dysrhythmias, hypotension, and tingling may indicate hypocalcemia, which occurs
when citrate (used as a preservative for some blood products) combines with the
patient’s calcium. Crackles in the bases of lungs and rising central venous
pressure (CVP) are indications of circulatory overload.
73. The patient is receiving a unit of packed RBCs.
Fifteen minutes into the procedure, he complains of severe kidney pain, and his
temperature increases by 3° F. The nurse stops the transfusion immediately,
suspecting that which of the following reactions is occurring?
a. Delayed hemolytic transfusion reaction
b. Nonhemolytic febrile reaction
c. Acute hemolytic transfusion reaction
d. Severe allergic reaction
ANS: C
Symptoms of an acute hemolytic reaction usually begin
within 15 minutes of transfusion initiation and include severe pain in the
kidney area and chest, increased temperature (up to 105° F), increased heart
rate, and a sensation of heat and pain along the vein receiving blood, as well
as chills, low back pain, headache, nausea, chest or back pain, chest
tightness, dyspnea, bronchospasm, anxiety, hypotension, vascular collapse,
disseminated intravascular coagulation, and possibly death. Symptoms of a
delayed hemolytic reaction usually begin 2 to 14 days after the transfusion and
include unexplained fever, an unexplained decrease in hemoglobin/hematocrit
(Hgb/Hct), increased bilirubin levels, and jaundice. Symptoms of a nonhemolytic
febrile reaction begin between 30 minutes after initiation and 6 hours after
completion of transfusion and include fever greater than 1° C above baseline,
flushing, chills, headache, and muscle pain; they occur most frequently in
immunosuppressed patients. Symptoms of an acute severe allergic reaction
usually begin within 5 to 15 minutes of initiation of transfusion and include
coughing, nausea, vomiting, respiratory distress, wheezing, hypotension, loss
of consciousness, and possible cardiac arrest.
74. The patient has been home from the hospital for 10
days. On the last day of his hospitalization, he received 2 units of packed
RBCs. This morning, he noticed that his skin had a yellow tint to it and his
temperature was elevated. Which reaction might this patient be experiencing?
a. Delayed hemolytic transfusion reaction
b. Acute hemolytic transfusion reaction
c. Nonhemolytic febrile reaction
d. Severe allergic transfusion reaction
ANS: A
Symptoms of a delayed hemolytic reaction usually begin
2 to 14 days after the transfusion and include unexplained fever, unexplained
decrease in Hgb/Hct, increased bilirubin levels, and jaundice. Symptoms of an
acute hemolytic reaction usually begin within 15 minutes of transfusion
initiation and include severe pain in the kidney area and chest, increased
temperature (up to 105° F), increased heart rate, and increased sensation of
heat and pain along the vein receiving blood, as well as chills, low back pain,
headache, nausea, chest or back pain, chest tightness, dyspnea, bronchospasm,
anxiety, hypotension, vascular collapse, disseminated intravascular
coagulation, and possibly death. Symptoms of a nonhemolytic febrile reaction
begin between 30 minutes after initiation and 6 hours after completion of
transfusion and include fever greater than 1° C above baseline, flushing,
chills, headache, and muscle pain; they occur most frequently in
immunosuppressed patients. Symptoms of an acute severe allergic reaction
usually begin within 5 to 15 minutes of initiation of transfusion and include
coughing, nausea, vomiting, respiratory distress, wheezing, hypotension, loss
of consciousness, and possible cardiac arrest.
75. The specific blood product used for replacement of
clotting factors and fibrinogen is:
a. whole blood.
b. packed RBCs.
c. cryoprecipitate.
d. albumin, 25% pooled.
ANS: C
Cryoprecipitate replaces factors VIII and XIII, von
Willebrand’s factor, and fibrinogen. It also replaces red cell mass and plasma
volume and is expected to raise hemoglobin by 1 g/100 mL and hematocrit by 3%
in a nonhemorrhaging adult. Using cryoprecipitate is the preferred method of
replacing red blood cell mass.
76. The nurse is administering 1 unit of packed red
blood cells as ordered by the primary care provider. While the nurse is
measuring vital signs 15 minutes after starting the transfusion, the patient
complains of chills and back pain. What is the nurse’s first action?
a. Stop the blood transfusion and keep the vein patent
by administering saline to infuse from the other side of the Y tubing.
b. Slow the blood transfusion and notify the charge
nurse.
c. Disconnect the blood tubing from the catheter and
replace it with an infusion of normal saline.
d. Stop the blood transfusion and notify the primary
care provider.
ANS: C
The nurse’s first priority is to stop the blood transfusion.
To keep the intravenous site patent, normal saline can be infused at a
keep-open rate, but the tubing must be changed to avoid administering more
blood as the saline flushes the blood from the tubing. If the tubing is not
changed, additional blood will be administered, and the possible transfusion
reaction will increase. The charge nurse or the primary care provider should be
notified only after the patient has been assessed.
77. Transfusion therapy is the intravenous (IV)
administration of which of the following? (Select all that apply.)
a. Whole blood
b. Plasma products
c. Red blood cells (RBCs)
d. Platelets
ANS: A, B, C, D
Transfusion therapy or blood replacement is the IV administration
of whole blood, its components, or plasma-derived product for therapeutic
purposes.
78. What is the purpose of administering a
transfusion? (Select all that apply.)
a. Restore intravascular volume.
b. Restore the oxygen-carrying capacity of blood.
c. Provide clotting factors.
d. Improve blood pressure.
ANS: A, B, C
Transfusions are used to restore intravascular volume
with whole blood or albumin, to restore the oxygen-carrying capacity of blood
with RBCs, and to provide clotting factors and/or platelets. Although
increasing blood volume may increase blood pressure, increasing blood pressure
is not a primary objective of transfusion
79. The patient is to receive 2 units of packed RBCs.
Before administering the blood, what does the nurse need to do? (Select all
that apply.)
a. Insert an 18-gauge IV cannula.
b. Have the patient complete a consent form.
c. Obtain pretransfusion vital signs.
d. Notify the physician for a temperature of 37° C.
ANS: B, C
In emergency situations that require rapid transfusions,
a large-gauge cannula is preferred; however, transfusions for therapeutic
indications may be infused with cannulas ranging from 20 to 24 gauge. Check
that the patient has properly completed and signed transfusion consent before
retrieving blood. Most agencies require patients to sign consent forms before
receiving blood component therapy because of the inherent risks. Obtain and
record pretransfusion vital signs, including temperature, immediately before
initiation of the transfusion. If the patient is febrile (temperature greater
than 100° F [37.8° C]), notify the physician or the health care provider before
initiating the transfusion. Change from baseline vital signs during infusion
will alert the nurse to a potential transfusion reaction or adverse effect of
therapy.
80. The patient is receiving blood when he suddenly
complains of low back pain and develops diaphoresis and chills. The nurse
should: (Select all that apply.)
a. stop the transfusion.
b. start normal saline connected to the Y tubing.
c. notify the physician.
d. start normal saline using new IV tubing.
ANS: A, C, D
If signs of a transfusion reaction occur, stop the
transfusion, start normal saline with new primed tubing directly to the ventricular
assist device (VAD) at the keep-vein-open rate (KVO), and notify the physician
immediately
81. Symptoms that indicate an adverse reaction to
blood products include which of the following? (Select all that apply.)
a. Fever
b. Skin rash
c. Hypotension
d. Cardiac arrest
ANS: A, B, C, D
Symptoms that indicate an adverse reaction range from
fever, chills, and skin rash to hypotension and cardiac arrest.
82. A transfusion in which the donor is the patient is
known as an ______________ transfusion or autotransfusion.
ANS: autologous
In autologous transfusion, or autotransfusion, the
donor is the patient.
83. The presence or absence of specific antigens on
the surface of red blood cells determines ___________________ in the ABO
system.
ANS: blood type
The presence or absence of specific antigens on the
surface of red blood cells determines blood type in the ABO system.
84. Antibodies that react against the A and B antigens
are naturally present in the plasma of people whose red blood cells do not carry
the antigen. These antibodies react against the foreign antigens. Incompatible
red blood cells clump together or _____________, which results in a
life-threatening hemolytic transfusion reaction.
ANS: agglutinate
Antibodies that react against the A and B antigens are
naturally present in the plasma of people whose red blood cells do not carry
the antigen. These antibodies (agglutinins) react against the foreign antigens
(agglutinogens). Incompatible red blood cells agglutinate (clump together),
which results in a life-threatening hemolytic transfusion reaction.
85. The nurse is caring for a patient who is receiving
blood while monitoring the patient for potential complications. The nurse knows
that a systemic response to administration of a blood product that is
incompatible with the blood of the recipient, contains allergens to which the
recipient is sensitive or allergic, or is contaminated with pathogens is known
as a _________.
ANS: hemolytic reaction
A hemolytic reaction is a systemic response to the
administration of a blood product that is incompatible with the blood of the
recipient, contains allergens to which the recipient is sensitive or allergic,
or is contaminated with pathogens.
86. The patient has received blood within the past 6
hours. The patient begins to feel short of breath and calls for the nurse. The
nurse finds that the patient is dusky in color with crackles throughout his
lungs and is coughing up pink frothy sputum. The nurse calls the physician
immediately, knowing that the patient is showing signs of _________________.
ANS: transfusion-related acute lung injury (TRALI)
Possible adverse outcomes that result from transfusion
therapy include transmission of diseases, circulatory overload, and TRALI
characterized by noncardiogenic pulmonary edema with onset within 6 hours of
transfusion.
87. Under the ABO system, the blood type __________
can be given to any individual and is known as the “Universal Donor.”
ANS: O negative
O negative can be given to people of any blood type
and is known as the “Universal Donor.”
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