Lewis Chapter 30: Hematologic Problems Practice Questions

A 62-year old man with chronic anemia is experiencing increased fatigue and occasional

palpitations at rest. The nurse would expect the patient's laboratory test findings to include

a. an RBC count of 4,500,000/L.

b. a hematocrit (Hct) value of 38%.

c. normal red blood cell (RBC) indices.

d. a hemoglobin (Hgb) of 8.6 g/dL (86 g/L).

ANS: D

The patient's clinical manifestations indicate moderate anemia, which is consistent with a Hgb

of 6 to 10 g/dL. The other values are all within the range of normal.

DIF: Cognitive Level: Understand (comprehension) REF: 607

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

Which menu choice indicates that the patient understands the nurse's teaching about

recommended dietary choices for iron-deficiency anemia?

a. Omelet and whole wheat toast c. Strawberry and banana fruit plate

b. Cantaloupe and cottage cheese d. Cornmeal muffin and orange juice

ANS: A

Eggs and whole grain breads are high in iron. The other choices are appropriate for other

nutritional deficiencies but are not the best choice for a patient with iron-deficiency anemia.

DIF: Cognitive Level: Apply (application) REF: 610

TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

A patient who is receiving methotrexate for severe rheumatoid arthritis develops a

megaloblastic anemia. The nurse will anticipate teaching the patient about increasing oral

intake of

a. iron.

b. folic acid.

c. cobalamin (vitamin B12).

d. ascorbic acid (vitamin C).

ANS: B

Methotrexate use can lead to folic acid deficiency. Supplementation with oral folic acid

supplements is the usual treatment. The other nutrients would not correct folic acid deficiency,

although they would be used to treat other types of anemia.

DIF: Cognitive Level: Apply (application) REF: 612

TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

A 52-yr-old patient has a new diagnosis of pernicious anemia. The nurse determines that the

patient understands the teaching about the disorder when the patient states,

a. "I need to start eating more red meat and liver."

b. "I will stop having a glass of wine with dinner."

c. "I could choose nasal spray rather than injections of vitamin B12."

d. "I will need to take a proton pump inhibitor such as omeprazole (Prilosec)."

ANS: C

Because pernicious anemia prevents the absorption of vitamin B12, this patient requires

injections or intranasal administration of cobalamin. Alcohol use does not cause cobalamin

deficiency. Proton pump inhibitors decrease the absorption of vitamin B12. Eating more foods

rich in vitamin B12 is not helpful because the lack of intrinsic factor prevents absorption of the

vitamin.

DIF: Cognitive Level: Apply (application) REF: 612

TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

An appropriate nursing intervention for a hospitalized patient with severe hemolytic anemia is

to

a. provide a diet high in vitamin K.

b. alternate periods of rest and activity.

c. teach the patient how to avoid injury.

d. place the patient on protective isolation.

ANS: B

Nursing care for patients with anemia should alternate periods of rest and activity to

encourage activity without causing undue fatigue. There is no indication that the patient has a

bleeding disorder, so a diet high in vitamin K or teaching about how to avoid injury is not

needed. Protective isolation might be used for a patient with aplastic anemia, but it is not

indicated for hemolytic anemia.

DIF: Cognitive Level: Apply (application) REF: 608

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

Which patient statement to the nurse indicates a need for additional instruction about taking

oral ferrous sulfate?

a. "I will call my health care provider if my stools turn black."

b. "I will take a stool softener if I feel constipated occasionally."

c. "I should take the iron with orange juice about an hour before eating."

d. "I should increase my fluid and fiber intake while I am taking iron tablets."

ANS: A

It is normal for the stools to appear black when a patient is taking iron, and the patient should

not call the health care provider about this. The other patient statements are correct.

DIF: Cognitive Level: Apply (application) REF: 609

TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

Which collaborative problem will the nurse include in a care plan for a patient admitted to the

hospital with idiopathic aplastic anemia?

a. Potential complication: seizures

b. Potential complication: infection

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 infection

and bleeding. There is no increased risk for seizures, neurogenic shock, or pulmonary edema.

DIF: Cognitive Level: Apply (application) REF: 614

TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

It is important for the nurse providing care for a patient with sickle cell crisis to

a. limit the patient's intake of oral and IV fluids.

b. evaluate the effectiveness of opioid 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. Fluid intake should be increased to reduce blood viscosity and

improve perfusion. Rest is usually ordered to decrease metabolic requirements. Patients are

instructed about the need for dietary folic acid, but high-protein, high-calorie diets are not

emphasized.

DIF: Cognitive Level: Apply (application) REF: 618

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

Which statement by a patient indicates good understanding of the nurse's teaching about

prevention of sickle cell crisis?

a. "Home oxygen therapy is frequently used to decrease sickling."

b. "There are no effective medications that can help prevent sickling."

c. "Routine continuous dosage narcotics are prescribed to prevent a crisis."

d. "Risk for a crisis is decreased by having an annual influenza vaccination."

ANS: D

Because infection is the most common cause of a sickle cell crisis, influenza, Haemophilus

influenzae, pneumococcal pneumonia, and hepatitis immunizations should be administered.

Although continuous dose opioids and oxygen may be administered during a crisis, patients

do not receive these therapies to prevent crisis. Hydroxyurea (Hydrea) is a medication used to

decrease the number of sickle cell crises.

DIF: Cognitive Level: Apply (application) REF: 617

TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

Which instruction will the nurse plan to include in discharge teaching for a patient admitted

with a sickle cell crisis?

a. Take a daily multivitamin with iron.

b. Limit fluids to 2 to 3 quarts per day.

c. Avoid exposure to crowds when possible.

d. Drink only two caffeinated beverages daily.

ANS: C

Exposure to crowds increases the patient's risk for infection, the most common cause of sickle

cell crisis. There is no restriction on caffeine use. Iron supplementation is generally not

recommended. A high-fluid intake is recommended.

DIF: Cognitive Level: Apply (application) REF: 617

TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

The nurse notes scleral jaundice in a patient being admitted with hemolytic anemia. The nurse

will plan to check the laboratory results for the

a. Schilling test. c. gastric analysis.

b. bilirubin level. d. stool occult blood.

ANS: B

Jaundice is caused by the elevation of bilirubin level associated with red blood cell hemolysis.

The other tests would not be helpful in monitoring or treating a hemolytic anemia.

DIF: Cognitive Level: Apply (application) REF: 615

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

A patient who has been receiving IV heparin infusion and oral warfarin (Coumadin) for a

deep vein thrombosis (DVT) is diagnosed with heparin-induced thrombocytopenia (HIT)

when the platelet level drops to 110,000/μL. Which action will the nurse include in the plan of

care?

a. Prepare for platelet transfusion.

b. Discontinue the heparin infusion.

c. Administer prescribed warfarin (Coumadin).

d. Use low-molecular-weight heparin (LMWH).

ANS: B

All heparin is discontinued when HIT is diagnosed. The patient should be instructed to never

receive heparin or LMWH. Warfarin is usually not given until the platelet count has returned

to 150,000/μL. The platelet count does not drop low enough in HIT for a platelet transfusion,

and platelet transfusions increase the risk for thrombosis.

DIF: Cognitive Level: Apply (application) REF: 622

TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

An expected action by the nurse caring for a patient who has an acute exacerbation of

polycythemia vera is to

a. place the patient on bed rest. c. avoid use of aspirin products.

b. administer iron supplements. d. monitor fluid intake and output.

ANS: D

Monitoring hydration status is important during an acute exacerbation because the patient is at

risk for fluid overload or underhydration. Aspirin therapy is used to decrease risk for

thrombosis. The patient should be encouraged to ambulate to prevent deep vein thrombosis.

Iron is contraindicated in patients with polycythemia vera.

DIF: Cognitive Level: Apply (application) REF: 621

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

Which intervention will be included in the nursing care plan for a patient with immune

thrombocytopenic purpura?

a. Assign the patient to a private room.

b. Avoid intramuscular (IM) injections.

c. Use rinses rather than a soft toothbrush for oral care.

d. Restrict activity to passive and active range of motion.

ANS: B

IM or subcutaneous injections should be avoided because of the risk for bleeding. A soft

toothbrush can be used for oral care. There is no need to restrict activity or place the patient in

a private room.

DIF: Cognitive Level: Apply (application) REF: 622

TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment

Which laboratory result will the nurse expect to show a decreased value if a patient develops

heparin-induced thrombocytopenia (HIT)?

a. Prothrombin time

b. Erythrocyte count

c. Fibrinogen degradation products

d. Activated partial thromboplastin time

ANS: D

Platelet aggregation in HIT causes neutralization of heparin, so the activated partial

thromboplastin time will be shorter, and more heparin will be needed to maintain therapeutic

levels. The other data will not be affected by HIT.

DIF: Cognitive Level: Understand (comprehension) REF: 622

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

The nurse is caring for a patient with type A hemophilia being admitted to the hospital with

severe pain and swelling in the right knee. The nurse should

a. apply heat to the knee.

b. immobilize the knee joint.

c. assist the patient with light weight bearing.

d. perform passive range of motion to the knee.

ANS: B

The initial action should be total rest of the knee to minimize bleeding. Ice packs are used to

decrease bleeding. Range of motion (ROM) and weight-bearing exercise are contraindicated

initially, but after the bleeding stops, ROM and physical therapy are started.

DIF: Cognitive Level: Apply (application) REF: 626

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

A young adult who has von Willebrand disease is admitted to the hospital for minor knee

surgery. The nurse will review the coagulation survey to check the

a. platelet count. c. thrombin time.

b. bleeding time. d. prothrombin time.

ANS: B

The bleeding time is affected by von Willebrand disease. Platelet count, prothrombin time,

and thrombin time are normal in von Willebrand disease.

DIF: Cognitive Level: Understand (comprehension) REF: 626

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

A routine complete blood count for an active older man indicates possible myelodysplastic

syndrome. The nurse will plan to teach the patient about

a. blood transfusion.

b. bone marrow biopsy.

c. filgrastim (Neupogen) administration.

d. erythropoietin (Epogen) administration.

ANS: B

Bone marrow biopsy is needed to make the diagnosis and determine the specific type of

myelodysplastic syndrome. The other treatments may be necessary if there is progression of

the myelodysplastic syndrome, but the initial action for this asymptomatic patient will be a

bone marrow biopsy.

DIF: Cognitive Level: Apply (application) REF: 634

TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

Which action will the admitting nurse include in the care plan for a patient who has

neutropenia?

a. Avoid intramuscular injections.

b. Check temperature every 4 hours.

c. Omit fruits or vegetables from the diet.

d. Place a "No Visitors" sign on the door.

ANS: B

The earliest sign of infection in a neutropenic patient is an elevation in temperature. Although

unpeeled fresh fruits and vegetables should be avoided, fruits and vegetables that are peeled or

cooked are acceptable. Injections may be required for administration of medications such as

filgrastim (Neupogen). The number of visitors may be limited and visitors with communicable

diseases should be avoided, but a "no visitors" policy is not needed.

DIF: Cognitive Level: Apply (application) REF: 632

TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

Which laboratory test will the nurse use to determine whether filgrastim (Neupogen) is

effective for a patient with acute lymphocytic leukemia who is receiving chemotherapy?

a. Platelet count c. Total lymphocyte count

b. Reticulocyte count d. Absolute neutrophil count

ANS: D

Filgrastim increases the neutrophil count and function in neutropenic patients. Although total

lymphocyte, platelet, and reticulocyte counts are also important to monitor in this patient, the

absolute neutrophil count is used to evaluate the effects of filgrastim.

DIF: Cognitive Level: Apply (application) REF: 634

TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

A patient who has acute myelogenous leukemia (AML) asks the nurse whether the planned

chemotherapy will be worth undergoing. Which response by the nurse is appropriate?

a. "If you do not want to have chemotherapy, other treatment options include stem

cell transplantation."

b. "The side effects of chemotherapy are difficult, but AML frequently goes into

remission with chemotherapy."

c. "The decision about treatment is one that you and the doctor need to make rather

than asking what I would do."

d. "You don't need to make a decision about treatment right now because leukemias in adults tend to progress slowly."

ANS: B

This response uses therapeutic communication by addressing the patient's question and giving

accurate information. The other responses either give inaccurate information or fail to address

the patient's question, which will discourage the patient from asking the nurse for

information.

DIF: Cognitive Level: Apply (application) REF: 636

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

A patient who has a history of a transfusion-related acute lung injury (TRALI) is to receive a

transfusion of packed red blood cells (PRBCs). Which action by the nurse will decrease the

risk for TRALI for this patient?

a. Infuse the PRBCs slowly over 4 hours.

b. Transfuse only leukocyte-reduced PRBCs.

c. Administer the scheduled diuretic before the transfusion.

d. Give the PRN dose of antihistamine before the transfusion.

ANS: B

TRALI is caused by a reaction between the donor and the patient leukocytes that causes

pulmonary inflammation and capillary leaking. The other actions may help prevent respiratory

problems caused by circulatory overload or by allergic reactions, but they will not prevent

TRALI.

DIF: Cognitive Level: Apply (application) REF: 651

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

A patient who has acute myelogenous leukemia (AML) is considering treatment with a

hematopoietic stem cell transplant (HSCT). The best approach for the nurse to assist the

patient with a treatment decision is to

a. discuss the need for insurance to cover post-HSCT care.

b. ask whether there are questions or concerns about HSCT.

c. emphasize the positive outcomes of a bone marrow transplant.

d. explain that a cure is not possible with any treatment except HSCT.

ANS: B

Offering the patient an opportunity to ask questions or discuss concerns about HSCT will

encourage the patient to voice concerns about this treatment and will allow the nurse to assess

whether the patient needs more information about the procedure. Treatment of AML using

chemotherapy is another option for the patient. It is not appropriate for the nurse to ask the

patient to consider insurance needs in making this decision.

DIF: Cognitive Level: Apply (application) REF: 635

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

Which action will the nurse include in the plan of care for a patient admitted with multiple

myeloma?

a. Monitor fluid intake and output.

b. Administer calcium supplements.

c. Assess lymph nodes for enlargement.

d. Limit weight bearing and ambulation.

ANS: A

A high fluid intake and urine output helps prevent the complications of kidney stones caused

by hypercalcemia and renal failure caused by deposition of Bence-Jones protein in the renal

tubules. Weight bearing and ambulation are encouraged to help bone retain calcium. Lymph

nodes are not enlarged with multiple myeloma. Calcium supplements will further increase the

patient's calcium level and are not used.

DIF: Cognitive Level: Apply (application) REF: 646

TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

An appropriate nursing intervention for a patient with non-Hodgkin's lymphoma whose

platelet count drops to 18,000/μL during chemotherapy is to

a. check all stools for occult blood.

b. encourage fluids to 3000 mL/day.

c. provide oral hygiene every 2 hours.

d. check the temperature every 4 hours.

ANS: A

Because the patient is at risk for spontaneous bleeding, the nurse should check stools for

occult blood. A low platelet count does not require an increased fluid intake. Oral hygiene is

important, but it is not necessary to provide oral care every 2 hours. The low platelet count

does not increase risk for infection, so frequent temperature monitoring is not indicated.

DIF: Cognitive Level: Apply (application) REF: 644

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

A patient who has acute myelogenous leukemia develops an absolute neutrophil count of

850/μL while receiving outpatient chemotherapy. Which action by the outpatient clinic nurse

is most appropriate?

a. Discuss the need for hospital admission to treat the neutropenia.

b. Teach the patient to administer filgrastim (Neupogen) injections.

c. Plan to discontinue the chemotherapy until the neutropenia resolves.

d. Order a high-efficiency particulate air (HEPA) filter for the patient's home.

ANS: B

The patient may be taught to self-administer filgrastim injections. Although chemotherapy

may be stopped with severe neutropenia (neutrophil count <500/μL), administration of

filgrastim usually allows the chemotherapy to continue. Patients with neutropenia are at

higher risk for infection when exposed to other patients in the hospital. HEPA filters are

expensive and are used in the hospital, where the number of pathogens is much higher than in

the patient's home environment.

DIF: Cognitive Level: Apply (application) REF: 633

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

Which assessment finding should the nurse caring for a patient with thrombocytopenia

communicate immediately to the health care provider?

a. The platelet count is 52,000/μL.

b. The patient is difficult to arouse.

c. There are purpura on the oral mucosa.

d. There are large bruises on the patient's back.

ANS: B

Difficulty in arousing the patient may indicate a cerebral hemorrhage, which is life threatening

and requires immediate action. The other information should be documented and reported but

would not be unusual in a patient with thrombocytopenia.

DIF: Cognitive Level: Analyze (analysis) REF: 623

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

The nurse is planning to administer a transfusion of packed red blood cells (PRBCs) to a

patient with blood loss from gastrointestinal hemorrhage. Which action can the nurse delegate

to unlicensed assistive personnel (UAP)?

a. Verify the patient identification (ID) according to hospital policy.

b. Obtain the temperature, blood pressure, and pulse before the transfusion.

c. Double-check the product numbers on the PRBCs with the patient ID band.

d. Monitor the patient for shortness of breath or chest pain during the transfusion.

ANS: B

UAP education includes measurement of vital signs. UAP would report the vital signs to the

registered nurse (RN). The other actions require more education and a larger scope of practice

and should be done by licensed nursing staff members.

DIF: Cognitive Level: Apply (application) REF: 632

OBJ: Special Questions: Delegation TOP: Nursing Process: Planning

MSC: NCLEX: Safe and Effective Care Environment

A postoperative patient receiving a transfusion of packed red blood cells develops chills,

fever, headache, and anxiety 35 minutes after the transfusion is started. After stopping the

transfusion, what action should the nurse take?

a. Give the PRN diphenhydramine .

b. Send a urine specimen to the laboratory.

c. Administer PRN acetaminophen (Tylenol).

d. Draw blood for a new type and crossmatch.

ANS: C

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. A urine specimen is needed if an acute hemolytic reaction is suspected.

Diphenhydramine is used for allergic reactions. This type of reaction does not indicate

incorrect crossmatching.

DIF: Cognitive Level: Apply (application) REF: 650

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

A patient in the emergency department complains of back pain and difficulty breathing 15

minutes after a transfusion of packed red blood cells is started. The nurse's first action should

be to

a. administer oxygen therapy at a high flow rate.

b. obtain a urine specimen to send to the laboratory.

c. notify the health care provider about the symptoms.

d. disconnect the transfusion and infuse normal saline.

ANS: D

The patient's symptoms indicate a possible acute hemolytic reaction caused by the

transfusion. The first action should be to disconnect the transfusion and infuse normal saline.

The other actions also are needed but are not the highest priority.

DIF: Cognitive Level: Analyze (analysis) REF: 650

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

Which patient should the nurse assign as the roommate for a patient who has aplastic anemia?

a. A patient with chronic heart failure

b. A patient who has viral pneumonia

c. A patient who has right leg cellulitis

d. A patient with multiple abdominal drains

ANS: A

Patients with aplastic anemia are at risk for infection because of the low white blood cell

production associated with this type of anemia, so the nurse should avoid assigning a

roommate with any possible infectious process.

DIF: Cognitive Level: Apply (application) REF: 614

OBJ: Special Questions: Multiple Patients

TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment

Which patient requires the most rapid assessment and care by the emergency department

nurse?

a. The patient with hemochromatosis who reports abdominal pain

b. The patient with neutropenia who has a temperature of 101.8° F

c. The patient with thrombocytopenia who has oozing gums after a tooth extraction

d. The patient with sickle cell anemia who has had nausea and diarrhea for 24 hours

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.

The other patients also require rapid assessment and care but not as urgently as the

neutropenic patient.

DIF: Cognitive Level: Analyze (analysis) REF: 632

OBJ: Special Questions: Multiple Patients | Special Questions: Prioritization

TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment

A patient with immune thrombocytopenic purpura (ITP) has an order for a platelet

transfusion. Which information indicates that the nurse should consult with the health care

provider before obtaining and administering platelets?

a. Platelet count is 42,000/L.

b. Petechiae are present on the chest.

c. Blood pressure (BP) is 94/56 mm Hg.

d. Blood is oozing from the venipuncture site.

ANS: A

Platelet transfusions are not usually indicated until the platelet count is below 10,000 to

20,000/L unless the patient is actively bleeding. Therefore the nurse should clarify the order

with the health care provider before giving the transfusion. The other data all indicate that

bleeding caused by ITP may be occurring and that the platelet transfusion is appropriate.

DIF: Cognitive Level: Apply (application) REF: 622

TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

Which problem reported by a patient with hemophilia is most important for the nurse to

communicate to the health care provider?

a. Leg bruises c. Skin abrasions

b. Tarry stools d. Bleeding gums

ANS: B

Melena is a sign of gastrointestinal bleeding and requires collaborative actions such as

checking hemoglobin and hematocrit and administration of coagulation factors. The other

problems indicate a need for patient teaching about how to avoid injury but are not indicators

of possible serious blood loss.

DIF: Cognitive Level: Analyze (analysis) REF: 628

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

A patient with septicemia develops prolonged bleeding from venipuncture sites and blood in

the stools. Which action is most important for the nurse to take?

a. Avoid other venipunctures.

b. Apply dressings to the sites.

c. Notify the health care provider.

d. Give prescribed proton-pump inhibitors.

ANS: C

The patient's new onset of bleeding and diagnosis of sepsis suggest that disseminated

intravascular coagulation (DIC) may have developed, which will require collaborative actions

such as diagnostic testing, blood product administration, and heparin administration. The

other actions are also appropriate, but the most important action should be to notify the health

care provider so that DIC treatment can be initiated rapidly.

DIF: Cognitive Level: Analyze (analysis) REF: 629

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

A patient with possible disseminated intravascular coagulation arrives in the emergency

department with a blood pressure of 82/40, temperature of 102° F (38.9° C), and severe back

pain. Which prescribed action will the nurse implement first?

a. Administer morphine sulfate 4 mg IV.

b. Give acetaminophen (Tylenol) 650 mg.

c. Infuse normal saline 500 mL over 30 minutes.

d. Schedule complete blood count and coagulation studies.

ANS: C

The patient's blood pressure indicates hypovolemia caused by blood loss and should be

addressed immediately to improve perfusion to vital organs. The other actions are also

appropriate and should be rapidly implemented, but improving perfusion is the priority for

this patient.

DIF: Cognitive Level: Analyze (analysis) REF: 629

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

Which action for a patient with neutropenia is appropriate for the registered nurse (RN) to

delegate to a licensed practical/vocational nurse (LPN/LVN)?

a. Assessing the patient for signs and symptoms of infection

b. Teaching the patient the purpose of neutropenic precautions

c. Administering subcutaneous filgrastim (Neupogen) injection

d. Developing a discharge teaching plan for the patient and family

ANS: C

Administration of subcutaneous medications is included in LPN/LVN education and scope of

practice. Patient teaching, assessment, and developing the plan of care require RN level

education and scope of practice.

DIF: Cognitive Level: Apply (application) REF: 649

OBJ: Special Questions: Delegation TOP: Nursing Process: Implementation

MSC: NCLEX: Safe and Effective Care Environment

Several patients call the outpatient clinic and ask to make an appointment as soon as possible.

Which patient should the nurse schedule to be seen first?

a. A 44-yr-old with sickle cell anemia who says his eyes always look sort of yellow

b. A 23-yr-old with no previous health problems who has a nontender lump in the

axilla

c. A 50-yr-old with early-stage chronic lymphocytic leukemia who reports chronic

fatigue

d. A 19-yr-old with hemophilia who wants to learn to self-administer factor VII

replacement

ANS: B

The patient's age and presence of a nontender axillary lump suggest possible lymphoma,

which needs rapid diagnosis and treatment. The other patients have questions about treatment

or symptoms that are consistent with their diagnosis but do not need to be seen urgently.

DIF: Cognitive Level: Analyze (analysis) REF: 641

OBJ: Special Questions: Multiple Patients

TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment

After receiving change-of-shift report for several patients with neutropenia, which patient

should the nurse assess first?

a. A 56-yr-old with frequent explosive diarrhea

b. A 33-yr-old with a fever of 100.8° F (38.2° C)

c. A 66-yr-old who has white pharyngeal lesions

d. A 23-yr-old who is complaining of severe fatigue

ANS: B

Any fever in a neutropenic patient indicates infection and can quickly lead to sepsis and septic

shock. Rapid assessment and (if prescribed) initiation of antibiotic therapy within 1 hour are

needed. The other patients also need to be assessed but do not exhibit symptoms of potentially

life-threatening problems.

DIF: Cognitive Level: Analyze (analysis) REF: 632

OBJ: Special Questions: Prioritization | Special Questions: Multiple Patients

TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment

Which action will the nurse include in the plan of care for a patient who has thalassemia

major?

a. Teach the patient to use iron supplements.

b. Avoid the use of intramuscular injections.

c. Administer iron chelation therapy as needed.

d. Notify health care provider of hemoglobin 11 g/dL.

ANS: C

The frequent transfusions used to treat thalassemia major lead to iron toxicity in patients

unless iron chelation therapy is consistently used. Iron supplementation is avoided in patients

with thalassemia. There is no need to avoid intramuscular injections. The goal for patients

with thalassemia major is to maintain a hemoglobin of 10 g/dL or greater.

DIF: Cognitive Level: Apply (application) REF: 611

TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

Which patient information is most important for the nurse to monitor when evaluating the

effectiveness of deferoxamine (Desferal) for a patient with hemochromatosis?

a. Skin color c. Liver function

b. Hematocrit d. Serum iron level

ANS: D

Because iron chelating agents are used to lower serum iron levels, the most useful information

will be the patient's iron level. The other parameters will also be monitored, but are not the

most important to monitor when determining the effectiveness of deferoxamine.

DIF: Cognitive Level: Analyze (analysis) REF: 620

OBJ: Special Questions: Prioritization TOP: Nursing Process: Evaluation

MSC: NCLEX: Physiological Integrity

Which finding about a patient with polycythemia vera is most important for the nurse to

report to the health care provider?

a. Hematocrit 55% c. Calf swelling and pain

b. Presence of plethora d. Platelet count 450,000/L

ANS: C

The calf swelling and pain suggest that the patient may have developed a deep vein

thrombosis, which will require diagnosis and treatment to avoid complications such as

pulmonary embolus. The other findings will also be reported to the health care provider but

are expected in a patient with this diagnosis.

DIF: Cognitive Level: Analyze (analysis) REF: 620

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

Following successful treatment of Hodgkin's lymphoma for a 55-yr-old woman, which topic

will the nurse include in patient teaching?

a. Potential impact of chemotherapy treatment on fertility

b. Application of soothing lotions to treat residual pruritus

c. Use of maintenance chemotherapy to maintain remission

d. Need for follow-up appointments to screen for malignancy

ANS: D

The chemotherapy used in treating Hodgkin's lymphoma results in a high incidence of

secondary malignancies; follow-up screening is needed. The fertility of a 55-yr-old woman

will not be impacted by chemotherapy. Maintenance chemotherapy is not used for Hodgkin's

lymphoma. Pruritus is a clinical manifestation of lymphoma but should not be a concern after

treatment.

DIF: Cognitive Level: Apply (application) REF: 640

TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

A patient who has non-Hodgkin's lymphoma is receiving combination treatment with

rituximab (Rituxan) and chemotherapy. Which patient assessment finding requires the most

rapid action by the nurse?

a. Anorexia c. Oral ulcers

b. Vomiting d. Lip swelling

ANS: D

Lip swelling in angioedema may indicate a hypersensitivity reaction to the rituximab. The

nurse should stop the infusion and further assess for anaphylaxis. The other findings may

occur with chemotherapy but are not immediately life threatening.

DIF: Cognitive Level: Analyze (analysis) REF: 642

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

Which information obtained by the nurse assessing a patient admitted with multiple myeloma

is most important to report to the health care provider?

a. Serum calcium level is 15 mg/dL.

b. Patient reports no stool for 5 days.

c. Urine sample has Bence-Jones protein.

d. Patient is complaining of severe back pain.

ANS: A

Hypercalcemia may lead to complications such as dysrhythmias or seizures, and should be

addressed quickly. The other patient findings will also be discussed with the health care

provider but are not life threatening.

DIF: Cognitive Level: Analyze (analysis) REF: 645

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

When a patient with splenomegaly is scheduled for splenectomy, which action will the nurse

include in the preoperative plan of care?

a. Discourage deep breathing to reduce risk for splenic rupture.

b. Teach the patient to use ibuprofen for left upper quadrant pain.

c. Schedule immunization with the pneumococcal vaccine (e.g., Pneumovax).

d. Avoid the use of acetaminophen (Tylenol) for at least 2 weeks prior to surgery.

ANS: C

Asplenic patients are at high risk for infection with pneumococcal infections and

immunization reduces this risk. There is no need to avoid acetaminophen use before surgery,

but nonsteroidal antiinflammatory drugs (NSAIDs) may increase bleeding risk and should be

avoided. The enlarged spleen may decrease respiratory depth, and the patient should be

encouraged to take deep breaths.

DIF: Cognitive Level: Apply (application) REF: 640

TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

The nurse has obtained the health history, physical assessment data, and laboratory results

shown in the accompanying figure for a patient admitted with aplastic anemia. Which

information is most important to communicate to the health care provider?

History

Fatigue, which has increased over last month

Frequent constipation

Physical Assessment

Conjunctiva pale pink, moist

Multiple bruises

Clear lung sounds

Laboratory Results

Hct 33%

WBC 1500/μL

Platelets 70,000/μL

a. Neutropenia c. Increasing fatigue

b. Constipation d. Thrombocytopenia

a. Neutropenia c. Increasing fatigue

b. Constipation d. Thrombocytopenia

ANS: A

The low white blood cell count indicates that the patient is at high risk for infection and needs

immediate actions to diagnose and treat the cause of the leukopenia. The other information

may require further assessment or treatment but does not place the patient at immediate risk

for complications.

DIF: Cognitive Level: Analyze (analysis) REF: 632

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

A patient is to receive an infusion of 250 mL of platelets over 2 hours through tubing that is

labeled: 1 mL equals 10 drops. How many drops per minute will the nurse infuse?

ANS:

21

To infuse 250 mL over 2 hours, the calculated drip rate is 20.8 drops/min or 21 drops/min.

DIF: Cognitive Level: Apply (application) REF: 649

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity