med surg 2 final exam (test bank)

The nurse is preparing for a home visit to a patient after surgery for a compound fracture. Which specific care does the nurse anticipate for this patient?

Changing wound dressings

A patient experiences a fracture of the lower leg and undergoes a closed reduction and placement of a fiberglass cast. The patient is 65 years old and has a medical 30-year history of diabetes mellitus. Which condition does the nurse recognize as a possible complication for this patient?

Delay or absence of healing

An older adult patient is postoperative for a total hip joint replacement. Which nursing care is inappropriate for this patient on the day of surgery?

Medicated with oral pain medications

The nurse is providing care for a patient who is scheduled for joint replacement the next day. Which patient care goals are appropriate at this time?

Manage preoperative pain.

The nurse is providing care for a patient following an open reduction of a compound fracture. Which neurologic finding does the nurse report immediately to the HCP or registered nurse (RN)?

There exists numbness and tingling sensations

A patient with gout has been instructed on the prescribed medication allopurinol (Zyloprim). Which patient statement indicates understanding of the action of this medication?

"It blocks formation of uric acid."

The nurse is contributing to the plan of care for a patient who has an upper extremity amputation. Which factor does the nurse keep in mind about this type of amputation being more debilitating than a lower extremity amputation?

The upper extremity is more specialized.

A patient who has a displaced midshaft fracture of the left femur is in balanced suspension skeletal traction with 35 pounds of weight. The patient reports calf pain with right foot dorsiflexion. Which action does the nurse take?

Notify the RN.

The home-care nurse is attending to a patient with osteomyelitis in a lower extremity from a traumatic bone fracture. The patient has an open wound that is infected. Which observation prompts the nurse to provide additional information to the patient and family?

Clean technique is used when the dressing is changed.

The nurse is providing care for a patient being treated after a complicated femur fracture. The nurse has noticed drowsiness, tachycardia, and a low-grade fever. Which additional manifestation alerts the nurse to the possibility of a fat emboli?

Presence of a petechial rash on chest and neck

The nurse is assisting with the preparation of materials for a health fair aimed at promoting health in women. Which reason does the nurse recognize as a probable cause of an increase in the incidence of osteoporosis?

The ages of adults have increased.

The nurse is providing care for a patient who experienced a closed reduction to a fracture of the ulna. Which manifestation does the nurse recognize as an early symptom of acute compartment syndrome?

Pallor with extremity warmth

The nurse is providing care for a patient after an above-the-knee amputation because of ischemia related to diabetes mellitus complications. Which nursing care is essential for promoting ambulation?

Lying on the abdomen as prescribed

A patient is being prepared for a prosthesis following surgery for an amputation. Which information will the nurse provide to the client regarding the use of a prosthesis?

Skin inspection is performed each time the sock is removed.

The nurse is providing care for a patient with external fixation for a fracture involving severe bone damage. Which is the most important focus for the nurse during care of this patient?

Monitoring pin and wound sites for signs of infection

The nurse is assisting with the care of a patient with rheumatoid arthritis (RA). The nurse must remember in which way RA care is different from osteoarthritis care. Which nursing care does the nurse specifically provide for the patient with RA?

It is essential to monitor all body systems for effects of the disease.

The nurse is assisting with patients on an orthopedic unit. Which is an important factor to remember when caring for patients after a total hip replacement?

A triangular pillow is used between the legs to avoid adduction.

The nurse is assisting with the care of patients who have had joint replacement surgery. Which action is unnecessary for the patient after a total knee replacement (TKR)?

Maintain proper joint alignment.

A patient asks the difference between osteoarthritis and RA. Which manifestations does the nurse explain are characteristic of RA? (Select all that apply.)

Early morning stiffness

Autoimmune disease

Low-grade fever

The nurse is collecting data from a patient suspected of developing a fat embolus from a fracture of the right femur. Which manifestations does the nurse expect? (Select all that

apply.)

Tachycardia

Mental confusion

Petechiae

The patient asks the nurse how much blood is in the body. Which response by the nurse is accurate?

4-6 liters

The nurse is reviewing laboratory values for a patient with thrombocytopenia. Which result would concern the nurse the most?

Platelets 50,000/mm3

The nurse is taking a health history and notes the patient has a history of a splenectomy. For which condition is this patient at risk?

Meningitis

The nurse is caring for a patient who reports feeling several enlarged lymph nodes. The nurse should plan to prepare the patient for which test?

A complete blood count (CBC)

The nurse is reviewing laboratory values for a female patient and notes a hemoglobin level

of 8.2 g/100 mL and a hematocrit level of 21%. These levels are found in patients with

which condition?

Anemia

A patient has a bone marrow aspiration from the posterior iliac crest. Before the procedure, the patient's vital signs were blood pressure 132/82 mm Hg and pulse 88 beats/min. One hour after the procedure, the blood pressure is 108/70 mm Hg and pulse is 96 beats/min. Which assessment is the least important for the patient at this time?

Check the patient's most recent CBC report.

The nurse is caring for a group of patients. Which patient should the nurse see first?

A patient with an RBC count of 2.4 million/mm3

A patient is prescribed to receive two units of packed red blood cells (PRBCs). What approach should the nurse use to ensure that the correct blood will be provided to this patient?

Follow the organization's verification process.

A patient is being prepared to receive a prescribed blood transfusion. What is the best way that the licensed practical nurse (LPN) can assist the health team to prevent a transfusion reaction?

Assist the registered nurse (RN) to correctly identify the patient and the blood product.

The nurse is caring for a patient who underwent a bone marrow biopsy. What is the role of the licensed practical nurse/licensed vocational nurse (LPN/LVN) in this patient's care?

Monitor the site for bleeding and infection.

A patient who underwent lymphangiography the day before asks the LPN, "Why does my urine look blue?" What should the LPN respond to this patient's concern?

The dye used in the procedure may cause bluish skin and urine for 2 days."

The nurse is caring for a patient with folic acid deficiency anemia. Which patient is at risk for this condition?

A patient who drinks alcohol daily

The nurse is preparing a patient for a blood transfusion. The patient has type O blood. Which blood type can this patient receive?

Type O

The nurse is caring for a patient with a clotting disorder. Which should the nurse plan to administer?

Fresh frozen plasma (FFP)

While receiving a unit of PRBCs, the patient begins to experience hives around the neck and upper chest. What actions should the nurse perform because of this reaction? (Select all that apply.)

Stop the transfusion.

Notify the HCP.

Administer prescribed antihistamines.

Restart the infusion and carefully monitor

The nurse is caring for a patient with anemia. Which clinical manifestations can the nurse expect to document? (Select all that apply.)

Pallor

Elevated respiratory rate

Clubbed fingers

The nurse is providing education to a patient newly diagnosed with iron deficiency anemia. Which of the following would be a component of the education?

Include citrus fruits while taking the medication for this disorder

The nurse is assisting in the development of a care plan for a patient with pernicious anemia. Which of the following would be the most common nursing diagnosis with this medical condition?

Activity intolerance related to tissue hypoxia

The nurse is providing care to the patient with thrombocytopenia. Which of the following activities should the patient avoid?

Receiving an influenza vaccination

The nurse is caring for a patient in sickle cell crisis. What is the rationale for providing warm compresses and blankets for this patient?

Heat increases circulation by preventing vasoconstriction.

The nurse is preparing to provide therapeutic treatment to the patient with an exacerbation of polycythemia vera (PV). Which of the following is the expected treatment for this patient?

Therapeutic phlebotomy

The nurse is providing care to a patient with a hematological disorder. Which of the following would be a manifestation of disseminated intravascular coagulation (DIC)?

Absent peripheral pulses

. The nurse is caring for a patient with thrombocytopenia. Which of the following products would the nurse anticipate being prescribed?

Cryoprecipitate

The nurse is triaging several patients in an urgent care center. One patient states that he has hemophilia and is bleeding, with no apparent signs of bleeding. Which action by the nurse is most appropriate at this time?

Place the patient in an examination room immediately and notify the physician of a potential bleeding crisis.

The nurse caring for a patient with chronic leukemia in an acute care setting. The patient asks the nurse to observe the patient's last bowel movement as it is very dark. The nurse immediately contacts the primary health care provider (HCP). What would explain the nurse's action?

The patient may have a gastrointestinal bleed.

The home care nurse is providing teaching to the family of a patient with multiple myeloma. Which nursing diagnosis should guide the nurse for this teaching?

Risk for injury related to compromised bone integrity

The nurse is assisting the patient with multiple myeloma in arranging a meal plan to lower the risk of complications from hypercalcemia. Which of the following would be the most important component of the patient's intake?

The patient should increase intake of fluids.

The nurse is providing care to the patient with Hodgkin disease who has cervical lymph node enlargement. Which of the following symptoms should the nurse attend to first?

Stridor

The nurse is caring for a patient with stage IV Hodgkin disease. Where should the nurse expect to find enlarged lymph nodes during the assessment?

Generalized throughout the body within multiple organs

The nurse is caring for the patient with iron deficiency anemia, who has been taking oral iron supplements. Which of the following laboratory tests would determine the effectiveness of this intervention?

Hemoglobin and hematocrit

The nurse is caring for the patient with pernicious anemia. The patient asks why this happened when she has regularly taken iron supplements while following a strict vegetarian diet. Which of the following would be the nurse's most appropriate response?

"Increase dairy products such as yogurt to increase your intake of vitamin B12."

The nurse is caring for a patient receiving treatment for a hemolytic anemia due to a reaction from a mismatched blood transfusion. The nurse understands that hemolytic anemia is a definition of what type of anemia?

Destruction of RBCs

The nurse is caring for a patient with iron deficiency anemia, which of the following would be the most appropriate nursing intervention for this patient?

Instruct the patient to notify the HCP of nausea or constipation

The nurse is providing care to the patient with suspected aplastic anemia. The HCP has completed a bone marrow biopsy. Which of the following would be a description of the bone marrow that would signify a positive diagnosis of aplastic anemia?

The bone marrow is pale, fatty, and fibrous.

The nurse is caring for the patient with hemoglobin less than 6 g/dL. Which of the following clinical manifestations would the nurse expect the patient to present?

Orthopnea, blurred vision, and pruritus

The nurse is following the care plan risk for ineffective peripheral perfusion related to sickled cells and infarction. Which of the following would be the most appropriate intervention?

Avoid restrictive clothing and raising the knee gatch in the bed.

The nurse is caring for a patient with chronic episodes of hypoxia secondary to chronic obstructive pulmonary disease. The nurse will monitor the patient's laboratory results for increased RBCs due to the low oxygen levels. Which of the following blood disorders will the nurse expect to find?

Aplastic anemia

The nurse is caring for the patient who recently underwent a colectomy due to a bowel perforation and peritonitis. The nurse is preparing to administer the anticoagulant heparin to prevent which of the following blood disorders?

DIC

The nurse is caring for a patient who has CLL when the patient suddenly develops petechiae, nausea, and severe back pain. The nurse recognizes this life-threatening event as which of the following?

DIC

The nurse is caring for the patient who underwent emergency treatment for DIC. The patient voices concern over how to explain the tubes and extensive bruising to his family members. Which of the following would be an appropriate nursing intervention for disturbed body image related to physical evidence of aggressive treatment procedures?

Enlist the aid of other members of the health care team to support the family.

The nurse is caring for a patient who must undergo a splenectomy for treatment for idiopathic thrombocytopenic purpura (ITP).Which of the following statements best describes the rationale for the splenectomy?

The spleen is the primary site for platelet destruction.

The nurse is providing education to a patient with mild hemophilia on how to avoid bleeding episodes. Which one of the following would be most appropriate to include in the teaching plan?

Administer desmopressin intranasally prior to any dental procedure or sports.

The nurse is assisting in developing a plan of care for the patient with hemophilia who is experiencing severe acute pain. Which of the following would be the most appropriate intervention based on the nursing diagnosis acute pain related to bleeding into tissues?

Administer opioids as prescribed, avoiding IM injections.

The nurse is assessing the patient recently diagnosed with chronic myelogenous leukemia (CML). What of the following indicates a positive diagnosis for CML?

Genetic analysis of bone marrow reveals Philadelphia chromosome.

The nurse is providing education to the patient with the nursing diagnosis of impaired oral membrane integrity related to chemotherapy and pancytopenia. The nurse is aware that the patient understands the teaching by which of the following actions?

The patient keeps her dentures in at all times except for cleaning.

The nurse is caring for the patient who is 1 day status postsplenectomy. The patient complains of pain with breathing especially with inspiration. What would be the most appropriate nursing intervention for this patient?

Medicate with opioids for pain and assist the patient to deep breathe, cough, and ambulate.

The nurse is caring for a patient with a folic acid deficiency. What foods should the nurse encourage the patient to improve this deficiency? (Select all that apply.)

Split pea soup with whole grain crackers

Garden salad with green leafy vegetables

Cereals made with fortified grain and wheat germ

The nurse is assessing a patient in a family practice clinic. The patient had extensive testing to rule out Hodgkin disease. Which of the following characteristics would indicate Hodgkin disease? (Select all that apply.)

The laboratory results show presence of Reed-Sternberg cells.

The patient has painless swelling of the cervical and axillary nodes.

The nurse is caring for a patient who has been recently diagnosed with aplastic anemia. Which of the following are indicators of this disease process? (Select all that apply.)

Bone marrow that is pale, fatty, and fibrous

A CBC with all low values

Increased total iron-binding capacity (TIBC)

The nurse is caring for a patient with a platelet count of <20,000/mm3 . Which of the following precautions should the nurse take in providing care for this patient? (Select all that apply.)

Monitor for black tarry stools.

Avoid blood draws when possible.

Use soft toothbrush to clean the teeth.

The nurse is providing care to the patient who has arrived at the clinic to discuss his diagnostic results. The HCP suspects multiple myeloma. Which of the following results may confirm the HCP's suspicions? (Select all that apply.)

Magnetic resonance imaging (MRI) shows diffuse osteoporosis in the bones.

Blood chemistries reveal an increase in serum calcium.

Blood and urine studies are positive for M-type globulins.

The nurse is collecting data for a patient with osteoporosis. Which serum calcium result indicates the typical changes that occur in serum calcium levels with osteoporosis?

6.5 mg/dL

The nurse is collecting data on a patient with manifestations of osteoarthritis. Which method of physical examination is unnecessary?

Auscultating for joint deformity

The nurse is preparing material for a presentation about the musculoskeletal system. Which information is inaccurate in regard to the functioning of this system?

Joint articulations are maintained by moisture from the lymph system.

The nurse is helping a patient understand all of the functions of the skeleton. Which function is incorrect?

It is the main system responsible for body movement.

The nurse is caring for a patient with a suspected bone tumor. Which serum laboratory result indicates to the nurse that this health problem is present?

Elevated alkaline phosphatase (ALP)

The nurse is collecting data on an older adult patient. Which finding is indicative of normal changes in the musculoskeletal system of this patient?

Presence of pain in knees joints in the morning

The nurse is collecting data on a patient who is experiencing hip pain. Which data does the nurse consider to be subjective?

A pain level of 7 on a 0-to-10 scale

The nurse is providing care for a patient scheduled for an arthrography. Which explanation about pain during the procedure does the nurse provide?

"There is temporary pain during dye injection."

A patient diagnosed with curvature of the spine asks the nurse why breathing is so much more difficult. Which answer by the nurse best answers the question?

"The thoracic cage has lost some flexibility."

The nurse is providing care for a patient who is diagnosed with rhabdomyolysis from a crushing injury. Laboratory results indicate elevated levels of CK, myoglobin, and serum potassium. Which nursing care is most important for the nurse implement?

Observe the color and amount of urine.

A patient arrives at a clinic with a knee joint that is noticeably swollen, warm to the touch, and painful. The HCP plans to perform an arthrocentesis. Given the patient's symptoms, which is the least likely reason for the procedure?

To mechanically inhibit the production of synovial fluid

The nurse is reviewing the laboratory results for a patient with severe bone pain. Which condition does the nurse suspect if the ALP level is elevated?

Bone cancer

A patient is scheduled for arthroscopic surgery on a knee. The patient is to receive light general anesthesia and will be discharged home. Which action will cause the nurse to contact the HCP or registered nurse (RN)?

A pain level of 8 on a 0-to-10 scale after mild analgesia

The nurse is providing care for a patient before a myelography for diagnosis of a spinal column condition. Which statement regarding nursing care related to this procedure is correct?

"You will be head down in bed so the medium flows to the neck."

A patient is receiving care for a torn ligament at the insertion site of an upper arm muscle. The patient asks the nurse how this condition will affect movement. Which information will the nurse correctly share?

The movement of the arm will seem normal.

A female patient arrives at the HCP's office for a routine checkup. The nurse notes that the patient is thin, of Asian descent, and experienced a surgery-induced menopause. Which test does the nurse expect the HCP to prescribe?

A dual-energy x-ray absorptiometry (DEXA)

A patient is prepared for a nuclear medicine scan of the skeleton, using gallium and thallium as the radioisotopes. Which nursing care will the nurse provide if the scan reveals high thallium concentrations?

Extend a willingness to sit and talk with the patient.

A patient just had an arthrogram performed for pain in a synovial joint. Which nursing care is inappropriate following this procedure?

Elevate the limb that was tested.

A patient is recovering from a biopsy of the right femur and was given pain medication 1 hour ago. Which symptom does the nurse report and closely monitor in this patient? (Select all that apply.)

Hematoma formation

Pain reported as 7 on a 0-to-10 scale

A patient was an unrestrained passenger in a motor vehicle accident and hit the windshield. In addition, the patient's leg was fractured. Which areas should be included in this patient's neurovascular checks? (Select all that apply.)

Pulses

Sensation

Movement