1.  A client’s nursing diagnosis is Deficient Fluid Volume related to excessive fluid loss. Which action related to the fluid management should be delegated to a nursing assistant?  

a. Administer IV fluids as prescribed by the physician.  b. Provide straws and offer fluids between meals.  c. Develop plan for added fluid intake over 24 hours  d. Teach family members to assist client with fluid intake   2. The client also has the nursing diagnosis Decreased Cardiac Output related to decrease plasma volume. Which finding on assessment supports this nursing diagnosis? a. Flattened neck veins when client is in supine position  b. Full and bounding pedal and post-tibial pulses  c. Pitting edema located in feet, ankles, and calves  d. Shallow respirations with crackles on auscultation  

3. The nursing care plan for the client with dehydration includes interventions for oral health. Which interventions are within the scope of practice for the LPN/LVN being supervised by the nurse? (Choose all that apply.)  a. Remind client to avoid commercial mouthwashes.  b. Encourage mouth rinsing with warm saline.  c. Assess lips, tongue, and mucous membranes  d. Provide mouth care every 2 hours while client is awake  e. Seek dietary consult to increase fluids on meal trays.   4. The physician has written the following orders for the client with Excess Fluid volume. The client’s morning assessment includes bounding peripheral pulses, weight gain of 2 pounds, pitting ankle edema, and moist crackles bilaterally. Which order takes priority at this time?  a. Weight client every morning.  b. Maintain accurate intake and output.  c. Restrict fluid to 1500 mL per day  d. Administer furosemide (Lasix) 40 mg IV push   5. You have been pulled to the telemetry unit for the day. The monitor informs you that the client has developed prominent U waves. Which laboratory value should you check immediately?  a. Sodium  b. Potassium  c. Magnesium  d. Calcium  

6. The client’s potassium level is 6.7 mEq/L. Which intervention should you delegate to the student nurse under your supervision?  a. Administer Kayexalate 15 g orally  b. Administer spironolactone 25 mg orally  c. Assess WCG strip for tall T waves  d. Administer potassium 10 mEq orally  

7. A client is admitted to the unit with a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH). For which electrolyte abnormality will you be sure to monitor?  a. Hypokalemia  b. Hyperkalemia  c. Hyponatremia  d. Hypernatremia  

8. The charge nurse assigned in the care for a client with acute renal failure and hypernatremia to you, a newly graduated RN. Which actions can you delegate to the nursing assistant?  a. Provide oral care every 3-4 hours  b. Monitor for indications of dehydration  c. Administer 0.45% saline by IV line  d. Assess daily weights for trends   9. The experienced LPN/LVN reports that a client’s blood pressure and heart rate have decreased and that when the face is assessed, one side twitches. What action should you take at this time?  a. Reassess the client’s blood pressure and heart rate  b. Review the client’s morning calcium level  c. Request a neurologic consult today  d. Check the client’s papillary reaction to light   

10.You are preparing to discharge a client whose calcium level was low but is now just slightly within the normal range (9-10.5 mg/dL). Which statement by the client indicates the need for additional teaching?  a. “I will call my doctor if I experience muscle twitching or seizures.”  b. “I will make sure to take my vitamin D with my calcium each day.”  c. “I will take my calcium pill every morning before breakfast.”  d. “I will avoid dairy products, broccoli, and spinach when I eat.”   11.A nursing assistant asks why the client with a chronically low phosphorus level needs so much assistance with activities of daily living. What is your best response?  a. “The client’s low phosphorus is probably due to malnutrition.”  b. “The client is just worn out form not getting enough rest.”  c. “The client’s skeletal muscles are weak because of the low phosphorus.”  d. “The client will do more for herself when her phosphorus is normal”   12.You are reviewing a client’s morning laboratory results. Which of these results is of most concern?  a. Serum potassium 5.2 mEq/L  b. Serum sodium 134 mEq/L  c. Serum calcium 10.6 mg/dL  d. Serum magnesium 0.8 mEq/L   

13. You are the charge nurse. Which client is most appropriate to assign to the step-down unit nurse pulled to the intensive care unit for the day?  a. A 68-year-old client on ventilator with acute respiratory failure and respiratory acidosis  b. A 72-year-old client with COPD and normal arterial blood gases (ABGs) who is ventilator-dependent  c. A 56-year-old new admission client with diabetic ketoacidosis (DKA) on a n insulin drip  d. A 38-year-old client on a ventilator with narcotic overdose and respiratory alkalosis  

14.A client with respiratory failure is receiving mechanical ventilation and continues to produce ABG results indicating respiratory acidosis. Which action should you expect to correct this problem?  a. Increase the ventilator rate from 6 to 10 per minute  b. Decrease the ventilator rate from 10 to 6 per minute  c. Increase the oxygen concentration fro 30% to 40%  d. Decrease the oxygen concentration fro 40% to 30%  

15.Which action should you delegate to the nursing assistant for the client with diabetic ketoacidosis? (Choose all that apply.)  a. Check fingerstick glucose every hour.  b. Record intake and output every hour.  c. Check vital signs every 15 minutes.  d. Assess for indicators of fluid imbalance.   16.You are admitting an elderly client to the medical unit. Which factor indicates that this client has a risk for acid-base imbalances?  a. Myocardial infarction 1 year ago  b. Occasional use of antacids  c. Shortness of breath with extreme exertion  d. Chronic renal insufficiency   17.A client with lung cancer has received oxycodone 10 mg orally for pain. When the student nurse assesses the client, which finding should you instruct the student to report immediately?  a. Respiratory rate of 8 to 10 per minute  b. Pain level decreased from 6/10 to 2/10  c. Client requests room door be closed.  d. Heart rate 90-100 per minute   18.The nursing assistant reports to you that a client seems very anxious and that vital signs included a respiratory rate of 38 per minute. Which acid-base imbalance should you suspect?  a. Respiratory acidosis  b. Respiratory alkalosis  c. Metabolic acidosis  d. Metabolic alkalosis   19.A client is admitted to the unit for chemotherapy. To prevent an acid-base problem, which of the following would you instruct the nursing assistant to report?  a. Repeated episodes of nausea and vomiting  b. Complaints of pain associated with exertion  c. Failure to eat all food on breakfast tray  d. Client hair loss during morning bath   20.A client has a nasogastric tube connected to intermittent wall suction. The student nurse asks why the client’s respiratory rate has increased. What your best response?  a. “It’s common for clients with uncomfortable procedures such as nasogastric tubes to have a higher rate to breathing.”  b. “The client may have a metabolic alkalosis due to the NG suctioning and the increased respiratory rate is a compensatory mechanism.”  c. “Whenever a client develops a respiratory acid-base problem, increasing the respiratory rate

helps correct the problem.”  d. “The client is hyperventilating because of anxiety and we will have to stay alert for development of a respiratory acidosis.” 

1. A female client is admitted with a diagnosis of acute renal failure. She is awake, alert, oriented, and complaining of severe back pain, nausea and vomiting and abdominal cramps. Her vital signs are blood pressure 100/70 mm Hg, pulse 110, respirations 30, and oral temperature 100.4°F (38°C). Her electrolytes are sodium 120 mEq/L, potassium 5.2 mEq/L; her urinary output for the first 8 hours is 50 ml. The client is displaying signs of which electrolyte imbalance? 

A. Hyponatremia B. Hyperkalemia C. Hyperphosphatemia D. Hypercalcemia 

2. Assessing the laboratory findings, which result would the nurse most likely expect to find in a client with chronic renal failure? 

A. BUN 10 to 30 mg/dl, potassium 4.0 mEq/L, creatinine 0.5 to 1.5 mg/dl B. Decreased serum calcium, blood pH 7.2, potassium 6.5 mEq/L C. BUN 15 mg/dl, increased serum calcium, creatinine l.0 mg/dl D. BUN 35 to 40 mg/dl, potassium 3.5 mEq/L, pH 7.35, decreased serum calcium 

3. Treatment with hemodialysis is ordered for a client and an external shunt is created. Which nursing action would be of highest priority with regard to the external shunt? 

A. Heparinize it daily. B. Avoid taking blood pressure measurements or blood samples from the affected arm. C. Change the Silastic tube daily. D. Instruct the client not to use the affected arm. 

4. Romeo Diaz, age 78, is admitted to the hospital with the diagnosis of benign prostatic hyperplasia (BPH). He is scheduled for a transurethral resection of the prostate (TURP). It would be inappropriate to include which of the following points in the preoperative teaching? 

A. TURP is the most common operation for BPH. B. Explain the purpose and function of a two-way irrigation system. C. Expect bloody urine, which will clear as healing takes place. D. He will be pain free. 

5. Roxy is admitted to the hospital with a possible diagnosis of appendicitis. On physical examination, the nurse should be looking for tenderness on palpation at McBurney’s point, which is located in the 

A. left lower quadrant B. left upper quadrant C. right lower quadrant D. right upper quadrant 

6. Mr. Valdez has undergone surgical repair of his inguinal hernia. Discharge teaching should include 

A. telling him to avoid heavy lifting for 4 to 6 weeks B. instructing him to have a soft bland diet for two weeks C. telling him to resume his previous daily activities without limitations D. recommending him to drink eight glasses of water daily 

7. A 30-year-old homemaker fell asleep while smoking a cigarette. She sustained severe burns of the face,neck, anterior chest, and both arms and hands. Using the rule of nines, which is the best estimate of total body-surface area burned? 

A. 18% B. 22% C. 31% D. 40% 

8. Nursing care planning is based on the knowledge that the first 24-48 hours post-burn are characterized by: 

A. An increase in the total volume of intracranial plasma B. Excessive renal perfusion with diuresis C. Fluid shift from interstitial space D. Fluid shift from intravascular space to the interstitial space 

9. If a client has severe bums on the upper torso, which item would be a primary concern? 

A. Debriding and covering the wounds B. Administering antibiotics C. Frequently observing for hoarseness, stridor, and dyspnea D. Establishing a patent IV line for fluid replacement 

10. Contractures are among the most serious long-term complications of severe burns. If a burn is located on the upper torso, which nursing measure would be least effective to help prevent contractures? 

A. Changing the location of the bed or the TV set, or both, daily B. Encouraging the client to chew gum and blow up balloons C. Avoiding the use of a pillow for sleep, or placing the head in a position of hyperextension D. Helping the client to rest in the position of maximal comfort 

11. An adult is receiving Total Parenteral Nutrition (TPN). Which of the following assessment is essential? 

A. evaluation of the peripheral IV site B. confirmation that the tube is in the stomach C. assess the bowel sound D. fluid and electrolyte monitoring 

12. Which drug would be least effective in lowering a client’s serum potassium level? 

A. Glucose and insulin B. Polystyrene sulfonate (Kayexalate) C. Calcium glucomite D. Aluminum hydroxide 

13. A nurse is directed to administer a hypotonic intravenous solution. Looking at the following labeled solutions, she should choose 

A. 0.45% NaCl B. 0.9% NaCl C. D5W D. D5NSS 

14. A patient is hemorrhaging from multiple trauma sites. The nurse expects that compensatory mechanisms associated with hypovolemia would cause all of the following symptoms EXCEPT 

A. hypertension B. oliguria C. tachycardia D. tachypnea 

15. Maria Sison, 40 years old, single, was admitted to the hospital with a diagnosis of Breast Cancer. She was scheduled for radical mastectomy. Nursing care during the preoperative period should consist of 

A. assuring Maria that she will be cured of cancer B. assessing Maria’s expectations and doubts C. maintaining a cheerful and optimistic environment D. keeping Maria’s visitors to a minimum so she can have time for herself 

16. Maria refuses to acknowledge that her breast was removed. She believes that her breast is intact under the dressing. The nurse should 

A. call the MD to change the dressing so Kathy can see the incision B. recognize that Kathy is experiencing denial, a normal stage of the grieving process C. reinforce Kathy’s belief for several days until her body can adjust to stress of surgery. D. remind Kathy that she needs to accept her diagnosis so that she can begin rehabilitation exercises. 

17. A chemotherapeutic agent 5FU is ordered as an adjunct measure to surgery. Which of the ff. statements about chemotherapy is true? 

A. it is a local treatment affecting only tumor cells B. it affects both normal and tumor cells C. it has been proven as a complete cure for cancer D. it is often used as a palliative measure. 

18. Which is an incorrect statement pertaining to the following procedures for cancer diagnostics? 

A. Biopsy is the removal of suspicious tissue and the only definitive method to diagnose cancer B. Ultrasonography detects tissue density changes difficult to observe by X-ray via sound waves. C. CT scanning uses magnetic fields and radio frequencies to provide cross-sectional view of tumor D. Endoscopy provides direct view of a body cavity to detect abnormality. 

19. A post-operative complication of mastectomy is lymphedema. This can be prevented by 

A. ensuring patency of wound drainage tube B. placing the arm on the affected side in a dependent position C. restricting movement of the affected arm D. frequently elevating the arm of the affected side above the level of the heart. 

20. Which statement by the client indicates to the nurse that the patient understands precautions necessary during internal radiation therapy for cancer of the cervix? 

A. “I should get out of bed and walk around in my room.” B. “My 7 year old twins should not come to visit me while I’m receiving treatment.” C. “I will try not to cough, because the force might make me expel the application.” D. “I know that my primary nurse has to wear one of those badges like the people in the x-ray department, but they are not necessary for anyone else who comes in here.” 

21. High uric acid levels may develop in clients who are receiving chemotherapy. This is caused by: 

A. The inability of the kidneys to excrete the drug metabolites B. Rapid cell catabolism C. Toxic effect of the antibiotic that are given concurrently D. The altered blood ph from the acid medium of the drugs 

22. Which of the following interventions would be included in the care of plan in a client with cervical implant? 

A. Frequent ambulation B. Unlimited visitors C. Low residue diet D. Vaginal irrigation every shift 

23. Which nursing measure would avoid constriction on the affected arm immediately after mastectomy? 

A. Avoid BP measurement and constricting clothing on the affected arm B. Active range of motion exercises of the arms once a day. C. Discourage feeding, washing or combing with the affected arm D. Place the affected arm in a dependent position, below the level of the heart 

24. A client suffering from acute renal failure has an unexpected increase in urinary output to 150ml/hr. The nurse assesses that the client has entered the second phase of acute renal failure. Nursing actions throughout this phase include observation for signs and symptoms of 

A. Hypervolemia, hypokalemia, and hypernatremia. B. Hypervolemia, hyperkalemia, and hypernatremia. C. Hypovolemia, wide fluctuations in serum sodium and potassium levels. D. Hypovolemia, no fluctuation in serum sodium and potassium levels. 

25. An adult has just been brought in by ambulance after a motor vehicle accident. When assessing the client, the nurse would expect which of the following manifestations could have resulted from sympathetic nervous system stimulation? 

A. A rapid pulse and increased RR B. Decreased physiologic functioning C. Rigid posture and altered perceptual focus D. Increased awareness and attention 

26. Ms. Sy undergoes surgery and the abdominal aortic aneurysm is resected and replaced with a graft. When she arrives in the RR she is still in shock. The nurse’s priority should be :

A. placing her in a trendeleburg position B. putting several warm blankets on her C. monitoring her hourly urine output D. assessing her VS especially her RR 

27. A major goal for the client during the first 48 hours after a severe bum is to prevent hypovolemic shock. The best indicator of adequate fluid balance during this period is 

A. Elevated hematocrit levels. B. Urine output of 30 to 50 ml/hr. C. Change in level of consciousness. D. Estimate of fluid loss through the burn eschar. 

28. A thoracentesis is performed on a chest-injured client, and no fluid or air is found. Blood and fluids is administered intravenously (IV), but the client’s vital signs do not improve. A central venous pressure line is inserted, and the initial reading is 20 cm H^O. The most likely cause of these findings is which of the following? 

A. Spontaneous pneumothorax B. Ruptured diaphragm C. Hemothorax D. Pericardial tamponade 

29. Intervention for a pt. who has swallowed a Muriatic Acid includes all of the following except; 

A. administering an irritant that will stimulate vomiting B. aspirating secretions from the pharynx if respirations are affected C. neutralizing the chemical D. washing the esophagus with large volumes of water via gastric lavage 

30. Which initial nursing assessment finding would best indicate that a client has been successfully resuscitated after a cardio-respiratory arrest? 

A. Skin warm and dry B. Pupils equal and react to light C. Palpable carotid pulse D. Positive Babinski’s reflex 

31. Chemical burn of the eye are treated with 

A. local anesthetics and antibacterial drops for 24 – 36 hrs. B. hot compresses applied at 15-minute intervals C. Flushing of the lids, conjunctiva and cornea with tap or preferably sterile water D. cleansing the conjunctiva with a small cotton-tipped applicator 

32. The Heimlich maneuver (abdominal thrust), for acute airway obstruction, attempts to: 

A. Force air out of the lungs B. Increase systemic circulation C. Induce emptying of the stomach D. Put pressure on the apex of the heart 

33. John, 16 years old, is brought to the ER after a vehicular accident. He is pronounced dead on arrival. When his parents arrive at the hospital, the nurse should: 

A. ask them to stay in the waiting area until she can spend time alone with them B. speak to both parents together and encourage them to support each other and express their emotions freely C. Speak to one parent at a time so that each can ventilate feelings of loss without upsetting the other D. ask the MD to medicate the parents so they can stay calm to deal with their son’s death. 

34. An emergency treatment for an acute asthmatic attack is Adrenaline 1:1000 given hypodermically. This is given to: 

A. increase BP B. decrease mucosal swelling C. relax the bronchial smooth muscle D. decrease bronchial secretions 

35. A nurse is performing CPR on an adult patient. When performing chest compressions, the nurse understands the correct hand placement is located over the 

A. upper half of the sternum B. upper third of the sternum C. lower half of the sternum D. lower third of the sternum 

36. The nurse is performing an eye examination on an elderly client. The client states ‘My vision is blurred, and I don’t easily see clearly when I get into a dark room.” The nurse best response is: 

A. “You should be grateful you are not blind.” B. “As one ages, visual changes are noted as part of degenerative changes. This is normal.” C. “You should rest your eyes frequently.” D. “You maybe able to improve you vision if you move slowly.” 

37. Which of the following activities is not encouraged in a patient after an eye surgery? 

A. sneezing, coughing and blowing the nose B. straining to have a bowel movement C. wearing tight shirt collars D. sexual intercourse 

38. Which of the following indicates poor practice in communicating with a hearing-impaired client? 

A. Use appropriate hand motions B. Keep hands and other objects away from your mouth when talking to the client C. Speak clearly in a loud voice or shout to be heard D. Converse in a quiet room with minimal distractions 

39. A client is to undergo lumbar puncture. Which is least important information about LP? 

A. Specimens obtained should be labeled in their proper sequence. B. It may be used to inject air, dye or drugs into the spinal canal. C. Assess movements and sensation in the lower extremities after the D. Force fluids before and after the procedure. 

40. A client diagnosed with cerebral thrombosis is scheduled for cerebral angiography. Nursing care of the client includes the following EXCEPT 

A. Inform the client that a warm, flushed feeling and a salty taste may be B. Maintain pressure dressing over the site of puncture and check for C. Check pulse, color and temperature of the extremity distal to the site of D. Kept the extremity used as puncture site flexed to prevent bleeding. 

41. Which is considered as the earliest sign of increased ICP that the nurse should closely observed for? A. abnormal respiratory pattern B. rising systolic and widening pulse pressure C. contralateral hemiparesis and ipsilateral dilation of the pupils D. progression from restlessness to confusion and disorientation to lethargy 

42. Which is irrelevant in the pharmacologic management of a client with CVA? 

A. Osmotic diuretics and corticosteroids are given to decrease cerebral edema B. Anticonvulsants are given to prevent seizures C. Thrombolytics are most useful within three hours of an occlusive CVA D. Aspirin is used in the acute management of a completed stroke. 

43. What would be the MOST therapeutic nursing action when a client’s expressive aphasia is severe? 

A. Anticipate the client wishes so she will not need to talk B. Communicate by means of questions that can be answered by the client shaking the head C. Keep us a steady flow rank to minimize silence D. Encourage the client to speak at every possible opportunity. 

44. A client with head injury is confused, drowsy and has unequal pupils. Which of the following nursing diagnosis is most important at this time? A. altered level of cognitive function B. high risk for injury C. altered cerebral tissue perfusion D. sensory perceptual alteration 

45. Which nursing diagnosis is of the highest priority when caring for a client with myasthenia gravis? 

A. Pain B. High risk for injury related to muscle weakness C. Ineffective coping related to illness D. Ineffective airway clearance related to muscle weakness 

46. The client has clear drainage from the nose and ears after a head injury. How can the nurse determine if the drainage is CSF? 

A. Measure the ph of the fluid B. Measure the specific gravity of the fluid C. Test for glucose D. Test for chlorides 

47. The nurse includes the important measures for stump care in the teaching plan for a client with an amputation. Which measure would be excluded from the teaching plan? 

A. Wash, dry, and inspect the stump daily. B. Treat superficial abrasions and blisters promptly. C. Apply a "shrinker" bandage with tighter arms around the proximal end of the affected limb. D. Toughen the stump by pushing it against a progressively harder substance (e.g., pillow on a foot-stool). 

48. A 70-year-old female comes to the clinic for a routine checkup. She is 5 feet 4 inches tall and weighs 180 pounds. Her major complaint is pain in her joints. She is retired and has had to give up her volunteer work because of her discomfort. She was told her diagnosis was osteoarthritis about 5 years ago. Which would be excluded from the clinical pathway for this client? A. Decrease the calorie count of her daily diet. B. Take warm baths when arising. C. Slide items across the floor rather than lift them. D. Place items so that it is necessary to bend or stretch to reach them. 

49. A client is admitted from the emergency department with severe-pain and edema in the right foot. His diagnosis is gouty arthritis. When developing a plan of care, which action would have the highest priority? 

A. Apply hot compresses to the affected joints. B. Stress the importance of maintaining good posture to prevent deformities. C. Administer salicylates to minimize the inflammatory reaction. D. Ensure an intake of at least 3000 ml of fluid per day. 

50. A client had a laminectomy and spinal fusion yesterday. Which statement is to be excluded from your plan of care? 

A. Before log rolling, place a pillow under the client’s head and a pillow between the client’s legs. B. Before log rolling, remove the pillow from under the client’s head and use no pillows between the client’s legs. C. Keep the knees slightly flexed while the client is lying in a semi-Fowler’s position in bed. D. Keep a pillow under the client’s head as needed for comfort.

ANSWER KEYRATIONALE  FLUID, ELECTROLYTE, AND ACID-BASE PROBLEMS  1. ANSWER B – The nursing assistant can reinforce additional fluild intake once it is part of the care plan. Administering IV fluids, developing plans, and teaching families require additional education and skills that are within the scope of practice for the RN.   2. ANSWER A – Normally, neck veins are distended when the client is in the supine position. The veins flatten as the client moves to a sitting position. The other three responses are characteristic of Excess Fluid Volume.   3. ANSWER A, B, C, D - The LPN/LVN’s scope of practice and educational preparation includes oral care and routine observation. State practice acts vary as to whether LPN/LVNs are permitted to perform assessment. The client should be reminded to avoid most commercial mouthwashes that contain alcohol, a drying agent. Initiating a dietary consult is within the purview of the RN or physician.   4. ANSWER D – Bilateral moist crackles indicate fluid-filled alveoli, which interferes with gas exchange. Furosemide is a potent loop diuretic that will help mobilize the fluid in the lungs. The other orders are important but not urgent.   5. ANSWER B – Suspect hypokalemia and check the client’s potassium level. Common ECG changes with hypokalemia include ST depression, inverted T waves, and prominent U waves. Client with hypokalemia may also develop heart block.   6. ANSWER A – The client’s potassium level is high (normal range 3.5-5.0). Kayexalate removes potassium from the body through the gastrointestinal system. Spironolactone is a potassium-sparing diuretic that may cause the client’s potassium level to go even higher. The nursing student may not have the skill to assess ECG strips and this should be done by the RN.   7. ANSWER C - SIADH causes a relative sodium deficit due to excessive retention of water.   8. ANSWER A – Providing oral care is within the scope of practice for the nursing assistant. Monitoring and assessing clients, as well as administering IV fluids, require the additional education and skill of the RN.   9. ANSWER B – A positive Chvostek’s sign (facial twitching of one side of the mouth, nose, and cheek in response to tapping the face just below and in front of the ear) is a neurologic manifestation of hypocalcemia. The LPN/LVN is experienced and possesses the skills to take accurate vital signs.   10. ANSWER D – Clients with low calcium levels should be encouraged to consume dairy products, seafood, nuts, broccoli, and spinach. Which are all good sources of dietary calcium.  11. ANSWER C – A musculoskeletal manifestation of low phosphorous is generalized muscle weakness that may lead to acute muscle breakdown (rhabdomyolysis). Even though the other statements are true, they do not answer the nursing assistant’s question.   12. ANSWER D – While all of these laboratory values are outside of the normal range, the magnesium is most outside of normal. With a magnesium level this low, the client is at risk for ECG changes and life-threatening ventricular dysrhythmias.  13. ANSWER B – The client with COPD, although ventilator dependent, is the most stable of this group. Clients with acid-base imbalances often require frequent laboratory assessment and changes in therapy to correct their disorders. In addition, the client with DKA is a new admission and will require an in-depth admission assessment. All three of these clients need care from an experienced critical care nurse.   14. ANSWER A – the blood gas component responsible for respiratory acidosis is CO2 (Carbon dioxide). Increasing the ventilator rate will blow off more CO2 and decrease the acidosis. Changes in the oxygen setting may improve oxygenation but will not affect respiratory acidosis.   15. ANSWER B, C – The nursing assistant’s training and education include how to take vital signs and record intake and output. The need to take vital signs this frequently indicates that the client maybe unstable. The nurse should give the nursing assistant reporting parameters when delegating this action, should also check the vital signs for indications in instability. Performing fingerstick glucose checks and assessing clients require additional education and skill that are appropriate to licensed nurses. Some facilities may train experienced nursing assistants to perform fingerstick glucose checks and change their role descriptions to designate their new skills, but this is beyond the normal scope of practice for a nursing assistant.   

16. ANSWER D – Risk factors for acid-base imbalances in the older adult include chronic renal disease and pulmonary disease. Occasional antacid use will not cause imbalances, although antacid abuse is a risk factor for metabolic alkalosis.   

17. ANSWER A – A decreased respiratory rate indicates respiratory depression which also puts the client at risk for respiratory acidosis, All of the other findings are important and should be reported to the RN, but the respiratory rate is urgent.  

18. ANSWER B – The client is most likely hyperventilating and blowing off CO2. This decrease in CO2 will lead to an increase in pH, causing respiratory alkalosis. Respiratory acidosis results from respiratory depression and retained CO2. Metabolic acidosis and alkalosis result from problems related to renal acid-base control.   

19. ANSWER A – Prolonged nausea and vomiting can result in acid deficit that can lead to metabolic alkalosis. The other findings are important and need to be assessed but are not related to acid-base imbalances.  

20. ANSWER B – Nasogastric suctioning can result in a decrease in acid components and metabolic alkalosis. The client’s increase in rate and depth of ventilation is an attempt to compensate by blowing off CO2. the first response maybe true but does not address all the components of the question. The third and fourth answers are inaccurate. 

1.       Answer: (A) Hyponatremia The normal serum sodium level is 135 – 145 mEq/L. The client’s serum sodium is below normal. Hyponatremia also manifests itself with abdominal cramps and nausea and vomiting2.       Answer: (B) Decreased serum calcium, blood pH 7.2, potassium 6.5 mEq/L Chronic renal failure is usually the end result of gradual tissue destruction and loss of renal function. With the loss of renal function, the kidneys ability to regulate fluid and electrolyte and acid base balance results. The serum Ca decreases as the kidneys fail to excrete phosphate, potassium and hydrogen ions are retained.3.       Answer: (B) Avoid taking blood pressure measurements or blood samples from the affected arm. In the client with an external shunt, don’t use the arm with the vascular access site to take blood pressure readings, draw blood, insert IV lines, or give injections because these procedures may rupture the shunt or occlude blood flow causing damage and obstructions in the shunt.4.       Answer: (D) He will be pain free. Surgical interventions involve an experience of pain for the client which can come in varying degrees. Telling the pain that he will be pain free is giving him false reassurance.5.       Answer: (C) right lower quadrant To be exact, the appendix is anatomically located at the Mc Burney’s point at the right iliac area of the right lower quadrant.6.       Answer: (A) telling him to avoid heavy lifting for 4 to 6 weeks The client should avoid lifting heavy objects and any strenuous activity for 4-6 weeks after surgery to prevent stress on the inguinal area. There is no special diet required. The fluid intake of eight glasses a day is good advice but is not a priority in this case.7.       Answer: (C) 31% Using the Rule of Nine in the estimation of total body surface burned, we allot the following: 9% – head; 9% – each upper extremity; 18%- front chest and abdomen; 18% – entire back; 18% – each lower extremity and 1% – perineum.8.       Answer: (D) Fluid shift from intravascular space to the interstitial space This period is the burn shock stage or the hypovolemic phase. Tissue injury causes vasodilation that results in increase capillary permeability making fluids shift from the intravascular to the interstitial space. This can lead to a decrease in circulating blood volume or hypovolemia which decreases renal perfusion and urine output.9.       Answer: (C) Frequently observing for hoarseness, stridor, and dyspnea Burns located in the upper torso, especially resulting from thermal injury related to fires can lead to inhalation burns. This causes swelling of the respiratory mucosa and blistering which can lead to airway obstruction manifested by hoarseness, noisy and difficult breathing. Maintaining a patent airway is a primary concern.10.    Answer: (D) Helping the client to rest in the position of maximal comfort Mobility and placing the burned areas in their functional position can help prevent contracture deformities related to burns. Pain can immobilize a client as he seeks the position where he finds

less pain and provides maximal comfort. But this approach can lead to contracture deformities and other complications.11.    Answer: (D) fluid and electrolyte monitoring Total parenteral nutrition is a method of providing nutrients to the body by an IV route. The admixture is made up of proteins, carbohydrates, fats, electrolytes, vitamins, trace minerals and sterile water based on individual client needs. It is intended to improve the clients nutritional status. Because of its composition, it is important to monitor the clients fluid intake and output including electrolytes, blood glucose and weight.12.    Answer: (D) Aluminum hydroxide Aluminum hydroxide binds dietary phosphorus in the GI tract and helps treat hyperphosphatemia. All the other medications mentioned help treat hyperkalemia and its effects.13.    Answer: (A) 0.45% NaCl Hypotonic solutions like 0.45% NaCl has a lower tonicity that the blood; 0.9% NaCl and D5W are isotonic solutions with same tonicity as the blood; and D5NSS is hypertonic with a higher tonicity thab the blood.14.    Answer: (A) hypertension In hypovolemia, one of the compenasatory mechanisms is activation of the sympathetic nervous system that increases the RR & PR and helps restore the BP to maintain tissue perfusion but not cause a hypertension. The SNS stimulation constricts renal arterioles that increases release of aldosterone, decreases glomerular filtration and increases sodium & water reabsorption that leads to oliguria.15.    Answer: (B) assessing Maria’s expectations and doubts Assessing the client’s expectations and doubts will help lessen her fears and anxieties. The nurse needs to encourage the client to verbalize and to listen and correctly provide explanations when needed.16.    Answer: (B) recognize that Kathy is experiencing denial, a normal stage of the grieving process A person grieves to a loss of a significant object. The initial stage in the grieving process is denial, then anger, followed by bargaining, depression and last acceptance. The nurse should show acceptance of the patient’s feelings and encourage verbalization.17.    Answer: (B) it affects both normal and tumor cells Chemotherapeutic agents are given to destroy the actively proliferating cancer cells. But these agents cannot differentiate the abnormal actively proliferating cancer cells from those that are actively proliferating normal cells like the cells of the bone marrow, thus the effect of bone marrow depression.18.    Answer: (C) CTscanning uses magnetic fields and radio frequencies to provide cross-sectional view of tumor CT scan uses narrow beam x-ray to provide cross-sectional view. MRI uses magnetic fields and radio frequencies to detect tumors.19.    Answer: (D) frequently elevating the arm of the affected side above the level of the heart. Elevating the arm above the level of the heart promotes good venous return to the heart and good lymphatic drainage thus preventing swelling.20.    Answer: (B) “My 7 year old twins should not come to visit me while I’m receiving treatment.” Children have cells that are normally actively dividing in the process of growth. Radiation acts not only against the abnormally actively dividing cells of cancer but also on the normally dividing cells thus affecting the growth and development of the child and even causing cancer itself.21.    Answer: (B) Rapid cell catabolism One of the oncologic emergencies, the tumor lysis syndrome, is caused by the rapid destruction of large number of tumor cells. . Intracellular contents are released, including potassium and purines, into the bloodstream faster than the body can eliminate them. The purines are converted in the liver to uric acid and released into the blood causing hyperuricemia. They can precipitate in the kidneys and block the tubules causing acute renal failure.22.    Answer: (C) Low residue diet It is important for the nurse to remember that the implant be kept intact in the cervix during therapy. Mobility and vaginal irrigations are not done. A low residue diet will prevent bowel movement that could lead to dislodgement of the implant. Patient is also strictly isolated to protect other people from the radiation emissions23.    Answer: (A) Avoid BP measurement and constricting clothing on the affected arm A BP cuff constricts the blood vessels where it is applied. BP measurements should be done on the unaffected arm to ensure adequate circulation and venous and lymph drainage in the affected arm24.    Answer: (C) Hypovolemia, wide fluctuations in serum sodium and potassium levels. The second phase of ARF is the diuretic phase or high output phase. The diuresis can result in an output of up to 10L/day of dilute urine. Loss of fluids and electrolytes occur.25.    Answer: (A) A rapid pulse and increased RR The fight or flight reaction of the sympathetic nervous system occurs during stress like in a motor vehicular accident. This is manifested by increased in cardiovascular function and RR to provide the immediate needs of the body for survival.26.    Answer: (D) assessing her VS especially her RR Shock is characterized by reduced tissue and organ perfusion and eventual organ dysfunction and failure. Checking on the VS especially the RR, which detects need for oxygenation, is a priority to help detect its progress and provide for prompt management before the occurrence of complications.27.    Answer: (B) Urine output of 30 to 50 ml/hr. Hypovolemia is a decreased in circulatory volume. This causes a decrease in tissue perfusion to the different organs of the body. Measuring the hourly urine output is the most quantifiable way of measuring tissue perfusion to the organs. Normal renal perfusion should produce 1ml/kg of BW/min. An output of 30-50 ml/hr is considered adequate and indicates good fluid balance.28.    Answer: (D) Pericardial tamponade Pericardial tamponade occurs when there is presence of fluid accumulation in the pericardial space that compresses on the ventricles causing a decrease in ventricular filling and stretching during diastole with a decrease in cardiac output. . This leads to right atrial and venous congestion manifested by a CVP reading above normal.29.    Answer: (A) administering an irritant that will stimulate vomiting Swallowing of corrosive substances causes severe irritation and tissue destruction of the mucous membrane of the GI tract. Measures are taken to immediately remove the toxin or reduce its absorption. For corrosive poison ingestion, such as in muriatic acid where burn or perforation of the mucosa may occur, gastric emptying procedure is immediately instituted, This includes gastric lavage and the administration of activated charcoal to absorb the poison. Administering an irritant with the concomitant vomiting to remove the swallowed poison will further cause irritation and damage to the mucosal lining of the digestive tract. Vomiting is only indicated when non-corrosive poison is swallowed.30.    Answer: (C) Palpable carotid pulse Presence of a palpable carotid pulse indicates the return of cardiac function which, together with the return of breathing, is the primary goal of CPR. Pulsations in arteries indicates blood flowing in the blood vessels with each cardiac contraction. Signs of effective tissue perfusion will be noted after.31.    Answer: (C) Flushing of the lids, conjunctiva and cornea with tap or preferably sterile water Prompt treatment of ocular chemical burns is important to prevent further damage. Immediate tap-water eye irrigation should be started on site even before transporting the patient to the nearest hospital facility. In the hospital, copious irrigation with normal saline, instillation of local anesthetic and antibiotic is done.32.    Answer: (A) Force air out of the lungs The Heimlich maneuver is used to assist a person choking on a foreign object. The pressure from the thrusts lifts the diaphragm, forces air out of the lungs and creates an artificial cough that expels the aspirated material.33.    Answer: (B) speak to both parents together and encourage them to support each other and express their emotions freely Sudden death of a family member creates a state of shock on the family. They go into a stage of denial and anger in their grieving. Assisting them with information they need to know, answering their questions and listening to them will provide the needed support for them to move on and be of support to one another.34.    Answer: (C) relax the bronchial smooth muscle Acute asthmatic attack is characterized by severe bronchospasm which can be relieved by the immediate administration of bronchodilators. Adrenaline or Epinephrine is an adrenergic agent that causes bronchial dilation by relaxing the bronchial smooth muscles.35.    Answer: (C) lower half of the sternum The exact and safe location to do cardiac compression is the lower half of the sternum. Doing it at the lower third of the sternum may cause gastric compression which can lead to a possible aspiration.36.    Answer: (B) “As one ages, visual changes are noted as part of degenerative changes. This is normal.” Aging causes less elasticity of the lens affecting accommodation leading to blurred vision. The muscles of the iris increase in stiffness and the pupils dilate slowly and less completely so that it takes the older person to adjust when going to and from light and dark environment and needs brighter light for close vision.37.    Answer: (D) sexual intercourse To reduce increases in IOP, teach the client and family about activity restrictions. Sexual intercourse can cause a sudden rise in IOP.

38.    Answer: (C) Speak clearly in a loud voice or shout to be heard Shouting raises the frequency of the sound and often makes understanding the spoken words difficult. It is enough for the nurse to speak clearly and slowly. 39.    Answer: (D) Force fluids before and after the procedure. LP involves the removal of some amount of spinal fluid. To facilitate CSF production, the client is instructed to increase fluid intake to 3L, unless contraindicated, for 24 to 48 hrs after the procedure.40.    Answer: (D) Kept the extremity used as puncture site flexed to prevent bleeding. Angiography involves the threading of a catheter through an artery which can cause trauma to the endothelial lining of the blood vessel. The platelets are attracted to the area causing thrombi formation. This is further enhanced by the slowing of blood flow caused by flexion of the affected extremity. The affected extremity must be kept straight and immobilized during the duration of the bedrest after the procedure. Ice bag can be applied intermittently to the puncture site.41.    Answer: (D) progression from restlessness to confusion and disorientation to lethargy The first major effect of increasing ICP is a decrease in cerebral perfusion causing hypoxia that produces a progressive alteration in the LOC. This is initially manifested by restlessness.42.    Answer: (D) Aspirin is used in the acute management of a completed stroke. The primary goal in the management of CVA is to improve cerebral tissue perfusion. Aspirin is a platelet deaggregator used in the prevention of recurrent or embolic stroke but is not used in the acute management of a completed stroke as it may lead to bleeding.43.    Answer: (D) Encourage the client to speak at every possible opportunity. Expressive or motor aphasia is a result of damage in the Broca’s area of the frontal lobe. It is amotor speech problem in which the client generally understands what is said but is unable to communicate verbally. The patient can best he helped therefore by encouraging him to communicate and reinforce this behavior positively.44.    Answer: (C) altered cerebral tissue perfusion The observations made by the nurse clearly indicate a problem of decrease cerebral perfusion. Restoring cerebral perfusion is most important to maintain cerebral functioning and prevent further brain damage.45.    Answer: (D) Ineffective airway clearance related to muscle weakness Myasthenia gravis causes a failure in the transmission of nerve impulses at the neuromuscular

junction which may be due to a weakening or decrease in acetylcholine receptor sites. This leads to sporadic, progressive weakness or abnormal fatigability of striated muscles that eventually causes loss of function. The respiratory muscles can become weak with decreased tidal volume and vital capacity making breathing and clearing the airway through coughing difficult. The respiratory muscle weakness may be severe enough to require and emergency airway and mechanical ventilation.46.    Answer: (C) Test for glucose The CSF contains a large amount of glucose which can be detected by using glucostix. A positive result with the drainage indicate CSF leakage.47.    Answer: (C) Apply a "shrinker" bandage with tighter arms around the proximal end of the affected limb. The “shrinker” bandage is applied to prevent swelling of the stump. It should be applied with the distal end with the tighter arms. Applying the tighter arms at the proximal end will impair circulation and cause swelling by reducing venous flow.48.    Answer: (D) Place items so that it is necessary to bend or stretch to reach them. Patients with osteoarthritis have decreased mobility caused by joint pain. Over-reaching and stretching to get an object are to be avoided as this can cause more pain and can even lead to falls. The nurse should see to it therefore that objects are within easy reach of the patient.49.    Answer: (D) Ensure an intake of at least 3000 ml of fluid per day. Gouty arthritis is a metabolic disease marked by urate deposits that cause painful arthritic joints. The patient should be urged to increase his fluid intake to prevent the development of urinary uric acid stones.50.    Answer: (B) Before log rolling, remove the pillow from under the client’s head and use no pillows between the client’s legs. Following a laminectomy and spinal fusion, it is important that the back of the patient be maintained in straight alignment and to support the entire vertebral column to promote complete healing. 

1. You are reviewing the complete blood count (CBC) for a client who has been admitted for knee arthroscopy. Which value is most important to report to the physician prior to surgery?  a. White blood cell count 16,000/mm3  b. Hematocrit 33%  c. Platelet count 426,000/ mm3  d. Hemoglobin 10.9 g/dL   2. A new RN is preparing to administer packed red blood cells (PRBCs) to a client whose anemia was caused by blood loss after surgery. Which action by the new RN requires that you, as charge nurse, intervene immediately?  a. The new RN waits 20 minutes after obtaining the PRBCs before starting the infusion.  b. The new RN starts an intravenous line for the transfusion using a 22-gauge catheter.  c. The new RN primes the transfusion set using 5% dextrose in lactated Ringer’s solution.  d. The new RN tells the client that the PRBCs may cause a serious transfusion reaction.   3. A 32-year-old client with a history of sickle cell anemia is admitted to the hospital during a sickle cell crisis. The physician orders all of these interventions. Which order will you implement first?  a. Give morphine sulfate 4-8 mg IV every hour as needed.  b. Start a large-gauge IV line and infuse normal saline at 200 mL/hour.  c. Immunize with Pneumovax and Haemophilus influenzae vaccines.  d. Administer oxygen at an F102 of 100% per non-rebreather mask.   4. A 78-year-old client admitted to the hospital with chronic anemia caused by possible gastrointestinal bleeding has all of these activities included in the care plan. Which activity is best delegated to an experienced nursing assistant (NA)?  a. Use Hemoccult slides to obtain stool specimens.  b. Have the client sign a colonoscopy consent form.  c. Administer PEG-ES (GoLYTELY) bowel preparation.  d. Check for allergies to contrast dye or shellfish.   5. As charge nurse, you are making the daily assignments on the medical-surgical unit. Which client is best assigned to a nurse who has floated from the post-anesthesia care unit (PACU)?  a. A 30-year-old client with thalassemia major who has an order for subcutaneous infusion of deferoxamine (Desferal)  b. A 43-year-old client with multiple myeloma who needs discharge teaching  c. A 52-year-old client with chronic gastrointestinal bleeding who has returned to the unit after a colonoscopy  d. A 65-year-old client with pernicious anemia who has just been admitted to the unit  

6. You are making a room assignment for a newly arrived client whose laboratory testing indicates pancytopenia. All of these clients are already on the nursing unit. Which one will be the best roommate for the new client?  a. The client with digoxin toxicity  b. The client with viral pneumonia  c. The client with shingles  d. The client with cellulitis  

 7. A client admitted to the hospital with a sickle cell crisis complains of severe abdominal, hip, and knee pain. You observe an LPN accomplishing these client care tasks. Which one requires that you, as charge nurse, intervene immediately?  a. The LPN encourages the client to use the ordered PCA.  b. The LPN positions cold packs on the client’s knees.  c. The LPN places a “No Visitors” sign on the client’s door.  d. The LPN checks the client’s temperature every 2 hours.   8. A 67-year-old client who is receiving chemotherapy for lung cancer is admitted to the hospital with thrombocytopenia. While you are taking the admission history, the client makes these statements. Which statement is of most concern?  a. “I’ve noticed that I bruise more easily since the chemotherapy started.”  b. “My bowel movements are soft and dark brown in color.”  c. “I take one aspirin every morning because of my history of angina.”  d. “My appetite has decreased since the chemotherapy strated.”  

9. Following a car accident, a client with a Medic-Alert bracelet indicating hemophilia A is admitted to the emergency department (ED). Which physician order should you implement first?  a. Transport to radiology for C-spine x-rays.  b. Transfuse Factor VII concentrate.  c. Type and cross-match for 4 units RBCs.  d. Infuse normal saline at 250 mL/hour.   10.As home health nurse, you are taking an admission history for a client who has a deep vein thrombosis and is taking warfarin (Coumadin) 2 mg daily. Which statement by the client is the best indicator that additional teaching about warfarin may be needed?  a. “I have started to eat more healthy foods like green salads and fruit.”  b. “The doctor said that it is important to avoid becoming constipated.”  c. “Coumadin makes me feel a little nauseated unless I take it with food.”  d. “I will need to have some blood testing done once or twice a week.”   11.A client is admitted to the intensive car unit (ICU) with disseminated intravascular coagulation (DIC) associated with a gram-negative infection. Which assessment information has the most immediate implications for the client’s care?  a. There is no palpable radial or pedal pulse.  b. The client complains of chest pain.  c. The client’s oxygen saturation is 87%  d. There is mottling of the hands and feet.  

12.A 22-year-old with stage I Hodgkin’s disease is admitted to the oncology unit for radiation therapy. During the initial assessment, the client tells you, “Sometimes I am afraid of dying.” Which response is most appropriate at this time?  a. “Many individuals with this diagnosis have some fears.”  b. “Perhaps you should ask the doctor about medication.”  c. “Tell me a little bit more about your fear of dying.”  d. “Most people with stage I Hodgkin’s disease survive.”   

13.After receiving change-of-shift report about all of these clients, which one will you assess first?  a. A 26-year-old with thalassemia major who has a short-stay admission for a blood transfusion  b. A 44-year-old who was admitted 3 days previously with a sickle cell crisis and has orders for a CT scan  c. A 50-year-old with newly diagnosed stage IV non-Hodgskin’s lymphoma who is crying and stating “I’m not ready to die.”  d. A 69-year-old with chemotherapy-induced neutropenia who has an elevated oral temperature  

14.A long-term-care client with chronic lymphocytic leukemia has a nursing diagnosis of Activity Intolerance related to weakness and anemia. Which of these nursing activities is most appropriate for you, as the charge nurse, to delegate to a nursing assistant?  a. Evaluate the client’s response to normal activities of daily living.  b. Check the client’s blood pressure and pulse rate after ambulation.  c. Determine which self-care activities the client can do independently.  d. Assist the client in choosing a diet that will improve strength.  

15.A transfusion of PRBCs has been infusing for 5 minutes when the client becomes flushed and tachypneic and says, “I am having chills. Please get me a blanket.” Which action should you take first?  a. Obtain a warm blanket for the client.  b. Check the client’s oral temperature.  c. Stop the medication.  d. Administer oxygen.  

16.A group of clients is assigned to an RN-LPN/LVN team. The LPN/LVN is most likely to be assigned to provide client care and administer medications to which of these clients?  a. A 36-year-old client with chronic renal failure who will need a subcutaneous injection of epoetin (Procrit)  b. A 39-year-old client with hemophilia B who has been admitted for a blood transfusion  c. A 50-year-old client with newly diagnosed polycythemia vera who is scheduled for phlebotomy  d. A 55-year-old client with a history of stem cell transplantation who will have a bone marrow aspiration   17.You obtain the following data about a client admitted with multiple myeloma. Which information has the most immediate implications for the client’s care?  a. The client complains of chronic bone pain.  b. The blood uric acid level is very elevated.  c. The 240hour urine shows Bence-Jones protein.  d. The client is unable to plantarflex the feet.   18.The nurse in the outpatient clinic is assessing a 22-year-old with a history of a recent splenectomy after a motor vehicle accident. Which information obtained during the assessment will be of most immediate concern to the nurse?  a. The client engages in unprotected sex.  b. The client has an oral temperature of 99.7o F  c. The client has abdominal pain with light palpation.  d. The client admits to occasional marijuana use.  

19.A client with graft-versus-host disease (GVHD) after a bone marrow transplant is being cared for on the medical unit. Which of these nursing activities is best delegated to a newly graduated RN who has had a 6-week orientation to the unit?  a. Administration of methotrexate and cyclosporine to the client  b. Assessment of the client for signs of infection caused by GVHD  c. Infusion of D5.45% normal saline at 125 mL/hour to the client  d. Education of the client about ways to prevent infection  

20.You are the charge nurse in an oncology unit. A client with an absolute neutrophil count (ANC) of 300/mm3 is placed in protective isolation. Which staff member should you assign to provide care for this client, under the supervision of an experienced  oncology RN?  a. An LPN who has floated from the same-day-surgery unit  b. An RN from the float pool who usually works on the surgical unit  c. An LPN with 2 years of experience on the oncology unit  d. An RN who transferred recently from the ED   21.You are transferring a client with newly diagnosed chronic myeloid leukemia to a long-term-care (LTC) facility. Which 

information is most important to the LTC charge nurse prior to transferring the client?  a. The Philadelphia chromosome is present in the blood smear  b. Glucose is elevated as a result of prednisone therapy  c. There has been a 20-pound weight loss over the past year  d. The client’s chemotherapy has resulted in neutropenia  

22.A client with acute myelogenous leukemia is receiving induction phase chemotherapy. Which assessment information is of most concern?  a. Serum potassium level of 7.8 mEq/L  b. Urine output less than intake by 400 mL  c. Inflammation and redness of oral mucosa  d. Ecchymoses present on anterior trunk  

23.A client who has been receiving cyclosporine following an organ transplant is experiencing these symptoms. Which one is of most concern?  a. Bleeding of the gums while brushing the teeth  b. Non-tender swelling in the right groin  c. Occasional nausea after taking the medication  d. Numbness and tingling of the feet  

24.You have developed the nursing diagnosis Risk for Impaired Tissue Integrity related to effects of radiation for a client with Hodgkin’s lymphoma who is receiving radiation to the groin area. Which nursing activity is best delegated to a nursing assistant caring for the client?  a. Check the skin for signs of redness or peeling.  b. Apply alcohol-free lotion to the area after cleaning.  c. Explain good skin care to the client and family.  d. Clean the skin over daily with a mild soap.  

25.After receiving the change-of-shift report, which client will you assess first?  a. A 20-year-old with possible acute myelogenous leukemia who has just arrived on the medical unit  b. A 38-year-old with aplastic anemia who needs teaching about decreasing infection risk prior to discharge  c. A 40-year-old with lymphedema who requests help to put on compression stockings before getting out of bed  d. A 60-year-old with non-Hodgkin’s lymphoma who is refusing the ordered chemotherapy regimen 

1. The nurse is preparing to teach a client with microcytic hypochromic anemia about the diet to follow after discharge. Which of the following foods should be included in the diet?a. Eggsb. Lettucec. Citrus fruitsd. Cheese2. The nurse would instruct the client to eat which of the following foods to obtain the best supply of vitamin B12?a. Whole grainsb. Green leafy vegetablesc. Meats and dairy productsd. Broccoli and Brussels sprouts3. The nurse has just admitted a 35-year-old female client who has a serum B12 concentration of 800 pg/ml. Which of the following laboratory findings would cue the nurse to focus the client history on specific drug or alcohol abuse?a. Total bilirubin, 0.3 mg/dLb. Serum creatinine, 0.5 mg/dLc. Hemoglobin, 16 g/dLd. Folate, 1.5 ng/mL4. The nurse understands that the client with pernicious anemia will have which distinguishing laboratory findings?a. Schilling’s test, elevatedb. Intrinsic factor, absent.c. Sedimentation rate, 16 mm/hourd. RBCs 5.0 million5. The nurse devises a teaching plan for the patient with aplastic anemia. Which of the following is the most important concept to teach for health maintenance?a. Eat animal protein and dark leafy vegetables each dayb. Avoid exposure to others with acute infectionc. Practice yoga and meditation to decrease stress and anxietyd. Get 8 hours of sleep at night and take naps during the day

6. A client comes into the health clinic 3 years after undergoing a resection of the terminal ileum complaining of weakness, shortness of breath, and a sore tongue. Which client statement indicates a need for intervention and client teaching?a. “I have been drinking plenty of fluids.”b. “I have been gargling with warm salt water for my sore tongue.”c. “I have 3 to 4 loose stools per day.”d. “I take a vitamin B12 tablet every day.”7. A vegetarian client was referred to a dietician for nutritional counseling for anemia. Which client outcome indicates that the client does not understand nutritional counseling? The client:a. Adds dried fruit to cereal and baked goodsb. Cooks tomato-based foods in iron potsc. Drinks coffee or tea with mealsd. Adds vitamin C to all meals8. A client was admitted with iron deficiency anemia and blood-streaked emesis. Which question is most appropriate for the nurse to ask in determining the extent of the client’s activity intolerance?a. “What activities were you able to do 6 months ago compared with the present?”b. “How long have you had this problem?”c. “Have you been able to keep up with all your usual activities?”d. “Are you more tired now than you used to be?”9. The primary purpose of the Schilling test is to measure the client’s ability to:a. Store vitamin B12b. Digest vitamin B12c. Absorb vitamin B12d. Produce vitamin B1210. The nurse implements which of the following for the client who is starting a Schilling test?a. Administering methylcellulose (Citrucel)b. Starting a 24- to 48 hour urine specimen collectionc. Maintaining NPO statusd. Starting a 72 hour stool specimen collection11. A client with pernicious anemia asks why she must take vitamin B12 injections for the rest of her life. What is the nurse’s best response?a. “The reason for your vitamin deficiency is an inability to absorb the vitamin because the stomach is not producing sufficient acid.”b. “The reason for your vitamin deficiency is an inability to absorb the vitamin because the stomach is not producing sufficient intrinsic factor.”c. “The reason for your vitamin deficiency is an excessive excretion of the vitamin because of kidney dysfunction.”d. “The reason for your vitamin deficiency is an increased requirement for the vitamin because of rapid red blood cell production.”12. The nurse is assessing a client’s activity intolerance by having the client walk on a treadmill for 5 minutes. Which of the following indicates an abnormal response?a. Pulse rate increased by 20 bpm immediately after the activityb. Respiratory rate decreased by 5 breaths/minutec. Diastolic blood pressure increased by 7 mm Hgd. Pulse rate within 6 bpm of resting phase after 3 minutes of rest.

13. When comparing the hematocrit levels of a post-op client, the nurse notes that the hematocrit decreased from 36% to 34% on the third day even though the RBC and hemoglobin values remained stable at 4.5 million and 11.9 g/dL, respectively. Which nursing intervention is most appropriate?a. Check the dressing and drains for frank bleedingb. Call the physicianc. Continue to monitor vital signsd. Start oxygen at 2L/min per NC14. A client is to receive epoetin (Epogen) injections. What laboratory value should the nurse assess before giving the injection?a. Hematocritb. Partial thromboplastin timec. Hemoglobin concentrationd. Prothrombin time15. A client states that she is afraid of receiving vitamin B12 injections because of the potential toxic reactions. What is the nurse’s best response to relieve these fears?a. “Vitamin B12 will cause ringing in the eats before a toxic level is reached.”b. “Vitamin B12 may cause a very mild skin rash initially.”c. “Vitamin B12 may cause mild nausea but nothing toxic.”d. “Vitamin B12 is generally free of toxicity because it is water soluble.”16. A client with microcytic anemia is having trouble selecting food items from the hospital menu. Which food is best for the nurse to suggest for satisfying the client’s nutritional needs and personal preferences?a. Egg yolksb. Brown ricec. Vegetablesd. Tea17. A client with macrocytic anemia has a burn on her foot and states that she had been watching television while lying on a heating pad. What is the nurse’s first response?a. Assess for potential abuseb. Check for diminished sensationsc. Document the findingsd. Clean and dress the area18. Which of the following nursing assessments is a late symptom of polycythemia vera?a. Headacheb. Dizzinessc. Pruritusd. Shortness of breath19. The nurse is teaching a client with polycythemia vera about potential complications from this disease. Which manifestations would the nurse include in the client’s teaching plan? Select all that apply.a. Hearing lossb. Visual disturbancec. Headached. Orthopneae. Goutf. Weight loss20. When a client is diagnosed with aplastic anemia, the nurse monitors for changes in which of the following physiological functions?a. Bleeding tendenciesb. Intake and outputc. Peripheral sensationd. Bowel function

ANSWER KEY1. ANSWER A – An elevation in white blood cells may indicate that the client has an infection, which would likely require rescheduling of the surgical procedure. The other values are slightly abnormal, but would not be likely to cause post-operative problems for a knee arthroscopy. Focus: Prioritization  

2. ANSWER C – Normal saline, an isotonic solution, should be used when priming the IV line to avoid causing hemolysis of RBCs. Ideally, blood products should be infused as soon as possible after they are obtained; however, a 20-minute delay would not be unsafe. Large-gauge IV catheters are preferable for blood

administration; if a smaller catheter must be used, normal saline may be used to dilute the RBCs. Although it is appropriate to instruct clients to notify the nurse if symptoms of a transfusion reaction such as shortness of breath or chest pain occur, it will cause unnecessary anxiety to indicate that a serious reaction is likely to occur. Focus: Prioritization  

3. ANSWER D – Hypoxia and deoxygenation of the red blood cells are the most common cause of sickling, so administration of oxygen is the priority intervention here. Pain control and hydration are also important interventions for this client and should be accomplished rapidly. Vaccination may help prevent future sickling

episodes by decreasing the risk of infection, but it will not help with the current sickling crisis. Focus: Prioritization  

4. ANSWER A – An experienced nursing assistant would have been taught how to obtain a stool specimen for the Hematoccult slide test, because this is a common screening test for hospitalized clients. Having the client sign an informed consent should be done by the physician who will be doing the colonoscopy. Administration of medications and checking for allergies are within the scope of practice for licensed nursing staff. Focus: Delegation  

5. ANSWER C – A nurse who works in the PACU will be familiar with the monitoring needed for a client who has just returned from a procedure like a colonoscopy, which requires conscious sedation. The other clients require more experience with various types of hematologic disorders and would be better to assign to nursing staff who regularly work on the medical – surgical unit. Focus: Prioritization  

6. ANSWER A – Clients with pancytopenia are at higher risk for infection. The client with digoxin toxicity presents the least risk of infecting the new client. Viral pneumonia, shingles, and cellulites are infectious processes. Focus: Prioritization  

7. ANSWER B – The joint pain that occurs in sickle cell crisis is caused by obstruction to blood flow by the sickled red blood cells. The appropriate therapy for this client would be application of moist heat to the joints to cause vasodilation and improve circulation. Because control of pain is a priority during sickle cell crisis, there is no need to restrict all visitors or to check the temperature every 2 hours. Focus: Prioritization 

8. ANSWER C – Because aspiring will decrease platelet aggregation, clients with thrombocytopenia should not use aspirin routinely. Client teaching about his should be included in the care plan. Bruising is consistent with the client’s admission problem of thrombocytopenia. Soft, dark brown stools indicate that there is no frank blood in the bowel movements. A decrease in appetite is common with chemotherapy, and more assessment is indicated. Focus: Prioritization  

9. ANSWER B – When a hemophiliac client is at high risk for bleeding, for example, after a motor vehicle accident, the priority intervention is to maximize the availability of clotting factors. The other orders also should be implemented rapidly, but do not have as high a priority. Focus: Prioritization  

10. ANSWER A – Clients taking warfarin are advised to avoid making sudden diet changes, because changing the oral intake of foods high in vitamin K (such as green leafy vegetables and some fruits) will have an impact on the effectiveness of the medication. The other statements suggest that further teaching may be indicated, but more assessment for teaching needs is indicated first. Focus: Prioritization  

11. ANSWER C – Because the decrease in oxygen saturation will have the greatest immediate effect on all body systems, improvement in oxygenation should be the priority goal of care. The other data also indicate the need for rapid intervention, but improvement of oxygenation is the most urgent need. Focus: Prioritization  

12. ANSWER C – Most assessment about what the client means is needed before any interventions can be planned or implemented. All of the other statements indicate a conclusion that the client is afraid of dying of Hodgkin’s disease. Focus: Prioritization  

13. ANSWER D – Any temperature elevation in a neutropenic client may indicate the presence of a life-threatening infection, so actions such as blood cultures and antibiotic administration should be initiated quickly. The other clients need to e assessed as soon as possible, but are not critically ill. Focus: Prioritization  

14. ANSWER B – Nursing assistant education include routine nursing skills such as assessment of vital signs. Evaluation, baseline assessment of client abilities, and nutrition planning are roles appropriate to RN practice.  

15. ANSWER C – The client’s symptoms indicate that a

transfusion reaction may be occurring so the first action should be to stop the transfusion. Chills are an indication of a febrile reaction, so warming the client is not appropriate. Checking the client’s temperature and administration of oxygen are also appropriate actions if a transfusion reaction is suspected; however, stopping the transfusion is the priority. Focus: Prioritization  

16. ANSWER A – Subcutaneous administration of epoetin is within the LPN/LVN scope of practice. The other clients require skills (blood transfusion and client teaching about phlebotomy and bone marrow aspiration) that are more appropriate to RN-level practice. Focus: Assignment  

17. ANSWER D – The lack of plantar flexion may indicate spinal cord compression, which should be evaluated and treated immediately by the physician to prevent further loss of function. While chronic bone pain, hyperuricemia, and the presence of Bence-Jones protein in the urine all are typical Focus: Prioritization  

18. ANSWER B – Because the spleen has an important role in the phagocytosis of microorganisms, the client is at higher risk for severe infection after a splenectomy. Medical therapy, such as antibiotic administration, is usually indicated for any symptoms of infection. The other information also indicates the need for more assessment and intervention, but prevention and treatment of infection are the highest priorities for this client. Focus: Prioritization  

19. ANSWER C – Infusion of IV fluids is indicated in RN education, and the new RN would also have had experience with this as part of an orientation to the medical unit. Administration of potent immunosuppressive medications, assessment for subtle indications of infection, and client teaching are more complex tasks that should be delegated to more experienced RN staff members. Focus:Delegation  

20. ANSWER C – Because many aspects of nursing care need to be modified to prevent infection when a client has a low ANC, care should be provided by the staff member with the most experience with neutropenic clients. The other staff members have the education required to care for this client, but are not as clinically experienced. When making acute care client assignments for LPN staff members, they must work under the supervision of an RN. The LPN in this case would report to the RN assigned to the client. Focus: Assignment  

21. ANSWER D – The neutropenic client is at increased risk for infection, so the LTC charge nurse needs to know this in order to make decisions about the client room assignment and to plan care. The other information also will impact on planning for client care, but the charge nurse needs the information about neutropenia before the client is transferred. Focus: Prioritization  

22. ANSWER A – Fatal hyperkalemia may be caused by tumor lysis syndrome, a potentially serious consequence of chemotherapy in acute leukemia. The other symptoms also indicate a need for further assessment or intervention, but are not as critical as the elevated potassium level. Focus: Prioritization  

23. ANSWER B – A non-tender swelling in this area (or near any lymph node) may indicate that he client has developed lymphoma, a possible adverse effect of immunosuppressive therapy. The client should receive further evaluation immediately. The other symptoms may also indicate side effects of cyclosporine (gingival hyperplasia, nausea, paresthesia) but do not indicate the need for immediate action. Focus: Prioritization  

24. ANSWER D – Skin care is included in nursing assistant education and job description. Assessment and client teaching are more complex tasks that should be delegated to registered nurses. Use of lotions to the irradiated area is usually avoided during radiation therapy. Focus: Delegation  

25. ANSWER A – The newly admitted client should be assessed first, because the baseline assessment and plan of care need to be completed. The other clients also need assessments or interventions, but do not need immediate nursing care. Focus: Prioritization 

1. ANSWER A. One of the microcytic, hypochromic anemias is iron-deficiency amenia. A rich source of iron is needed in the diet, and eggs are high in iron. Other foods high in iron include organ and muscle (dark) meats; shellfish, shrimp, and tuna; enriched, whole-grain, and fortified cereals and breads; legumes, nuts, dried fruits, and beans; oatmeal; and sweet potatoes. Dark green leafy vegetables and citrus fruits are good sources of vitamin C. Cheese is a good source of calcium.2. ANSWER C. Good sources of vitamin B12 include meats and dairy products. Whole grains are a good source of thiamine. Green leafy vegetables are good sources of niacin, folate, and carotenoids (precursors of vitamin A). Broccoli and Brussels sprouts are good sources of ascorbic acid (vitamin C).3. ANSWER D. The normal range of folic acid is 1.8 to 9 ng/mL, and the normal range of vitamin B12 is 200 to 900 pg/mL. A low folic acid level in the presence of a normal vitamin B12 level is indicative of a primary folic acid-deficiency anemia. Factors that affect the absorption of folic acid are drugs such as methotrexate, oral contraceptives, antiseizure drugs, and alcohol. The total bilirubin, serum creatinine, and hemoglobin values are within normal limits. 4. ANSWER B. The defining characteristic of pernicious anemia, a megaloblastic anemia, is lack of the intrinsic factor, which results from atrophy of the stomach wall. Without the intrinsic factor, vitamin B12 cannot be absorbed in the small intestines, and folic acid needs vitamin B12 for DNA synthesis of RBCs. The gastric analysis was done to determine the primary cause of the anemia. An elevated excretion of the injected radioactive vitamin B12, which is protocol for the first and second stage of the Schilling test, indicates that the client has the intrinsic factor and can absorb vitamin B12 into the intestinal tract. A sedimentation rate of 16 mm/hour is normal for both men and women and is a nonspecific test to detect the presence of inflammation. It is not specific to anemias. An RBC value of 5.0 million is a normal value for both men and women and does not indicate anemia.5. ANSWER B. Clients with aplastic anemia are severely immunocompromised and at risk for infection and possible death related to bone marrow suppression and pancytopenia. Strict aseptic technique and reverse isolation are important measures to prevent infection. Although diet, reduced stress, and rest are valued in supporting health, the potentially fatal consequence of an acute infection places it as a priority for teaching the client about health maintenance. Animal meat and dark green leafy vegetables, good sources of vitamin B12 andfolic acid, should be included in the daily diet. Yoga and meditation are good complimentary therapies to reduce stress. Eight hours of rest and naps are good for spacing and pacing activity and rest.6. ANSWER D. Vitamin B12 combines with intrinsic factor in the stomach and is then carried to the ileum, where it is absorbed in the bloodstream. In this situation, vitamin B12 cannot be absorbed regardless of the amount of oral intake of sources of vitamin B12 such as animal protein or vitamin B12 tablets. Vitamin B12 needw to be injected every month, because the ileum has been surgically removed. Replacement of fluids and electrolytes is important when the client has continuous multiple loose stools on a daily basis. Warm salt water is used to soothe sore mucous membranes. Crohn’s disease and small bowel resection may cause several loose stools a day.7. ANSWER C. Coffee and tea increase gastrointestinal mobility and inhibit the absorption of nonheme iron. Clients are instructed to add dried fruits to dishes at every meal because dried fruits are a nonheme or nonanimal iron source. Cooking in iron cookware, especially acid-based foods such as tomatoes, adds iron to the diet. Clients are instructed to add a rich supply of vitamin C to every meal because the absorption of iron is increased when food with vitamin C or ascorbic acid is consumed.8. ANSWER A. It is difficult to determine activity intolerance without objectively comparing activities from one time frame to another. Because iron deficiency anemia can occur gradually and individual endurance varies, the nurse can best assess the client’s activity tolerance by asking the client to compare activities 6 months ago and at the present. Asking a client how long a problem has existed is a very open-ended question that allows for too much subjectivity for any definition of the client’s activity tolerance. Also, the client may not even identify that a “problem” exists. Asking the client whether

he is staying abreast of usual activities addresses whether the tasks were completed, not the tolerance of the client while the tasks were beingcompleted or the resulting condition of the client after the tasks were completed. Asking the client if he is more tired now than usual does not address his activity tolerance. Tiredness is a subjective evaluation and again can be distorted by factors such as the gradual onset of the anemia or the endurance of the individual.9. ANSWER C. Pernicious anemia is caused by the body’s inability to absorb vitamin B12. This results in a lack of intrinsic factor in the gastric juices. Schilling’s test helps diagnose pernicious anemia by determining the client’s ability to absorb vitamin B12.10. ANSWER B. Urinary vitamin B12 levels are measured after the ingestion of radioactive vitamin B12. A 24-to 48- hour urine specimen is collected after administration of an oral dose of radioactively tagged vitamin B12 and an injection of nonradioactive vitamin B12. In a healthy state of absorption, excess vitamin B12 is excreted in the urine; in a malabsorption state or when the intrinsic factor is missing, vitamin B12 is excreted in the feces. Citrucel is a bulk-forming agent. Laxatives interfere with the absorption of vitamin B12. The client is NPO 8 to 12 hours before the test but is not NPO during the test. A stool collection is not part of the Schilling test. If stool contaminates the urine collection, the results will be altered.11. ANSWER B. Most clients with pernicious anemia have deficient production of intrinsic factor in the stomach. Intrinsic factor attaches to the vitamin in the stomach and forms a complex that allows the vitamin to be absorbed in the small intestine. The stomach is producing enough acid, there is not an excessive excretion of the vitamin, and there is not a rapid production of RBCs in this condition.12. ANSWER B. The normal physiologic response to activity is an increased metabolic rate over the resting basal rate. The decrease in respiratory rate indicates that the client is not strong enough to complete the mechanical cycle of respiration needed for gas exchange. The postactivity pulse is expected to increase immediately after activity but by no more than 50 bpm if it is strenuous activity. The diastolic blood pressure is expected to rise but by no more than 15 mm Hg. The pulse returns to within 6 bpm of the resting pulse after 3 minutes of rest.13. ANSWER C. The nurse should continue to monitor the client, because this value reflects a normal physiologic response. The physician does not need to be called, and oxygen does not need to be started based on these laboratory findings. Immediately after surgery, the client’s hematocrit reflects a falsely high value related to the body’s compensatory response to the stress of sudden loss of fluids and blood. Activation of the intrinsic pathway and the renin-angiotensin cycle via antidiuretic hormone produces vasoconstriction and retention of fluid for the first 1 to 2 day post-op. By the second to third day, this response decreases and the client’s hematocrit level is more reflective of the amount of RBCs in the plasma. Fresh bleeding is a less likely occurrence on the third post-op day but is not impossible; however, the nurse would have expected to see a decrease in the RBC and hemoglobin values accompanying the hematocrit.14. ANSWER A. Epogen is a recombinant DNA form of erythropoietin, which stimulates the production of RBCs and therefore causes the hematocrit to rise. The elevation in hematocrit causes an elevation in blood pressure; therefore, the blood pressure is a vital sign that should be checked. The PTT, hemoglobin level, and PT are not monitored for this drug.15. ANSWER D. Vitamin B12 is a water-soluble vitamin. When water-soluble vitamins are taken in excess of the body’s needs, they are filtered through the kidneys and excreted. Vitamin B12 is considered to be nontoxic. Adverse reactions that have occurred are believed to be related to impurities or to the preservative in B12 preparations. Ringing in the ears, skin rash, and nausea are not considered to be related to vitamin B12 administration.16. ANSWER B. Brown rice is a source of iron from plant sources (nonheme iron). Other sources of nonheme iron are whole-grain cereals and breads, dark green vegetables, legumes, nuts, dried fruits (apricots, raisins, dates), oatmeal, and sweet potatoes. Egg yolks have iron but it is not as well absorbed as iron from other sources. Vegetables are a good source of vitamins that may facilitate iron absorption. Tea contains tannin, which combines with nonheme iron, preventing its absorption.

17. ANSWER B. Macrocytic anemias can result from deficiencies in vitamin B12 or ascorbic acid. Only vitamin B12 deficiency causes diminished sensations of peripheral nerve endings. The nurse should assess for peripheral neuropathy and instruct the client in self-care activities for her diminished sensation to heat and pain. The burn could be related to abuse, but this conclusion would require more supporting data. The findings should be documented, but the nurse would want to address the client’s sensations first. The decision of how to treat the burn should be determined by the physician.18. ANSWER C. Pruritus is a late symptom that results from abnormal histamine metabolism. Headache and dizziness are early symptoms from engorged veins. Shortness of breath is an early symptom from congested mucous membrane and ineffective gas exchange.19. ANSWERS B, C, D and E. Polycythemia vera, a condition in which too many RBCs are produced in the blood serum, can lead to an increase in the hematocrit and hypervolemia, hyperviscosity, and hypertension. Subsequently, the client can experience dizziness, tinnitus, visual disturbances, headaches, or a feeling of fullness in the head. The client may also experience cardiovascular symptoms such as heart failure (shortness of breath and orthopnea) and increased clotting time or symptoms of an increased uric acid level such as painful swollen joints (usually the big toe). Hearing loss and weight loss are not manifestations associated with polycythemia vera.20. ANSWER A. Aplastic anemia decreases the bone marrow production of RBCs, WBCs, and platelets. The client is at risk for bruising and bleeding tendencies. A change in the intake and output is important, but assessment for the potential for bleeding takes priority. Change in the peripheral nervous system is a priority problem specific to clients with vitamin B12 deficiency. Change in bowel function is not associated with aplastic anemia.