Question 1
Question
A nurse in a clinic is caring for a client who has suspected anemia. Which of the following laboratory test results should the nurse expect?
Answer
-
Iron 90 mcg/dL
-
RBC 6.5 million/uL
-
WBC 4,800 mm3
-
Hgb 10 g/dL
Question 2
Question
A nurse is caring for a client who is receiving warfarin for anticoagulation therapy. Which of the following laboratory test results indicates to the nurse that the client needs an increase in the dosage?
Answer
-
aPTT 38 seconds
-
INR 1.1
-
PT 22 seconds
-
D‑dimer negative
Question 3
Question
A nurse is providing teaching for a client who is scheduled for a bone marrow biopsy of the iliac crest. Which of the following statements made by the client indicates an understanding of the teaching?
Answer
-
“This test will be performed while I am lying flat on my back.”
-
“I will need to stay in bed for about an hour after the test.”
-
“This test will determine which antibiotic I should take for treatment.”
-
“I will receive general anesthesia for the test.”
Question 4
Question
A nurse is preparing to administer packed RBCs to a client who has a Hgb of 8 g/dL. Which of the following actions should the nurse plan to take during the first 15 min of the transfusion?
Answer
-
Obtain consent from the client for the transfusion.
-
Assess for an acute hemolytic reaction.
-
Explain the transfusion procedure to the client.
-
Obtain blood culture specimens to send to the lab.
Question 5
Question
A nurse is caring for a client who is receiving a blood transfusion. Which of the following actions should the nurse expect if an allergic transfusion reaction is suspected? (Select all that apply.)
Answer
-
Stop the transfusion.
-
Monitor for hypertension.
-
Maintain an IV infusion with 0.9% sodium chloride.
-
Position the client in an upright position with the feet lower than the heart.
-
Administer diphenhydramine.
Question 6
Question
A nurse is monitoring a client who began receiving a unit of packed RBCs 10 min ago. Which of the following findings should the nurse identify as an indication of a febrile transfusion reaction? (Select all that apply.)
Answer
-
Temperature change from 37° C (98.6° F) pretransfusion to 37.2° C (99.0° F)
-
Current blood pressure 178/90 mm Hg
-
Heart rate change from 88/min pretransfusion to 120/min
-
Client report of itching
-
Client appears flushed
Question 7
Question
A nurse is providing preoperative teaching for a client who requests autologous donation in preparation for a scheduled orthopedic surgical procedure. Which of the following statements should the nurse include in the teaching?
Answer
-
“you should make an appointment to donate blood 8 weeks prior to the surgery.”
-
“If you need an autologous transfusion, the blood your brother donates can be used.”
-
“you can donate blood each week if your hemoglobin is stable.”
-
“Any unused blood that is donated can be used for other clients.”
Question 8
Question
A nurse preceptor is observing a newly licensed nurse on the unit who is preparing to administer a blood transfusion to an older adult client. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure?
Answer
-
Inserts an 18‑gauge IV catheter in the client
-
Verifies blood compatibility and expiration date of the blood with an assistive personnel (AP)
-
Administers dextrose 5% in 0.9% sodium chloride IV with the transfusion
-
Obtains vital signs every 15 min throughout the procedure
Question 9
Question
A nurse is planning care for a client who has Hgb 7.5 g/dL and Hct 21.5%. Which of the following actions should the nurse include in the plan of care? (Select all that apply.)
Answer
-
Provide assistance with ambulation.
-
Monitor oxygen saturation.
-
Weigh the client weekly.
-
Obtain stool specimen for occult blood.
-
Schedule daily rest periods.
Question 10
Question
A nurse is teaching a client who has a new prescription for ferrous sulfate. Which of the following information should the nurse include in the teaching?
Question 11
Question
A nurse is providing discharge teaching to a client who had a gastrectomy for stomach cancer. Which of the following information should the nurse include in the teaching? (Select all that apply.)
Answer
-
“you will need a monthly injection of vitamin B12 for the rest of your life.”
-
“Using the nasal spray form of vitamin B12 on a daily basis can be an option.”
-
“An oral supplement of vitamin B12 taken on a daily basis can be an option.”
-
“you should increase your intake of animal proteins, legumes, and dairy products to increase vitamin B12 in your diet.”
-
“Add soy milk fortified with vitamin B12 to your diet to decrease the risk of pernicious anemia.”
Question 12
Question
A nurse is completing an integumentary assessment of a client who has anemia. Which of the following findings should the nurse expect?
Answer
-
Absent turgor
-
Spoon‑shaped nails
-
Shiny, hairless legs
-
Yellow mucous membranes
Question 13
Question
A nurse in a clinic receives a phone call from a client seeking information about a new prescription for erythropoietin. Which of the following information should the nurse review with the client?
Answer
-
The client needs an erythrocyte sedimentation rate (ESR) test weekly.
-
The client should have his hemoglobin checked twice a week.
-
Oxygen saturation levels should be monitored.
-
Folic acid production will increase.
Question 14
Question
A nurse is caring for a client who has disseminated intravascular coagulation (DIC). Which of the following laboratory values indicates the client’s clotting factors are depleted? (Select all that apply.)
Answer
-
Platelets 100,000/mm3
-
Fibrinogen levels 57 mg/dL
-
Fibrin degradation products 4.3 mcg/mL
-
D‑dimer 0.03 mcg/mL
-
Sedimentation rate 38 mm/hr
Question 15
Question
A nurse is assessing a client and suspects the client is experiencing DIC. Which of the following physical findings should the nurse anticipate?
Answer
-
Bradycardia
-
Hypertension
-
Epistaxis
-
Xerostomia
Question 16
Question
A nurse is caring for a client who has idiopathic thrombocytopenic purpura (ITP). The nurse should notify the provider and report possible small‑vessel clotting when which of the following is assessed?
Question 17
Question
A nurse is caring for a client who has DIC. Which of the following medications should the nurse anticipate administering?
Answer
-
Heparin
-
Vitamin K
-
Mefoxin
-
Simvastatin
Question 18
Question
A nurse is teaching a newly licensed nurse about heparin‑induced thrombocytopenia. Which of the following risk factors for this disorder should the nurse include in the teaching?
Answer
-
Warfarin therapy for atrial fibrillation
-
Placental abruption
-
Systemic lupus erythematosus
-
Heparin therapy for deep‑vein thrombosis
Question 19
Question
A nurse is admitting a client who reports nausea, vomiting, and weakness. The client has dry oral mucous membranes, temperature 38.5° C (101.3° F), pulse 92/min, respirations 24/min, skin cool with tenting present, and blood pressure 102/64 mm Hg. Urine is concentrated with a high specific gravity. Which of the following are manifestations of fluid volume deficit for which the nurse should monitor? (Select all that apply.)
Answer
-
Decreased skin turgor
-
Concentrated urine
-
Bradycardia
-
Low‑grade fever
-
Tachypnea
Question 20
Question
A nurse is admitting an older adult client who is experiencing dyspnea, weakness, weight gain of 2 lb, and 1+ bilateral edema of the lower extremities. The client has temperature 37.2° C (99° F), pulse 96/min, respirations 26/min, oxygen saturation 94% on 3 L oxygen via nasal cannula, and blood pressure 152/96 mm Hg. Which of the following manifestations of fluid volume excess should the nurse expect? (Select all that apply.)
Answer
-
Dyspnea
-
Edema
-
Bradycardia
-
Hypertension
-
Weakness
Question 21
Question
A nurse is assessing a client who is dehydrated for fluid volume deficit. Which of the following findings should the nurse expect in the client?
Answer
-
Moist skin
-
Distended neck veins
-
Increased urinary output
-
Tachycardia
Question 22
Question
A nurse is caring for an older adult client in a long‑term care facility. The client has become weak and confused. He ate 40% of his breakfast and lunch. The client’s temperature is 38.3° C (100.9° F), pulse 92/min, respirations 20/min, and blood pressure 108/60 mm Hg. He has lost ¾ lb and reports dizziness when assisted to the bathroom. He also has a nonproductive cough with diminished breath sounds in the right lower lobe. Which of the following actions should the nurse take?
Answer
-
Initiate fluid restrictions to limit intake.
-
Observe for signs of peripheral edema.
-
Encourage the client to ambulate to promote oxygenation.
-
Monitor for orthostatic hypotension
Question 23
Question
A nurse is caring for a client who has a serum sodium level 133 mEq/L and serum potassium level 3.4 mEq/L. The nurse should recognize that which of the following treatments can result in these laboratory findings?
Question 24
Question
A nurse is caring for a client who has a serum potassium 5.4 mEq/L. The nurse should assess for which of the following manifestations?
Answer
-
ECG changes
-
Constipation
-
Polyuria
-
Hypotension
Question 25
Question
A nurse is caring for a client who has a nasogastric tube attached to low intermittent suctioning. The nurse should monitor for which of the following electrolyte imbalances?
Answer
-
Hypercalcemia
-
Hyponatremia
-
Hyperphosphatemia
-
Hypomagnesemia
Question 26
Question
A nurse is assessing a client who has hyperkalemia. The nurse should identify which of the following conditions as being associated with this electrolyte imbalance?
Answer
-
Diabetic ketoacidosis
-
Heart failure
-
Cushing’s syndrome
-
Thyroidectomy
Question 27
Question
A nurse is assessing a client for Chvostek’s sign. Which of the following techniques should the nurse use to perform this test?
Answer
-
Apply a blood pressure cuff to the client’s arm.
-
Place the stethoscope bell over the client’s carotid artery.
-
Tap lightly on the client’s cheek.
-
Ask the client to lower her chin to her chest.
Question 28
Question
A nurse is caring for a client admitted with confusion and lethargy. The client was found at home unresponsive with an empty bottle of aspirin lying next to her bed. Vital signs reveal blood pressure 104/72 mm Hg, heart rate 116/min with regular rhythm, and respiratory rate 42/min and deep. Which of the following arterial blood gas findings should the nurse expect?
Answer
-
pH 7.68 PaO2 96 mm Hg PaCO2 38 mm Hg HCO3− 28 mEq/L
-
pH 7.48 PaO2 100 mm Hg PaCO2 28 mm Hg HCO3− 23 mEq/L
-
pH 6.98 PaO2 100 mm Hg PaCO2 30 mm Hg HCO3− 18 mEq/L
-
pH 7.58 PaO2 96 mm Hg PaCO2 38 mm Hg HCO3− 29 mEq/L
Question 29
Question
A nurse is caring for a client who was in a motor‑vehicle accident. The client reports chest pain and difficulty breathing. A chest x‑ray reveals the client has a pneumothorax. Which of the following arterial blood gas findings should the nurse expect?
Answer
-
pH 7.06 PaO2 86 mm Hg PaCO2 52 mm Hg HCO3− 24 mEq/L
-
pH 7.42 PaO2 100 mm Hg PaCO2 38 mm Hg HCO3− 23 mEq/L
-
pH 6.98 PaO2 100 mm Hg PaCO2 30 mm Hg HCO3− 18 mEq/L
-
pH 7.58 PaO2 96 mm Hg PaCO2 38 mm Hg HCO3− 29 mEq/L
Question 30
Question
A nurse is obtaining arterial blood gases for a client who has vomited for 24 hr. The nurse should expect which of the following acid‑base imbalances to result from vomiting for 24 hr?
Answer
-
Respiratory acidosis
-
Respiratory alkalosis
-
Metabolic acidosis
-
Metabolic alkalosis
Question 31
Question
A charge nurse is teaching a group of nurses about conditions related to metabolic acidosis. Which of the following statements by a unit nurse indicates the teaching has been effective?
Answer
-
“Metabolic acidosis can occur due to diabetic ketoacidosis.”
-
“Metabolic acidosis can occur in a client who has myasthenia gravis.”
-
“Metabolic acidosis can occur in a client who has asthma.”
-
“Metabolic acidosis can occur due to cancer.”
Question 32
Question
A nurse is assessing a client who has pancreatitis. The client’s arterial blood gases reveal metabolic acidosis. Which of the following are expected findings? (Select all that apply.)
Answer
-
Tachycardia
-
Hypertension
-
Bounding pulses
-
Hyperreflexia
-
Dysrhythmia
-
Tachypnea