NursGuru
    Login/Signup
    Review ModeExam ModePractice Mode

    Exam Review

    1. The nurse is triaging several patients in an urgent care center. One patient states that he has hemophilia and is bleeding, with of bleeding. Which priority action by the nurse is most appropriate at this time?
      A)
      Send the patient for routine x-rays to locate the source of bleeding and place him in an examination room.
      B)
      Have the patient take a number and stay in the waiting area.
      C)
      Palpate the suspected area of bleeding for tenderness and edema.
      D)
      Place the patient in an examination room immediately and notify the physician of a potential bleeding crisis.
      E)
      Place the patient in an examination room immediately and notify the physician of a potential bleeding crisis.
    2. A pediatric nurse is assisting with the care of a school-age child who has leukemia Exhibits Which of the following data collection findings should the nurse report to the provider? Select the 5 findings that should be reported to the provider.
      (SATA)
      A)
      Blood pressure
      B)
      Skin assessment
      C)
      Breath sounds
      D)
      Oxygen saturation
      E)
      WBC count
      F)
      Retractions
      G)
      Respiratory rate
      H)
      Hemoglobin
    3. A nurse is preparing to administer 1,000 mL of lactated Ringer's IV over 6 hr. The drop factor of the manual IV tubing is 10 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
      Correct Answer:28 gtt/min
    4. A nurse is assisting with the care of a client who is receiving a blood transfusion. The nurse should monitor for which of the following findings as an indication the client is having an acute hemolytic reaction?
      A)
      Pulmonary congestion
      B)
      Vomiting
      C)
      Urticaria
      D)
      Low back pain
    Page 1 of 7

    Exam Review

    1. A nurse is calculating a client's fluid intake over the past 8 hr. The client had one 8-oz cup of coffee, 3 oz of juice, and 12 oz of soda. The client's water pitcher had 800 mL and 200 mL remain. The client also had IV fluids infusing at 40 mL/hr via an IV pump. How many mL should the nurse document as the client's total intake for the shift?
      Correct Answer:1, 610 mL
    2. A nurse is collecting data from a client who has leukemia. Which of the following findings has the highest priority?
      A)
      Platelet count 125,000/mm3 (150,000 - 400,000)
      B)
      Hematocrit 35% (F 37% -47%; M 42% -52%)
      C)
      Bone pain
      D)
      Weight loss
    3. The nurse is assisting in the development of a care plan for a patient with pernicious anemia. Which of the following would be the most common nursing diagnosis with this medical condition?
      A)
      Ineffective airway clearance related to dyspnea.
      B)
      Risk for infection related to reduction in white blood cells (WBCs)
      C)
      Chronic pain related to bone marrow dysfunction
      D)
      Activity intolerance related to tissue hypoxia
    4. A nurse is reviewing laboratory findings for a client admitted with multiple myeloma. The nurse should expect to see an increase in which of the Following laboratory tests?
      A)
      WBCs
      B)
      Absolute neutrophil count
      C)
      Calcium
      D)
      Platelets
    Page 2 of 7

    Exam Review

    1. The nurse is caring for a patient with stage IV Hodgkin disease. Where should the nurse expect to find enlarged lymph nodes during the assessment?
      A)
      Generalized throughout the body within multiple organs
      B)
      Two or more areas on the same side of the diaphragm
      C)
      Localized in the cervical neck area only
      D)
      Two areas of lymph nodes above and below the diaphragm
    2. The nurse is caring for a patient in sickle cell crisis. What is the rationale for providing warm compresses and blankets for this patient?
      A)
      Sickle cell crisis pain can be exacerbated with shivering.
      B)
      Heat promotes proper formation of red blood cells (RBCs) and prevents sickling.
      C)
      Heat relaxes the muscles and distracts the patient from the pain.
      D)
      Heat increases circulation by preventing vasoconstriction.
    3. The nurse is caring for the patient who is 1 day status post splenectomy. The patient complains of pain of a 3 on inspiration. What would be the most appropriate priority nursing intervention for this patient?
      A)
      Contact the surgeon to request a chest x-ray and a laboratory draw for CBC with differential.
      B)
      Medicate with opioids for pain and assist the patient to deep breathe, cough, and ambulate.
      C)
      Contact the surgeon to obtain orders for a nebulizer treatment from respiratory therapy.
      D)
      Provide the patient with a heating pad alternated with a cold pack for incisional pain.
    4. The home care nurse is providing teaching to the family of a patient with multiple myeloma. Which nursing diagnosis should guide the nurse for this teaching?
      A)
      Ineffective tissue perfusion related to vascular occlusion
      B)
      Risk for injury related to compromised bone integrity
      C)
      Ineffective airway clearance related to swelling of the lymph nodes
      D)
      Risk for deficit fluid volume related to a bleeding disorder
    Page 3 of 7

    Exam Review

    1. A nurse is caring for a client who is receiving a unit of packed RBCs. About 15 min following the start of the transfusion, the nurse notes that the client is flushed and febrile, and reports chills. To help confirm that the client is having an acute hemolytic transfusion reaction, the nurse should observe for which of the following manifestations?
      A)
      Distended neck veins
      B)
      Hypotension
      C)
      Urticaria
      D)
      Jaw Pain
    2. A nurse is reinforcing teaching with a client who is to have a bone marrow aspiration and biopsy. The nurse should tell the client that, in addition to the iliac crest, a common site for this procedure is which of the following?
      A)
      Humerus
      B)
      Hip
      C)
      Sternum
      D)
      Cervical spine
    3. What types of cells are present in Hodgkin's lymphoma?
      A)
      Reed-Sternberg Cell
      B)
      Stem Cells
      C)
      RBC'S
      D)
      Bence-Jones Cells
    4. A nurse is assisting in planning care for a client who has advanced multiple myeloma. When planning care, the nurse should recognize that the client is at risk for which of the following complications?
      A)
      Gastrointestinal bleeding
      B)
      Myxedema
      C)
      Retinopathy
      D)
      Pathologic fracture
    Page 4 of 7

    Exam Review

    1. The nurse is preparing to assist the physician with a bone marrow biopsy. Which of the following interventions is most important for the nurse to carry out before the procedure?
      A)
      Drape the biopsy site
      B)
      Explain the procedure to the patient's family
      C)
      Observe the patient for bleeding
      D)
      Administer an analgesic to the patient
    2. The nurse is caring for a patient receiving treatment for a hemolytic reaction from a mismatched blood transfusion. The nurse understands that this the incompatible blood is causing what?
      A)
      An abundance of immature RBCs
      B)
      Destruction of RBCs
      C)
      Malformed RBCS
      D)
      A deficiency in vitamin B12
    3. The nurse is teaching the parent of a child with hemophilia. Which of the following statements by the parent demonstrates understanding about preventing bleeding episodes?
      A)
      "My son will have to grow a beard"
      B)
      "My son will have to avoid fresh foods such as fruit in his diet"
      C)
      "My son will always have to live near a major hospital"
      D)
      "My son will have to avoid contact sports"
    4. A nurse is reinforcing teaching with a client has a new diagnosis of aplastic anemia. When discussing the pathology of this disease, which of the following instructions should the nurse include in the teaching?
      A)
      "Aplastic anemia is associated with the decreased intake of iron."
      B)
      "Aplastic anemia results from decreased bone marrow production of RBCs."
      C)
      "Aplastic anemia results in an increased rate of RBC destruction."
      D)
      "Aplastic anemia is directly related to impaired liver function."
    Page 5 of 7

    Exam Review

    1. A nurse is caring for an adolescent who is having a sickle cell crisis. Which of the following nursing actions should the nurse take?
      A)
      Assist with administering a blood transfusion.
      B)
      Initiate a 2 L/day fluid restriction.
      C)
      Withhold opioids to avoid dependence.
      D)
      Encourage exercise.
    2. A nurse is reviewing data for a client who has disseminated intravascular coagulation (DIC). Which of the following findings should the nurse expect?
      A)
      Increased clotting factors.
      B)
      Progressive increase in platelet production.
      C)
      Excessive thrombosis and bleeding.
      D)
      Immediate sodium and fluid retention.
    3. A nurse is reinforcing teaching about pernicious anemia with a client following a total gastrectomy. Which of the following dietary supplements should the nurse include in the teaching as the treatment for pernicious anemia?
      A)
      Vitamin C
      B)
      Iron
      C)
      Vitamin B12
      D)
      Folate
    4. The nurse is assessing a patient in a family practice clinic. The patient had extensive testing to rule out Hodgkin disease. Which of the following characteristics would indicate Hodgkin disease?
      A)
      The patient is complaining of excessive thirst and hunger
      B)
      Results indicate the presence of the Philadelphia chromosome
      C)
      Results indicate the presence of Reed Sternberg cells
      D)
      The patient is cyanotic
    Page 6 of 7