30. When assessing venous disease in a patients lower extremities, the nurse knows
that what test will most likely be ordered?
A) Duplex ultrasonography
B) Echocardiography
C) Positron emission tomography (PET)
D) Radiography
Give this one a try later!
, A
Feedback:
Duplex ultrasound may be used to determine the level and extent of
venous disease as well as its chronicity. Radiographs (x-rays), PET scanning,
and echocardiography are never used for this purpose as they do not allow
visualization of blood flow.
32. A patient is receiving a blood transfusion and complains of a new onset of slight
dyspnea. The nurses rapid assessment reveals bilateral lung crackles and elevated BP.
What is the nurses most appropriate action?
A) Slow the infusion rate and monitor the patient closely.
B) Discontinue the transfusion and begin resuscitation.
C) Pause the transfusion and administer a 250 mL bolus of normal saline.
D) Discontinue the transfusion and administer a beta-blocker, as ordered.
Give this one a try later!
A
Feedback:
The patient is showing early signs of hypervolemia; the nurse should slow
the infusion rate and assess the patient closely for any signs of
exacerbation. At this stage, discontinuing the transfusion is not necessary. A
bolus would worsen the patients fluid overload.
33. A patient comes into the clinic complaining of fatigue. Blood work shows an
increased bilirubin concentration and an increased reticulocyte count. What would
the nurse suspect the patient has?
A) A hypoproliferative anemia
B) A leukemia
C) Thrombocytopenia
D) A hemolytic anemia
Give this one a try later!
, D
Feedback:
In hemolytic anemias, premature destruction of erythrocytes results in the
liberation of hemoglobin from the erythrocytes into the plasma; the
released hemoglobin is converted in large part to bilirubin, and therefore
the bilirubin concentration rises. The increased erythrocyte destruction
leads to tissue hypoxia, which in turn stimulates erythropoietin production.
This increased production is reflected in an increased reticulocyte count as
the bone marrow responds to the loss of erythrocytes. Hypoproliferative
anemias, leukemia, and thrombocytopenia lack this pathology and
presentation.
31. A nurse is performing blood pressure screenings at a local health fair. While
obtaining subjective assessment data from a patient with hypertension, the nurse
learns that the patient has a family history of hypertension and she herself has high
cholesterol and lipid levels. The patient says she smokes one pack of cigarettes daily
and drinks about a pack of beer every day. The nurse notes what nonmodifiable risk
factor for hypertension?
A) Hyperlipidemia
B) Excessive alcohol intake
C) A family history of hypertension
D) Closer adherence to medical regimen
Give this one a try later!
C
Feedback:
Unlike cholesterol levels, alcohol intake and adherence to treatment, family
history is not modifiable
A nurse is developing a teaching plan for a patient with COPD. What should the nurse
include as the most important area of teaching?
A) Avoiding extremes of heat and cold
B) Setting and accepting realistic short- and long-range goals
, C) Adopting a lifestyle of moderate activity
D) Avoiding emotional disturbances and stressful situations
Give this one a try later!
B
Feedback: A major area of teaching involves setting and accepting realistic
short-term and long-range goals. The other options should also be
included in the teaching plan, but they are not areas that are as high a
priority as setting and accepting realistic goals.
The nurse is caring for a patient who has been scheduled for a bronchoscopy. How
should the nurse prepare the patient for this procedure?
A) Administer a bolus of IV fluids.
B) Arrange for the insertion of a peripherally inserted central catheter.
C) Administer nebulized bronchodilators every 2 hours until the test.
D) Withhold food and fluids for several hours before the test.
Give this one a try later!
D
Feedback: Food and fluids are withheld for 4 to 8 hours before the test to
reduce the risk of aspiration when the cough reflex is blocked by
anesthesia. IV fluids, bronchodilators, and a central line are unnecessary.
33. An adult patient has been diagnosed with iron-deficiency anemia. What nursing
diagnosis is most likely to apply to this patients health status?
A) Risk for deficient fluid volume related to impaired erythropoiesis
B) Risk for infection related to tissue hypoxia
C) Acute pain related to uncontrolled hemolysis
D) Fatigue related to decreased oxygen-carrying capacity
Give this one a try later!
that what test will most likely be ordered?
A) Duplex ultrasonography
B) Echocardiography
C) Positron emission tomography (PET)
D) Radiography
Give this one a try later!
, A
Feedback:
Duplex ultrasound may be used to determine the level and extent of
venous disease as well as its chronicity. Radiographs (x-rays), PET scanning,
and echocardiography are never used for this purpose as they do not allow
visualization of blood flow.
32. A patient is receiving a blood transfusion and complains of a new onset of slight
dyspnea. The nurses rapid assessment reveals bilateral lung crackles and elevated BP.
What is the nurses most appropriate action?
A) Slow the infusion rate and monitor the patient closely.
B) Discontinue the transfusion and begin resuscitation.
C) Pause the transfusion and administer a 250 mL bolus of normal saline.
D) Discontinue the transfusion and administer a beta-blocker, as ordered.
Give this one a try later!
A
Feedback:
The patient is showing early signs of hypervolemia; the nurse should slow
the infusion rate and assess the patient closely for any signs of
exacerbation. At this stage, discontinuing the transfusion is not necessary. A
bolus would worsen the patients fluid overload.
33. A patient comes into the clinic complaining of fatigue. Blood work shows an
increased bilirubin concentration and an increased reticulocyte count. What would
the nurse suspect the patient has?
A) A hypoproliferative anemia
B) A leukemia
C) Thrombocytopenia
D) A hemolytic anemia
Give this one a try later!
, D
Feedback:
In hemolytic anemias, premature destruction of erythrocytes results in the
liberation of hemoglobin from the erythrocytes into the plasma; the
released hemoglobin is converted in large part to bilirubin, and therefore
the bilirubin concentration rises. The increased erythrocyte destruction
leads to tissue hypoxia, which in turn stimulates erythropoietin production.
This increased production is reflected in an increased reticulocyte count as
the bone marrow responds to the loss of erythrocytes. Hypoproliferative
anemias, leukemia, and thrombocytopenia lack this pathology and
presentation.
31. A nurse is performing blood pressure screenings at a local health fair. While
obtaining subjective assessment data from a patient with hypertension, the nurse
learns that the patient has a family history of hypertension and she herself has high
cholesterol and lipid levels. The patient says she smokes one pack of cigarettes daily
and drinks about a pack of beer every day. The nurse notes what nonmodifiable risk
factor for hypertension?
A) Hyperlipidemia
B) Excessive alcohol intake
C) A family history of hypertension
D) Closer adherence to medical regimen
Give this one a try later!
C
Feedback:
Unlike cholesterol levels, alcohol intake and adherence to treatment, family
history is not modifiable
A nurse is developing a teaching plan for a patient with COPD. What should the nurse
include as the most important area of teaching?
A) Avoiding extremes of heat and cold
B) Setting and accepting realistic short- and long-range goals
, C) Adopting a lifestyle of moderate activity
D) Avoiding emotional disturbances and stressful situations
Give this one a try later!
B
Feedback: A major area of teaching involves setting and accepting realistic
short-term and long-range goals. The other options should also be
included in the teaching plan, but they are not areas that are as high a
priority as setting and accepting realistic goals.
The nurse is caring for a patient who has been scheduled for a bronchoscopy. How
should the nurse prepare the patient for this procedure?
A) Administer a bolus of IV fluids.
B) Arrange for the insertion of a peripherally inserted central catheter.
C) Administer nebulized bronchodilators every 2 hours until the test.
D) Withhold food and fluids for several hours before the test.
Give this one a try later!
D
Feedback: Food and fluids are withheld for 4 to 8 hours before the test to
reduce the risk of aspiration when the cough reflex is blocked by
anesthesia. IV fluids, bronchodilators, and a central line are unnecessary.
33. An adult patient has been diagnosed with iron-deficiency anemia. What nursing
diagnosis is most likely to apply to this patients health status?
A) Risk for deficient fluid volume related to impaired erythropoiesis
B) Risk for infection related to tissue hypoxia
C) Acute pain related to uncontrolled hemolysis
D) Fatigue related to decreased oxygen-carrying capacity
Give this one a try later!
