A patient who has non-Hodgkin's lymphoma is receiving combination treatment with
rituximab (Rituxan) and chemotherapy. Which patient assessment finding requires the
most
rapid action by the nurse?
a. Anorexia c. Oral ulcers
b. Vomiting d. Lip swelling
Give this one a try later!
, ANS: D
Lip swelling in angioedema may indicate a hypersensitivity reaction to the
rituximab. The
nurse should stop the infusion and further assess for anaphylaxis. The other
findings may
occur with chemotherapy but are not immediately life threatening.
DIF: Cognitive Level: Analyze (analysis) REF: 642
OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity
Which laboratory test will the nurse use to determine whether filgrastim (Neupogen)
is
effective for a patient with acute lymphocytic leukemia who is receiving
chemotherapy?
a. Platelet count c. Total lymphocyte count
b. Reticulocyte count d. Absolute neutrophil count
Give this one a try later!
ANS: D
Filgrastim increases the neutrophil count and function in neutropenic
patients. Although total
lymphocyte, platelet, and reticulocyte counts are also important to monitor
in this patient, the
absolute neutrophil count is used to evaluate the effects of filgrastim.
DIF: Cognitive Level: Apply (application) REF: 634
TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
The nurse notes scleral jaundice in a patient being admitted with hemolytic anemia.
The nurse
will plan to check the laboratory results for the
a. Schilling test. c. gastric analysis.
b. bilirubin level. d. stool occult blood.
,Give this one a try later!
ANS: B
Jaundice is caused by the elevation of bilirubin level associated with red
blood cell hemolysis.
The other tests would not be helpful in monitoring or treating a hemolytic
anemia.
DIF: Cognitive Level: Apply (application) REF: 615
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
Prevention of AKI is important because of the high mortality rate. Which patients are
at increased risk for AKI (select all that apply)?
a. An 86-yr-old woman scheduled for a cardiac catheterization
b. A 48-yr-old man with multiple injuries from a motor vehicle accident
c. A 32-yr-old woman following a C-section delivery for abruptio placentae
d. A 64-yr-old woman with chronic heart failure admitted with bloody stools
e. A 58-yr-old man with prostate cancer undergoing preoperative workup for
prostatectomy
Give this one a try later!
a, b, c, d, e. High-risk patients include those exposed to nephrotoxic agents
and advanced age (a), massive trauma (b), prolonged hypovolemia or
hypotension (possibly b, c, and d), obstetric complications (c), cardiac
failure (d), preexisting chronic kidney disease (CKD), extensive burns, or
sepsis. Patients with prostate cancer may have obstruction of the outflow
tract, which increases risk of postrenal AKI (e).
Normal findings expected by the nurse on physical assessment of the urinary system
include (select all that apply)
a. nonpalpable left kidney.
b. auscultation of renal artery bruit.
c. CVA tenderness elicited by a kidney punch.
, d. no CVA tenderness elicited by a kidney punch.
e. palpable bladder to the level of the pubic symphysis.
Give this one a try later!
a. nonpalpable left kidney.
d. no CVA tenderness elicited by a kidney punch.
A routine complete blood count for an active older man indicates possible
myelodysplastic
syndrome. The nurse will plan to teach the patient about
a. blood transfusion.
b. bone marrow biopsy.
c. filgrastim (Neupogen) administration.
d. erythropoietin (Epogen) administration.
Give this one a try later!
ANS: B
Bone marrow biopsy is needed to make the diagnosis and determine the
specific type of
myelodysplastic syndrome. The other treatments may be necessary if there
is progression of
the myelodysplastic syndrome, but the initial action for this asymptomatic
patient will be a
bone marrow biopsy.
DIF: Cognitive Level: Apply (application) REF: 634
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
12. A patient who is infected with human immunodeficiency virus (HIV) is being taught
by the nurse about health promotion activities such as good nutrition; avoiding
alcohol, tobacco, drug use, and exposure to infectious agents; keeping up to date
with vaccines; getting adequate rest; and stress management. What is the rationale
behind these interventions that the nurse knows?
rituximab (Rituxan) and chemotherapy. Which patient assessment finding requires the
most
rapid action by the nurse?
a. Anorexia c. Oral ulcers
b. Vomiting d. Lip swelling
Give this one a try later!
, ANS: D
Lip swelling in angioedema may indicate a hypersensitivity reaction to the
rituximab. The
nurse should stop the infusion and further assess for anaphylaxis. The other
findings may
occur with chemotherapy but are not immediately life threatening.
DIF: Cognitive Level: Analyze (analysis) REF: 642
OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity
Which laboratory test will the nurse use to determine whether filgrastim (Neupogen)
is
effective for a patient with acute lymphocytic leukemia who is receiving
chemotherapy?
a. Platelet count c. Total lymphocyte count
b. Reticulocyte count d. Absolute neutrophil count
Give this one a try later!
ANS: D
Filgrastim increases the neutrophil count and function in neutropenic
patients. Although total
lymphocyte, platelet, and reticulocyte counts are also important to monitor
in this patient, the
absolute neutrophil count is used to evaluate the effects of filgrastim.
DIF: Cognitive Level: Apply (application) REF: 634
TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
The nurse notes scleral jaundice in a patient being admitted with hemolytic anemia.
The nurse
will plan to check the laboratory results for the
a. Schilling test. c. gastric analysis.
b. bilirubin level. d. stool occult blood.
,Give this one a try later!
ANS: B
Jaundice is caused by the elevation of bilirubin level associated with red
blood cell hemolysis.
The other tests would not be helpful in monitoring or treating a hemolytic
anemia.
DIF: Cognitive Level: Apply (application) REF: 615
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
Prevention of AKI is important because of the high mortality rate. Which patients are
at increased risk for AKI (select all that apply)?
a. An 86-yr-old woman scheduled for a cardiac catheterization
b. A 48-yr-old man with multiple injuries from a motor vehicle accident
c. A 32-yr-old woman following a C-section delivery for abruptio placentae
d. A 64-yr-old woman with chronic heart failure admitted with bloody stools
e. A 58-yr-old man with prostate cancer undergoing preoperative workup for
prostatectomy
Give this one a try later!
a, b, c, d, e. High-risk patients include those exposed to nephrotoxic agents
and advanced age (a), massive trauma (b), prolonged hypovolemia or
hypotension (possibly b, c, and d), obstetric complications (c), cardiac
failure (d), preexisting chronic kidney disease (CKD), extensive burns, or
sepsis. Patients with prostate cancer may have obstruction of the outflow
tract, which increases risk of postrenal AKI (e).
Normal findings expected by the nurse on physical assessment of the urinary system
include (select all that apply)
a. nonpalpable left kidney.
b. auscultation of renal artery bruit.
c. CVA tenderness elicited by a kidney punch.
, d. no CVA tenderness elicited by a kidney punch.
e. palpable bladder to the level of the pubic symphysis.
Give this one a try later!
a. nonpalpable left kidney.
d. no CVA tenderness elicited by a kidney punch.
A routine complete blood count for an active older man indicates possible
myelodysplastic
syndrome. The nurse will plan to teach the patient about
a. blood transfusion.
b. bone marrow biopsy.
c. filgrastim (Neupogen) administration.
d. erythropoietin (Epogen) administration.
Give this one a try later!
ANS: B
Bone marrow biopsy is needed to make the diagnosis and determine the
specific type of
myelodysplastic syndrome. The other treatments may be necessary if there
is progression of
the myelodysplastic syndrome, but the initial action for this asymptomatic
patient will be a
bone marrow biopsy.
DIF: Cognitive Level: Apply (application) REF: 634
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
12. A patient who is infected with human immunodeficiency virus (HIV) is being taught
by the nurse about health promotion activities such as good nutrition; avoiding
alcohol, tobacco, drug use, and exposure to infectious agents; keeping up to date
with vaccines; getting adequate rest; and stress management. What is the rationale
behind these interventions that the nurse knows?
