3
CHAPTER THREE
Practice Exam 3 and
Rationales
1. A 43-year-old African American male is admitted with sickle cell
✓
Quick Check
Quick Answer: 223
anemia. The nurse plans to assess circulation in the lower extrem- Detailed Answer: 225
ities every two hours. Which of the following outcome criteria
would the nurse use?
❍ A. Body temperature of 99°F or less
❍ B. Toes moved in active range of motion
❍ C. Sensation reported when soles of feet are touched
❍ D. Capillary refill of < 3 seconds
2. A 30-year-old male from Haiti is brought to the emergency depart- Quick Answer: 223
ment in sickle cell crisis. What is the best position for this client? Detailed Answer: 225
❍ A. Side-lying with knees flexed
❍ B. Knee-chest
❍ C. High Fowler’s with knees flexed
❍ D. Semi-Fowler’s with legs extended on the bed
3. A 25-year-old male is admitted in sickle cell crisis. Which of the Quick Answer: 223
following interventions would be of highest priority for this client? Detailed Answer: 225
❍ A. Taking hourly blood pressures with mechanical cuff
❍ B. Encouraging fluid intake of at least 200mL per hour
❍ C. Position in high Fowler’s with knee gatch raised
❍ D. Administering Tylenol as ordered
4. Which of the following foods would the nurse encourage the client Quick Answer: 223
in sickle cell crisis to eat? Detailed Answer: 225
❍ A. Steak
❍ B. Cottage cheese
❍ C. Popsicle
❍ D. Lima beans
,170 Chapter 3
5. A newly admitted client has sickle cell crisis. He is complaining of
✓
Quick Check
Quick Answer: 223
pain in his feet and hands. The nurse’s assessment findings Detailed Answer: 225
include a pulse oximetry of 92. Assuming that all the following
interventions are ordered, which should be done first?
❍ A. Adjust the room temperature
❍ B. Give a bolus of IV fluids
❍ C. Start O2
❍ D. Administer meperidine (Demerol) 75mg IV push
6. The nurse is instructing a client with iron-deficiency anemia. Quick Answer: 223
Which of the following meal plans would the nurse expect the Detailed Answer: 225
client to select?
❍ A. Roast beef, gelatin salad, green beans, and peach pie
❍ B. Chicken salad sandwich, coleslaw, French fries, ice
cream
❍ C. Egg salad on wheat bread, carrot sticks, lettuce salad,
raisin pie
❍ D. Pork chop, creamed potatoes, corn, and coconut cake
7. Clients with sickle cell anemia are taught to avoid activities that Quick Answer: 223
cause hypoxia and hypoxemia. Which of the following activities Detailed Answer: 225
would the nurse recommend?
❍ A. A family vacation in the Rocky Mountains
❍ B. Chaperoning the local boys club on a snow-skiing trip
❍ C. Traveling by airplane for business trips
❍ D. A bus trip to the Museum of Natural History
8. The nurse is conducting an admission assessment of a client with Quick Answer: 223
vitamin B12 deficiency. Which finding reinforces the diagnosis of Detailed Answer: 225
B12 deficiency?
❍ A. Enlarged spleen
❍ B. Elevated blood pressure
❍ C. Bradycardia
❍ D. Beefy tongue
9. The body part that would most likely display jaundice in the dark- Quick Answer: 223
skinned individual is the: Detailed Answer: 225
❍ A. Conjunctiva of the eye
❍ B. Soles of the feet
❍ C. Roof of the mouth
❍ D. Shins
, Practice Exam 3 and Rationales 171
10. The nurse is conducting a physical assessment on a client with
✓
Quick Check
Quick Answer: 223
anemia. Which of the following clinical manifestations would be Detailed Answer: 226
most indicative of the anemia?
❍ A. BP 146/88
❍ B. Respirations 28 shallow
❍ C. Weight gain of 10 pounds in six months
❍ D. Pink complexion
11. The nurse is teaching the client with polycythemia vera about pre- Quick Answer: 223
vention of complications of the disease. Which of the following Detailed Answer: 226
statements by the client indicates a need for further teaching?
❍ A. “I will drink 500mL of fluid or less each day.”
❍ B. “I will wear support hose.”
❍ C. “I will check my blood pressure regularly.”
❍ D. “I will report ankle edema.”
12. A 33-year-old male is being evaluated for possible acute leukemia. Quick Answer: 223
Which of the following findings is most likely related to the diag- Detailed Answer: 226
nosis of leukemia?
❍ A. The client collects stamps as a hobby.
❍ B. The client recently lost his job as a postal worker.
❍ C. The client had radiation for treatment of Hodgkin’s dis-
ease as a teenager.
❍ D. The client’s brother had leukemia as a child.
13. Where is the best site for examining for the presence of petechiae Quick Answer: 223
in an African American client? Detailed Answer: 226
❍ A. The abdomen
❍ B. The thorax
❍ C. The earlobes
❍ D. The soles of the feet
14. The client is being evaluated for possible acute leukemia. Which Quick Answer: 223
inquiry by the nurse is most important? Detailed Answer: 226
❍ A. “Have you noticed a change in sleeping habits
recently?”
❍ B. “Have you had a respiratory infection in the last six
months?”
❍ C. “Have you lost weight recently?”
❍ D. “Have you noticed changes in your alertness?”
, 172 Chapter 3
15. Which of the following would be the priority nursing diagnosis for
✓
Quick Check
Quick Answer: 223
the adult client with acute leukemia? Detailed Answer: 226
❍ A. Oral mucous membrane, altered related to chemo-
therapy
❍ B. Risk for injury related to thrombocytopenia
❍ C. Fatigue related to the disease process
❍ D. Interrupted family processes related to life-threatening
illness of a family member
16. A 21-year-old male with Hodgkin’s lymphoma is a senior at the Quick Answer: 223
local university. He is engaged to be married and is to begin a new Detailed Answer: 226
job upon graduation. Which of the following diagnoses would be a
priority for this client?
❍ A. Sexual dysfunction related to radiation therapy
❍ B. Anticipatory grieving related to terminal illness
❍ C. Tissue integrity related to prolonged bed rest
❍ D. Fatigue related to chemotherapy
17. A client has autoimmune thrombocytopenic purpura. To determine Quick Answer: 223
the client’s response to treatment, the nurse would monitor: Detailed Answer: 226
❍ A. Platelet count
❍ B. White blood cell count
❍ C. Potassium levels
❍ D. Partial prothrombin time (PTT)
18. The home health nurse is visiting a client with autoimmune thrombo- Quick Answer: 223
cytopenic purpura (ATP). The client’s platelet count currently is Detailed Answer: 226
80,000. It will be most important to teach the client and family about:
❍ A. Bleeding precautions
❍ B. Prevention of falls
❍ C. Oxygen therapy
❍ D. Conservation of energy
19. The client has surgery for removal of a Prolactinoma. Which of Quick Answer: 223
the following interventions would be appropriate for this client? Detailed Answer: 226
❍ A. Place the client in Trendelenburg position for postural
drainage.
❍ B. Encourage coughing and deep breathing every two
hours.
❍ C. Elevate the head of the bed 30°.
❍ D. Encourage the Valsalva maneuver for bowel movements.
CHAPTER THREE
Practice Exam 3 and
Rationales
1. A 43-year-old African American male is admitted with sickle cell
✓
Quick Check
Quick Answer: 223
anemia. The nurse plans to assess circulation in the lower extrem- Detailed Answer: 225
ities every two hours. Which of the following outcome criteria
would the nurse use?
❍ A. Body temperature of 99°F or less
❍ B. Toes moved in active range of motion
❍ C. Sensation reported when soles of feet are touched
❍ D. Capillary refill of < 3 seconds
2. A 30-year-old male from Haiti is brought to the emergency depart- Quick Answer: 223
ment in sickle cell crisis. What is the best position for this client? Detailed Answer: 225
❍ A. Side-lying with knees flexed
❍ B. Knee-chest
❍ C. High Fowler’s with knees flexed
❍ D. Semi-Fowler’s with legs extended on the bed
3. A 25-year-old male is admitted in sickle cell crisis. Which of the Quick Answer: 223
following interventions would be of highest priority for this client? Detailed Answer: 225
❍ A. Taking hourly blood pressures with mechanical cuff
❍ B. Encouraging fluid intake of at least 200mL per hour
❍ C. Position in high Fowler’s with knee gatch raised
❍ D. Administering Tylenol as ordered
4. Which of the following foods would the nurse encourage the client Quick Answer: 223
in sickle cell crisis to eat? Detailed Answer: 225
❍ A. Steak
❍ B. Cottage cheese
❍ C. Popsicle
❍ D. Lima beans
,170 Chapter 3
5. A newly admitted client has sickle cell crisis. He is complaining of
✓
Quick Check
Quick Answer: 223
pain in his feet and hands. The nurse’s assessment findings Detailed Answer: 225
include a pulse oximetry of 92. Assuming that all the following
interventions are ordered, which should be done first?
❍ A. Adjust the room temperature
❍ B. Give a bolus of IV fluids
❍ C. Start O2
❍ D. Administer meperidine (Demerol) 75mg IV push
6. The nurse is instructing a client with iron-deficiency anemia. Quick Answer: 223
Which of the following meal plans would the nurse expect the Detailed Answer: 225
client to select?
❍ A. Roast beef, gelatin salad, green beans, and peach pie
❍ B. Chicken salad sandwich, coleslaw, French fries, ice
cream
❍ C. Egg salad on wheat bread, carrot sticks, lettuce salad,
raisin pie
❍ D. Pork chop, creamed potatoes, corn, and coconut cake
7. Clients with sickle cell anemia are taught to avoid activities that Quick Answer: 223
cause hypoxia and hypoxemia. Which of the following activities Detailed Answer: 225
would the nurse recommend?
❍ A. A family vacation in the Rocky Mountains
❍ B. Chaperoning the local boys club on a snow-skiing trip
❍ C. Traveling by airplane for business trips
❍ D. A bus trip to the Museum of Natural History
8. The nurse is conducting an admission assessment of a client with Quick Answer: 223
vitamin B12 deficiency. Which finding reinforces the diagnosis of Detailed Answer: 225
B12 deficiency?
❍ A. Enlarged spleen
❍ B. Elevated blood pressure
❍ C. Bradycardia
❍ D. Beefy tongue
9. The body part that would most likely display jaundice in the dark- Quick Answer: 223
skinned individual is the: Detailed Answer: 225
❍ A. Conjunctiva of the eye
❍ B. Soles of the feet
❍ C. Roof of the mouth
❍ D. Shins
, Practice Exam 3 and Rationales 171
10. The nurse is conducting a physical assessment on a client with
✓
Quick Check
Quick Answer: 223
anemia. Which of the following clinical manifestations would be Detailed Answer: 226
most indicative of the anemia?
❍ A. BP 146/88
❍ B. Respirations 28 shallow
❍ C. Weight gain of 10 pounds in six months
❍ D. Pink complexion
11. The nurse is teaching the client with polycythemia vera about pre- Quick Answer: 223
vention of complications of the disease. Which of the following Detailed Answer: 226
statements by the client indicates a need for further teaching?
❍ A. “I will drink 500mL of fluid or less each day.”
❍ B. “I will wear support hose.”
❍ C. “I will check my blood pressure regularly.”
❍ D. “I will report ankle edema.”
12. A 33-year-old male is being evaluated for possible acute leukemia. Quick Answer: 223
Which of the following findings is most likely related to the diag- Detailed Answer: 226
nosis of leukemia?
❍ A. The client collects stamps as a hobby.
❍ B. The client recently lost his job as a postal worker.
❍ C. The client had radiation for treatment of Hodgkin’s dis-
ease as a teenager.
❍ D. The client’s brother had leukemia as a child.
13. Where is the best site for examining for the presence of petechiae Quick Answer: 223
in an African American client? Detailed Answer: 226
❍ A. The abdomen
❍ B. The thorax
❍ C. The earlobes
❍ D. The soles of the feet
14. The client is being evaluated for possible acute leukemia. Which Quick Answer: 223
inquiry by the nurse is most important? Detailed Answer: 226
❍ A. “Have you noticed a change in sleeping habits
recently?”
❍ B. “Have you had a respiratory infection in the last six
months?”
❍ C. “Have you lost weight recently?”
❍ D. “Have you noticed changes in your alertness?”
, 172 Chapter 3
15. Which of the following would be the priority nursing diagnosis for
✓
Quick Check
Quick Answer: 223
the adult client with acute leukemia? Detailed Answer: 226
❍ A. Oral mucous membrane, altered related to chemo-
therapy
❍ B. Risk for injury related to thrombocytopenia
❍ C. Fatigue related to the disease process
❍ D. Interrupted family processes related to life-threatening
illness of a family member
16. A 21-year-old male with Hodgkin’s lymphoma is a senior at the Quick Answer: 223
local university. He is engaged to be married and is to begin a new Detailed Answer: 226
job upon graduation. Which of the following diagnoses would be a
priority for this client?
❍ A. Sexual dysfunction related to radiation therapy
❍ B. Anticipatory grieving related to terminal illness
❍ C. Tissue integrity related to prolonged bed rest
❍ D. Fatigue related to chemotherapy
17. A client has autoimmune thrombocytopenic purpura. To determine Quick Answer: 223
the client’s response to treatment, the nurse would monitor: Detailed Answer: 226
❍ A. Platelet count
❍ B. White blood cell count
❍ C. Potassium levels
❍ D. Partial prothrombin time (PTT)
18. The home health nurse is visiting a client with autoimmune thrombo- Quick Answer: 223
cytopenic purpura (ATP). The client’s platelet count currently is Detailed Answer: 226
80,000. It will be most important to teach the client and family about:
❍ A. Bleeding precautions
❍ B. Prevention of falls
❍ C. Oxygen therapy
❍ D. Conservation of energy
19. The client has surgery for removal of a Prolactinoma. Which of Quick Answer: 223
the following interventions would be appropriate for this client? Detailed Answer: 226
❍ A. Place the client in Trendelenburg position for postural
drainage.
❍ B. Encourage coughing and deep breathing every two
hours.
❍ C. Elevate the head of the bed 30°.
❍ D. Encourage the Valsalva maneuver for bowel movements.
