Exam (elaborations) NURS 101 Nclex-Exam Practice p164

Exam (elaborations) NURS 101 Nclex-Exam Practice p164 Introduction A 24-item NCLEX style exam all about the ADPIE or the Nursing Process. Topics  Nursing Process Guidelines  Read each question carefully and choose the best answer.  You are given one minute per question. Spend your time wisely!  Answers and rationales are given below. Be sure to read them.  If you need more clarifications, please direct them to the comments section. Questions 1. Once a nurse assesses a client’s condition and identifies appropriate nursing diagnoses, a: 1. Plan is developed for nursing care. 2. Physical assessment begins 3. List of priorities is determined. 4. Review of the assessment is conducted with other team members. 2. Planning is a category of nursing behaviors in which: 1. The nurse determines the health care needed for the client. 2. The Physician determines the plan of care for the client. 3. Client-centered goals and expected outcomes are established. 4. The client determines the care needed. 3. Priorities are established to help the nurse anticipate and sequence nursing interventions when a client has multiple problems or alterations. Priorities are determined by the client’s: 1. Physician 2. Non Emergent, non-life threatening needs 3. Future well-being. 4. Urgency of problems 4. A client centered goal is a specific and measurable behavior or response that reflects a client’s: 1. Desire for specific health care interventions 2. Highest possible level of wellness and independence in function. 3. Physician’s goal for the specific client. 4. Response when compared to another client with a like problem. 5. For clients to participate in goal setting, they should be: 1. Alert and have some degree of independence. 2. Ambulatory and mobile. 3. Able to speak and write. 4. Able to read and write. 6. The nurse writes an expected outcome statement in measurable terms. An example is: 1. Client will have less pain. 2. Client will be pain free. 3. Client will report pain acuity less than 4 on a scale of 0-10. 4. Client will take pain medication every 4 hours around the clock. 1 NURS 101 Nclex-Exam Practice p164 7. As goals, outcomes, and interventions are developed, the nurse must: 1. Be in charge of all care and planning for the client. 2. Be aware of and committed to accepted standards of practice from nursing and other disciples. 3. Not change the plan of care for the client. 4. Be in control of all interventions for the client. 8. When establishing realistic goals, the nurse: 1. Bases the goals on the nurse’s personal knowledge. 2. Knows the resources of the health care facility, family, and the client. 3. Must have a client who is physically and emotionally stable. 4. Must have the client’s cooperation. 9. To initiate an intervention the nurse must be competent in three areas, which include: 1. Knowledge, function, and specific skills 2. Experience, advanced education, and skills. 3. Skills, finances, and leadership. 4. Leadership, autonomy, and skills. 10. Collaborative interventions are therapies that require: 1. Physician and nurse interventions. 2. Nurse and client interventions. 3. Client and Physician intervention. 4. Multiple health care professionals. 11. Well formulated, client-centered goals should: 1. Meet immediate client needs. 2. Include preventative health care. 3. Include rehabilitation needs. 4. All of the above. 12. The following statement appears on the nursing care plan for an immunosuppressed client: The client will remain free from infection throughout hospitalization. This statement is an example of a (an): 1. Nursing diagnosis 2. Short-term goal 3. Long-term goal 4. Expected outcome 13. The following statements appear on a nursing care plan for a client after a mastectomy: Incision site approximated; absence of drainage or prolonged erythema at incision site; and client remains afebrile. These statements are examples of: 1. Nursing interventions 2. Short-term goals 3. Long-term goals 4. Expected outcomes. 14. The planning step of the nursing process includes which of the following activities? 1. Assessing and diagnosing 2. Evaluating goal achievement. 3. Performing nursing actions and documenting them. 4. Setting goals and selecting interventions. 15. The nursing care plan is: 1. A written guideline for implementation and evaluation. 2. A documentation of client care. 2 3. A projection of potential alterations in client behaviors 4. A tool to set goals and project outcomes. 16. After determining a nursing diagnosis of acute pain, the nurse develops the following appropriate client-centered goal: 1. Encourage client to implement guided imagery when pain begins. 2. Determine effect of pain intensity on client function. 3. Administer analgesic 30 minutes before physical therapy treatment. 4. Pain intensity reported as a 3 or less during hospital stay. 17. When developing a nursing care plan for a client with a fractured right tibia, the nurse includes in the plan of care independent nursing interventions, including: 1. Apply a cold pack to the tibia. 2. Elevate the leg 5 inches above the heart. 3. Perform range of motion to right leg every 4 hours. 4. Administer aspirin 325 mg every 4 hours as needed. 18. Which of the following nursing interventions are written correctly? (Select all that apply.) 1. Apply continuous passive motion machine during day. 2. Perform neurovascular checks. 3. Elevate head of bed 30 degrees before meals. 4. Change dressing once a shift. 19. A client’s wound is not healing and appears to be worsening with the current treatment. The nurse first considers: 1. Notifying the physician. 2. Calling the wound care nurse 3. Changing the wound care treatment. 4. Consulting with another nurse. 20. When calling the nurse consultant about a difficult client-centered problem, the primary nurse is sure to report the following: 1. Length of time the current treatment has been in place. 2. The spouse’s reaction to the client’s dressing change. 3. Client’s concern about the current treatment. 4. Physician’s reluctance to change the current treatment plan. 21. The primary nurse asked a clinical nurse specialist (CNS) to consult on a difficult nursing problem. The primary nurse is obligated to: 1. Implement the specialist’s recommendations. 2. Report the recommendations to the primary physician. 3. Clarify the suggestions with the client and family members. 4. Discuss and review advised strategies with CNS. 22. After assessing the client, the nurse formulates the following diagnoses. Place them in order of priority, with the most important (classified as high) listed first. 1. Constipation 2. Anticipated grieving 3. Ineffective airway clearance 4. Ineffective tissue perfusion. 23. The nurse is reviewing the critical paths of the clients on the nursing unit. In performing a variance analysis, which of the following would indicate the need for further action and analysis? 3 1. A client’s family attending a diabetic teaching session. 2. Canceling physical therapy sessions on the weekend. 3. Normal VS and absence of wound infection in a post-op client. 4. A client demonstrating accurate medication administration following teaching. 24. The RN has received her client assignment for the day-shift. After making the initial rounds and assessing the clients, which client would the RN need to develop a care plan first? 1. A client who is ambulatory. 2. A client, who has a fever, is diaphoretic and restless. 3. A client scheduled for OT at 1300. 4. A client who just had an appendectomy and has just received pain medication. Answers and Rationale 1. A 2. B 3. D 4. B 5. A 6. C 7. B 8. B 9. A 10. D 11. D 12. B 13. D 14. D 15. A 16. D. This is measurable and objective. 17. B. This does not require a physician’s order. (A & D require an order; C is not appropriate for a fractured tibia) 18. C. It is specific in what to do and when. 19. B. Calling in the wound care nurse as a consultant is appropriate because he or she is a specialist in the area of wound management. Professional and competent nurses recognize limitations and seek appropriate consultation. (a. This might be appropriate after deciding on a plan of action with the wound care nurse specialist. The nurse may need to obtain orders for special wound care products. c. Unless the nurse is knowledgeable in wound management, this could delay wound healing. Also, the current wound management plan could have been ordered by the physician. d. Another nurse most likely will not be knowledgeable about wounds, and the primary nurse would know the history of the wound management plan.) 20. A. This gives the consulting nurse facts that will influence a new plan. (b, c, and d. These are all subjective and emotional issues/conclusions about the current treatment plan and may cause a bias in the decision of a new treatment plan by the nurse consultant.) 21. D. Because the primary nurse requested the consultation, it is important that they communicate and discuss recommendations. The primary nurse can then accept or reject the CNS recommendations. (a. Some of the recommendations may not be appropriate for this client. The primary nurse would know this information. A consultation requires review of the recommendations, but not immediate implementation. b. This would be appropriate after first talking with the CNS about 4 recommended changes in the plan of care and the rationale. Then the primary nurse should call the physician. c. The client and family do not have the knowledge to determine whether new strategies are appropriate or not. Better to wait until the new plan of care is agreed upon by the primary nurse and physician before talking with the client and/or family.) 22. C, D, A, B. 23. B. 24. B. This clients needs are a priority. Introduction An NCLEX practice exam dedicated to Coronary Artery Disease and Hypertension. This exam contains 50 items about the two diseases. Topics  Coronary Artery Disease  Hypertension Guidelines  Read each question carefully and choose the best answer.  You are given one minute per question. Spend your time wisely!  Answers and rationales are given below. Be sure to read them.  If you need more clarifications, please direct them to the comments section. Questions 1. A client is scheduled for a cardiac catheterization using a radiopaque dye. Which of the following assessments is most critical before the procedure? 1. Intake and output 2. Baseline peripheral pulse rates 3. Height and weight 4. Allergy to iodine or shellfish 2. A client with no history of cardiovascular disease comes into the ambulatory clinic with flu-like symptoms. The client suddenly complains of chest pain. Which of the following questions would best help a nurse to discriminate pain caused by a non-cardiac problem? 1. “Have you ever had this pain before?” 2. “Can you describe the pain to me?” 3. “Does the pain get worse when you breathe in?” 4. “Can you rate the pain on a scale of 1-10, with 10 being the worst?” 3. A client with myocardial infarction has been transferred from a coronary care unit to a general medical unit with cardiac monitoring via telemetry. A nurse plans to allow for which of the following client activities? 1. Strict bed rest for 24 hours after transfer 2. Bathroom privileges and self-care activities 3. Unsupervised hallway ambulation with distances under 200 feet 4. Ad lib activities because the client is monitored. 5 4. A nurse notes 2+ bilateral edema in the lower extremities of a client with myocardial infarction who was admitted 2 days ago. The nurse would plan to do which of the following next? 1. Review the intake and output records for the last 2 days 2. Change the time of diuretic administration from morning to evening 3. Request a sodium restriction of 1 g/day from the physician. 4. Order daily weights starting the following morning. 5. A client is wearing a continuous cardiac monitor, which begins to sound its alarm. A nurse sees no electrocardiogram complexes on the screen. The first action of the nurse is to: 1. Check the client status and lead placement 2. Press the recorder button on the electrocardiogram console. 3. Call the physician 4. Call a code blue 6. A nurse is assessing the blood pressure of a client diagnosed with primary hypertension. The nurse ensures accurate measurement by avoiding which of the following? 1. Seating the client with arm bared, supported, and at heart level. 2. Measuring the blood pressure after the client has been seated quietly for 5 minutes. 3. Using a cuff with a rubber bladder that encircles at least 80% of the limb. 4. Taking a blood pressure within 15 minutes after nicotine or caffeine ingestion. 7. IV heparin therapy is ordered for a client. While implementing this order, a nurse ensures that which of the following medications is available on the nursing unit? 1. Vitamin K 2. Aminocaproic acid 3. Potassium chloride 4. Protamine sulfate 8. A client is at risk for pulmonary embolism and is on anticoagulant therapy with warfarin (Coumadin). The client’s prothrombin time is 20 seconds, with a control of 11 seconds. The nurse assesses that this result is: 1. The same as the client’s own baseline level 2. Lower than the needed therapeutic level 3. Within the therapeutic range 4. Higher than the therapeutic range 9. A client who has been receiving heparin therapy also is started on warfarin. The client asks a nurse why both medications are being administered. In formulating a response, the nurse incorporates the understanding that warfarin: 1. Stimulates the breakdown of specific clotting factors by the liver, and it takes 2-3 days for this to exert an anticoagulant effect. 2. Inhibits synthesis of specific clotting factors in the liver, and it takes 3-4 days for this medication to exert an anticoagulant effect. 3. Stimulates production of the body’s own thrombolytic substances, but it takes 2-4 days for this to begin. 4. Has the same mechanism of action as Heparin, and the crossover time is needed for the serum level of warfarin to be therapeutic. 10. A 60-year-old male client comes into the emergency department with complaints of crushing chest pain that radiates to his shoulder and left arm. The admitting diagnosis is acute myocardial infarction. Immediate admission orders include oxygen by NC at 6 4L/minute, blood work, chest x-ray, an ECG, and 2 mg of morphine given intravenously. The nurse should first: 1. Administer the morphine 2. Obtain a 12-lead ECG 3. Obtain the lab work 4. Order the chest x-ray 11. When administered a thrombolytic drug to the client experiencing an MI, the nurse explains to him that the purpose of this drug is to: 1. Help keep him well hydrated 2. Dissolve clots he may have 3. Prevent kidney failure 4. Treat potential cardiac arrhythmias. 12. When interpreting an ECG, the nurse would keep in mind which of the following about the P wave? Select all that apply. 1. Reflects electrical impulse beginning at the SA node 2. Indicated electrical impulse beginning at the AV node 3. Reflects atrial muscle depolarization 4. Identifies ventricular muscle depolarization 5. Has duration of normally 0.11 seconds or less. 13. A client has driven himself to the ER. He is 50 years old, has a history of hypertension, and informs the nurse that his father died of a heart attack at 60 years of age. The client is presently complaining of indigestion. The nurse connects him to an ECG monitor and begins administering oxygen at 2 L/minute per NC. The nurse’s next action would be to: 1. Call for the doctor 2. Start an intravenous line 3. Obtain a portable chest radiograph 4. Draw blood for laboratory studies 14. The nurse receives emergency laboratory results for a client with chest pain and immediately informs the physician. An increased myoglobin level suggests which of the following? 1. Cancer 2. Hypertension 3. Liver disease 4. Myocardial infarction 15. When teaching a client about propranolol hydrochloride, the nurse should base the information on the knowledge that propranolol hydrochloride: 1. Blocks beta-adrenergic stimulation and thus causes decreased heart rate, myocardial contractility, and conduction. 2. Increases norepinephrine secretion and thus decreases blood pressure and heart rate. 3. Is a potent arterial and venous vasodilator that reduces peripheral vascular resistance and lowers blood pressure. 4. Is an angiotensin-converting enzyme inhibitor that reduces blood pressure by blocking the conversion of angiotensin I to angiotensin II. 16. The most important long-term goal for a client with hypertension would be to: 1. Learn how to avoid stress 2. Explore a job change or early retirement 7 3. Make a commitment to long-term therapy 4. Control high blood pressure 17. Hypertension is known as the silent killer. This phrase is associated with the fact that hypertension often goes undetected until symptoms of other system failures occur. This may occur in the form of: 1. Cerebrovascular accident 2. Liver disease 3. Myocardial infarction 4. Pulmonary disease 18. During the previous few months, a 56-year-old woman felt brief twinges of chest pain while working in her garden and has had frequent episodes of indigestion. She comes to the hospital after experiencing severe anterior chest pain while raking leaves. Her evaluation confirms a diagnosis of stable angina pectoris. After stabilization and treatment, the client is discharged from the hospital. At her follow-up appointment, she is discouraged because she is experiencing pain with increasing frequency. She states that she is visiting an invalid friend twice a week and now cannot walk up the second flight of steps to the friend’s apartment without pain. Which of the following measures that the nurse could suggest would most likely help the client deal with this problem? 1. Visit her friend earlier in the day. 2. Rest for at least an hour before climbing the stairs. 3. Take a nitroglycerin tablet before climbing the stairs. 4. Lie down once she reaches the friend’s apartment. 19. Which of the following symptoms should the nurse teach the client with unstable angina to report immediately to her physician? 1. A change in the pattern of her pain 2. Pain during sex 3. Pain during an argument with her husband 4. Pain during or after an activity such as lawn mowing 20. The physician refers the client with unstable angina for a cardiac catheterization. The nurse explains to the client that this procedure is being used in this specific case to: 1. Open and dilate the blocked coronary arteries 2. Assess the extent of arterial blockage 3. Bypass obstructed vessels 4. Assess the functional adequacy of the valves and heart muscle. 21. As an initial step in treating a client with angina, the physician prescribes nitroglycerin tablets, 0.3mg given sublingually. This drug’s principal effects are produced by: 1. Antispasmodic effect on the pericardium 2. Causing an increased myocardial oxygen demand 3. Vasodilation of peripheral vasculature 4. Improved conductivity in the myocardium 22. The nurse teaches the client with angina about the common expected side effects of nitroglycerin, including: 1. Headache 2. High blood pressure 3. Shortness of breath 4. Stomach cramps 8 23. Sublingual nitroglycerin tablets begin to work within 1 to 2 minutes. How should the nurse instruct the client to use the drug when chest pain occurs? 1. Take one tablet every 2 to 5 minutes until the pain stops. 2. Take one tablet and rest for 10 minutes. Call the physician if pain persists after 10 minutes. 3. Take one tablet, then an additional tablet every 5 minutes for a total of 3 tablets. Call the physician if pain persists after three tablets. 4. Take one tablet. If pain persists after 5 minutes, take two tablets. If pain still persists 5 minutes later, call the physician. 24. Which of the following arteries primarily feeds the anterior wall of the heart? 1. Circumflex artery 2. Internal mammary artery 3. Left anterior descending artery 4. Right coronary artery 25. When do coronary arteries primarily receive blood flow? 1. During inspiration 2. During diastolic 3. During expiration 4. During systole 26. Prolonged occlusion of the right coronary artery produces an infarction in which of the following areas of the heart? 1. Anterior 2. Apical 3. Inferior 4. Lateral 27. A murmur is heard at the second left intercostal space along the left sternal border. Which valve is this? 1. Aortic 2. Mitral 3. Pulmonic 4. Tricuspid 28. Which of the following blood tests is most indicative of cardiac damage? 1. Lactate dehydrogenase 2. Complete blood count (CBC) 3. Troponin I 4. Creatine kinase (CK) 29. Which of the following diagnostic tools is most commonly used to determine the location of myocardial damage? 1. Cardiac catheterization 2. Cardiac enzymes 3. Echocardiogram 4. Electrocardiogram (ECG) 30. Which of the following types of pain is most characteristic of angina? 1. Knifelike 2. Sharp 3. Shooting 4. Tightness 9 31. Which of the following parameters is the major determinant of diastolic blood pressure? 1. Baroreceptors 2. Cardiac output 3. Renal function 4. Vascular resistance 32. Which of the following factors can cause blood pressure to drop to normal levels? 1. Kidneys’ excretion of sodium only 2. Kidneys’ retention of sodium and water 3. Kidneys’ excretion of sodium and water 4. Kidneys’ retention of sodium and excretion of water 33. Baroreceptors in the carotid artery walls and aorta respond to which of the following conditions? 1. Changes in blood pressure 2. Changes in arterial oxygen tension 3. Changes in arterial carbon dioxide tension 4. Changes in heart rate 34. Which of the following terms describes the force against which the ventricle must expel blood? 1. Afterload 2. Cardiac output 3. Overload 4. Preload 35. Which of the following terms is used to describe the amount of stretch on the myocardium at the end of diastole? 1. Afterload 2. Cardiac index 3. Cardiac output 4. Preload 36. A 57-year-old client with a history of asthma is prescribed propranolol (Inderal) to control hypertension. Before administered propranolol, which of the following actions should the nurse take first? 1. Monitor the apical pulse rate 2. Instruct the client to take medication with food 3. Question the physician about the order 4. Caution the client to rise slowly when standing. 37. One hour after administering IV furosemide (Lasix) to a client with heart failure, a short burst of ventricular tachycardia appears on the cardiac monitor. Which of the following electrolyte imbalances should the nurse suspect? 1. Hypocalcemia 2. Hypermagnesemia 3. Hypokalemia 4. Hypernatremia 38. A client is receiving spironolactone to treat hypertension. Which of the following instructions should the nurse provide? 1. “Eat foods high in potassium.” 2. “Take daily potassium supplements.” 10 3. “Discontinue sodium restrictions.” 4. “Avoid salt substitutes.” 39. When assessing an ECG, the nurse knows that the P-R interval represents the time it takes for the: 1. Impulse to begin atrial contraction 2. Impulse to transverse the atria to the AV node 3. SA node to discharge the impulse to begin atrial depolarization 4. Impulse to travel to the ventricles 40. Following a treadmill test and cardiac catheterization, the client is found to have coronary artery disease, which is inoperative. He is referred to the cardiac rehabilitation unit. During his first visit to the unit he says that he doesn’t understand why he needs to be there because there is nothing that can be done to make him better. The best nursing response is: 1. “Cardiac rehabilitation is not a cure but can help restore you to many of your former activities.” 2. “Here we teach you to gradually change your lifestyle to accommodate your heart disease.” 3. “You are probably right but we can gradually increase your activities so that you can live a more active life.” 4. “Do you feel that you will have to make some changes in your life now?” 41. To evaluate a client’s condition following cardiac catheterization, the nurse will palpate the pulse: 1. In all extremities 2. At the insertion site 3. Distal to the catheter insertion 4. Above the catheter insertion 42. A client’s physician orders nuclear cardiography and makes an appointment for a thallium scan. The purpose of injecting radioisotope into the bloodstream is to detect: 1. Normal vs. abnormal tissue 2. Damage in areas of the heart 3. Ventricular function 4. Myocardial scarring and perfusion 43. A client enters the ER complaining of severe chest pain. A myocardial infarction is suspected. A 12 lead ECG appears normal, but the doctor admits the client for further testing until cardiac enzyme studies are returned. All of the following will be included in the nursing care plan. Which activity has the highest priority? 1. Monitoring vital signs 2. Completing a physical assessment 3. Maintaining cardiac monitoring 4. Maintaining at least one IV access site 44. A client is experiencing tachycardia. The nurse’s understanding of the physiological basis for this symptom is explained by which of the following statements? 1. The demand for oxygen is decreased because of pleural involvement 2. The inflammatory process causes the body to demand more oxygen to meet its needs. 3. The heart has to pump faster to meet the demand for oxygen when there is lowered arterial oxygen tension. 4. Respirations are labored. 45. A client enters the ER complaining of chest pressure and severe epigastric distress. His VS are 158/90, 94, 24, and 99*F. The doctor orders cardiac enzymes. If the client were 11 diagnosed with an MI, the nurse would expect which cardiac enzyme to rise within the next 3 to 8 hours? 1. Creatine kinase (CK or CPK) 2. Lactic dehydrogenase (LDH) 3. LDH-1 4. LDH-2 46. A 45-year-old male client with leg ulcers and arterial insufficiency is admitted to the hospital. The nurse understands that leg ulcers of this nature are usually caused by: 1. Decreased arterial blood flow secondary to vasoconstriction 2. Decreased arterial blood flow leading to hyperemia 3. Atherosclerotic obstruction of the arteries 4. Trauma to the lower extremities 47. Which of the following instructions should be included in the discharge teaching for a patient discharged with a transdermal nitroglycerin patch? 1. “Apply the patch to a non hairy, nonfatty area of the upper torso or arms.” 2. “Apply the patch to the same site each day to maintain consistent drug absorption.” 3. “If you get a headache, remove the patch for 4 hours and then reapply.” 4. “If you get chest pain, apply a second patch right next to the first patch.” 48. In order to prevent the development of tolerance, the nurse instructs the patient to: 1. Apply the nitroglycerin patch every other day 2. Switch to sublingual nitroglycerin when the patient’s systolic blood pressure elevates to >140 mm Hg 3. Apply the nitroglycerin patch for 14 hours each and remove for 10 hours at night 4. Use the nitroglycerin patch for acute episodes of angina only 49. Direct-acting vasodilators have which of the following effects on the heart rate? 1. Heart rate decreases 2. Heart rate remains significantly unchanged 3. Heart rate increases 4. Heart rate becomes irregular 50. When teaching a patient why spironolactone (Aldactone) and furosemide (Lasix) are prescribed together, the nurse bases teaching on the knowledge that: 1. Moderate doses of two different types of diuretics are more effective than a large dose of one type 2. This combination promotes diuresis but decreases the risk of hypokalemia 3. This combination prevents dehydration and hypovolemia 4. Using two drugs increases osmolality of plasma and the glomerular filtration rate Answers and Rationale Gauge your performance by counter checking your answers to the answers below. Learn more about the question by reading the rationale. If you have any disputes or questions, please direct them to the comments section. 1. Answer: 4. This procedure requires an informed consent because it involves injection of a radiopaque dye into the blood vessel. The risk of allergic reaction and possible anaphylaxis is serious and must be assessed before the procedure. 2. Answer: 3. Chest pain is assessed by using the standard pain assessment parameters. Options 1, 2, and 4 may or may not help discriminate the origin of pain. Pain of pleuropulmonary origin usually worsens on inspiration. 12 3. Answer: 2. On transfer from the CCU, the client is allowed self-care activities and bathroom privileges. Supervised ambulation for brief distances are encouraged, with distances gradually increased (50, 100, 200 feet). 4. Answer: 1. Edema, the accumulation of excess fluid in the interstitial spaces, can be measured by intake greater than output and by a sudden increase in weight. Diuretics should be given in the morning whenever possible to avoid nocturia. Strict sodium restrictions are reserved for clients with severe symptoms. 5. Answer: 1. Sudden loss of electrocardiogram complexes indicates ventricular asystole or possible electrode displacement. Accurate assessment of the client and equipment is necessary to determine the cause and identify the appropriate intervention. 6. Answer: 4. BP should be taken with the client seated with the arm bared, positioned with support and at heart level. The client should sit with the legs on the floor, feet uncrossed, and not speak during the recording. The client should not have smoked tobacco or taken in caffeine in the 30 minutes preceding the measurement. The client should rest quietly for 5 minutes before the reading is taken. The cuff bladder should encircle at least 80% of the limb being measured. Gauges other than a mercury sphygmomanometer should be calibrated every 6 months to ensure accuracy. 7. Answer: 4. The antidote to heparin is protamine sulfate and should be readily available for use if excessive bleeding or hemorrhage should occur. Vitamin K is an antidote for warfarin. 8. . Detection of myoglobin is one diagnostic tool to determine whether myocardial damage has occurred. Myoglobin is generally Answer: 3. The therapeutic range for prothrombin time is 1.5 to 2 times the control for clients at risk for thrombus. Based on the client’s control value, the therapeutic range for this individual would be 16.5 to 22 seconds. Therefore the result is within therapeutic range. 9. Answer: 2. Warfarin works in the liver and inhibits synthesis of four vitamin K-dependent clotting factors (X, IX, VII, and II), but it takes 3 to 4 days before the therapeutic effect of warfarin is exhibited. 10. Answer: 1. Although obtaining the ECG, chest x-ray, and blood work are all important, the nurse’s priority action would be to relieve the crushing chest pain. 11. Answer: 2. Thrombolytic drugs are administered within the first 6 hours after onset of a MI to lyse clots and reduce the extent of myocardial damage. 12. Answer: 1, 3, 5. In a client who has had an ECG, the P wave represents the activation of the electrical impulse in the SA node, which is then transmitted to the AV node. In addition, the P wave represents atrial muscle depolarization, not ventricular depolarization. The normal duration of the P wave is 0.11 seconds or less in duration and 2.5 mm or more in height. 13. Answer: 2. Advanced cardiac life support recommends that at least one or two intravenous lines be inserted in one or both of the antecubital spaces. Calling the physician, obtaining a portable chest radiograph, and drawing blood are important but secondary to starting the intravenous line. 14. Answer: 4detected about one hour after a heart attack is experienced and peaks within 4 to 6 hours after infarction (Remember, less than 90 mg/L is normal). 15. Answer: 1. Propranolol hydrochloride is a beta-adrenergic blocking agent. Actions of propranolol hydrochloride include reducing heart rate, decreasing myocardial contractility, and slowing conduction. 16. Answer: 3. Compliance is the most critical element of hypertensive therapy. In most cases, hypertensive clients require lifelong treatment and their hypertension cannot be managed successfully without drug therapy. Stress management and weight management are important components of hypertension therapy, but the priority goal is related to compliance. 17. Answer: 1. Hypertension is referred to as the silent killer for adults, because until the adult has significant damage to other systems, the hypertension may go undetected. CVA’s can be related to 13 long-term hypertension. Liver or pulmonary disease is generally not associated with hypertension. Myocardial infarction is generally related to coronary artery disease. 18. Answer: 3. Nitroglycerin may be used prophylactically before stressful physical activities such as stair climbing to help the client remain pain free. Visiting her friend early in the day would have no impact on decreasing pain episodes. Resting before or after an activity is not as likely to help prevent an activity-related pain episode. 19. Answer: 1. The client should report a change in the pattern of chest pain. It may indicate increasing severity of CAD. 20. Answer: 2. Cardiac catheterization is done in clients with angina primarily to assess the extent and severity of the coronary artery blockage, A decision about medical management, angioplasty, or coronary artery bypass surgery will be based on the catheterization results. 21. Answer: 3. Nitroglycerin produces peripheral vasodilation, which reduces myocardial oxygen consumption and demand. Vasodilation in coronary arteries and collateral vessels may also increase blood flow to the ischemic areas of the heart. Nitroglycerin decreases myocardial oxygen demand. Nitroglycerin does not have an effect on pericardial spasticity or conductivity in the myocardium. 22. Answer: 1. Because of the widespread vasodilating effects, nitroglycerin often produces such side effects as headache, hypotension, and dizziness. The client should lie or shit down to avoid fainting. Nitro does not cause shortness of breath or stomach cramps. 23. Answer: 3. The correct protocol for nitroglycerin used involves immediate administration, with subsequent doses taken at 5-minute intervals as needed, for a total dose of 3 tablets. Sublingual nitroglycerin appears in the bloodstream within 2 to 3 minutes and is metabolized within about 10 minutes. 24. Answer: 3. The left anterior descending artery is the primary source of blood flow for the anterior wall of the heart. The circumflex artery supplies the lateral wall, the internal mammary supplies the mammary, and the right coronary artery supplies the inferior wall of the heart. 25. Answer: 2. Although the coronary arteries may receive a minute portion of blood during systole, most of the blood flow to coronary arteries is supplied during diastole. Breathing patterns are irrelevant to blood flow. 26. Answer: 3. The right coronary artery supplies the right ventricle, or the inferior portion of the heart. Therefore, prolonged occlusion could produce an infarction in that area. The right coronary artery doesn’t supply the anterior portion (left ventricle), lateral portion (some of the left ventricle and the left atrium), or the apical portion (left ventricle) of the heart. 27. Answer: 3. Abnormalities of the pulmonic valve are auscultated at the second left intercostal space along the left sternal border. Aortic valve abnormalities are heard at the second intercostal space, to the right of the sternum. Mitral valve abnormalities are heard at the fifth intercostal space in the midclavicular line. Tricupsid valve abnormalities are heard at the 3rd and 4th intercostal spaces along the sternal border. 28. Answer: 3. Troponin I levels rise rapidly and are detectable within 1 hour of myocardial injury. Troponin levels aren’t detectable in people without cardiac injury. 29. Answer: 4. The ECG is the quickest, most accurate, and most widely used tool to determine the location of myocardial infarction. Cardiac enzymes are used to diagnose MI but can’t determine the location. An echocardiogram is used most widely to view myocardial wall function after an MI has been diagnosed. Cardiac catheterization is an invasive study for determining coronary artery disease and may also indicate the location of myocardial damage, but the study may not be performed immediately. 14 30. Answer: 4. The pain of angina usually ranges from a vague feeling of tightness to heavy, intense pain. Pain impulses originate in the most visceral muscles and may move to such areas as the chest, neck, and arms. 31. Answer: 4. Vascular resistance is the impedance of blood flow by the arterioles that most predominantly affects the diastolic pressure. Cardiac output determines systolic blood pressure. 32. Answer: 3. The kidneys respond to a rise in blood pressure by excreting sodium and excess water. This response ultimately affects systolic pressure by regulating blood volume. 33. Answer: 1. Baroreceptors located in the carotid arteries and aorta sense pulsatile pressure. Decreases in pulsatile pressure cause a reflex increase in heart rate. Chemoreceptors in the medulla are primarily stimulated by carbon dioxide. Peripheral chemoreceptors in the aorta and carotid arteries are primarily stimulated by oxygen. 34. Answer: 1. Afterload refers to the resistance normally maintained by the aortic and pulmonic valves, the condition and tone of the aorta, and the resistance offered by the systemic and pulmonary arterioles. Cardiac output is the amount of blood expelled from the heart per minute. Overload refers to an abundance of circulating volume. Preload is the volume of blood in the ventricle at the end of diastole. 35. Answer: 4. Preload is the amount of stretch of the cardiac muscle fibers at the end of diastole. The volume of blood in the ventricle at the end of diastole determines the preload. Afterload is the force against which the ventricle must expel blood. Cardiac index is the individualized measurement of cardiac output, based on the client’s body surface area. Cardiac output is the amount of blood the heart is expelling per minute. 36. Answer: 3. Propranolol and other beta-adrenergic blockers are contraindicated in a client with asthma, so the nurse should question the physician before giving the dose. The other responses are appropriate actions for a client receiving propranolol, but questioning the physician takes priority. The client’s apical pulse should always be checked before giving propranolol; if the pulse rate is extremely low, the nurse should withhold the drug and notify the physician. 37. Answer: 3. Furosemide is a potassium-depleting diuretic than can cause hypokalemia. In turn, hypokalemia increases myocardial excitability, leading to ventricular tachycardia. 38. Answer: 4. Because spironolactone is a potassium-sparing diuretic, the client should avoid salt substitutes because of their high potassium content. The client should also avoid potassium-rich foods and potassium supplements. To reduce fluid-volume overload, sodium restrictions should continue. 39. Answer: 4. The P-R interval is measured on the ECG strip from the beginning of the P wave to the beginning of the QRS complex. It is the time it takes for the impulse to travel to the ventricle. 40. Answer: 1. Such a response does not have false hope to the client but is positive and realistic. The answer tells the client what cardiac rehabilitation is and does not dwell upon his negativity about it. 41. Answer: 3. Palpating pulses distal to the insertion site is important to evaluate for thrombophlebitis and vessel occlusion. They should be bilateral and strong. 42. Answer: 4. This scan detects myocardial damage and perfusion, an acute or chronic MI. It is a more specific answer than (1) or (2). Specific ventricular function is tested by a gated cardiac blood pool scan. 43. Answer: 3. Even though initial tests seem to be within normal range, it takes at least 3 hours for the cardiac enzyme studies to register. In the meantime, the client needs to be watched for bradycardia, heart block, ventricular irritability, and other arrhythmias. Other activities can be accomplished around the MI monitoring. 44. Answer: 3. The arterial oxygen supply is lowered and the demand for oxygen is increased, which results in the heart’s having to beat faster to meet the body’s needs for oxygen. 15 45. Answer: 1. Creatine kinase (CK, formally known as CPK) rises in 3-8 hours if an MI is present. When the myocardium is damaged, CPK leaks out of the cell membranes and into the bloodstream. Lactic dehydrogenase rises in 24-48 hours, and LDH-1 and LDH-2 rises in 8-24 hours. 46. Answer: 1. Decreased arterial flow is a result of vasospasm. The etiology is unknown. It is more problematic in colder climates or when the person is under stress. Hyperemia occurs when the vasospasm is relieved. 47. Answer: 1. A nitroglycerin patch should be applied to a non hairy, nonfatty area for the best and most consistent absorption rates. Sites should be rotated to prevent skin irritation, and the drug should be continued if headache occurs because tolerance will develop. Sublingual nitroglycerin should be used to treat chest pain. 48. Answer: 3. Tolerance can be prevented by maintaining an 8- to 12-hour nitrate-free period each day. 49. Answer: 3. Heart rate increases in response to decreased blood pressure caused by vasodilation. 50. Answer: 2. Spironolactone is a potassium-sparing diuretic; furosemide is a potassium-losing diuretic. Giving these together minimizes electrolyte imbalance. Introduction This is a 40-item examination about Hematologic Disorders like Hemophilia, Sickle Cell Disease, Anemia and Polycythemia Vera. This is an NCLEX style examination. Topics  Hemophilia  Sickle Cell Disease  Anemia  Polycythemia Vera Guidelines  Read each question carefully and choose the best answer.  You are given one minute per question. Spend your time wisely!  Answers and rationales are given below. Be sure to read them.  If you need more clarifications, please direct them to the comments section. Questions 1. The nurse is preparing to teach a client with microcytic hypochromic anemia about the diet to follow after discharge. Which of the following foods should be included in the diet? 1. Eggs 2. Lettuce 3. Citrus fruits 4. Cheese 2. The nurse would instruct the client to eat which of the following foods to obtain the best supply of vitamin B12? 1. Whole grains 2. Green leafy vegetables 3. Meats and dairy products 4. Broccoli and Brussels sprouts 16 3. The nurse has just admitted a 35-year-old female client who has a serum B12 concentration of 800 pg/ml. Which of the following laboratory findings would cue the nurse to focus the client history on specific drug or alcohol abuse? 1. Total bilirubin, 0.3 mg/dL 2. Serum creatinine, 0.5 mg/dL 3. Hemoglobin, 16 g/dL 4. Folate, 1.5 ng/mL 4. The nurse understands that the client with pernicious anemia will have which distinguishing laboratory findings? 1. Schilling’s test, elevated 2. Intrinsic factor, absent. 3. Sedimentation rate, 16 mm/hour 4. RBCs 5.0 million 5. The nurse devises a teaching plan for the patient with aplastic anemia. Which of the following is the most important concept to teach for health maintenance? 1. Eat animal protein and dark leafy vegetables each day 2. Avoid exposure to others with acute infection 3. Practice yoga and meditation to decrease stress and anxiety 4. Get 8 hours of sleep at night and take naps during the day 6. A client comes into the health clinic 3 years after undergoing a resection of the terminal ileum complaining of weakness, shortness of breath, and a sore tongue. Which client statement indicates a need for intervention and client teaching? 1. “I have been drinking plenty of fluids.” 2. “I have been gargling with warm salt water for my sore tongue.” 3. “I have 3 to 4 loose stools per day.” 4. “I take a vitamin B12 tablet every day.” 7. A vegetarian client was referred to a dietitian for nutritional counseling for anemia. Which client outcome indicates that the client does not understand nutritional counseling? The client: 1. Adds dried fruit to cereal and baked goods 2. Cooks tomato-based foods in iron pots 3. Drinks coffee or tea with meals 4. Adds vitamin C to all meals 8. A client was admitted with iron deficiency anemia and blood-streaked emesis. Which question is most appropriate for the nurse to ask in determining the extent of the client’s activity intolerance? 1. “What activities were you able to do 6 months ago compared with the present?” 2. “How long have you had this problem?” 3. “Have you been able to keep up with all your usual activities?” 4. “Are you more tired now than you used to be?” 9. The primary purpose of the Schilling test is to measure the client’s ability to: 1. Store vitamin B12 2. Digest vitamin B12 3. Absorb vitamin B12 4. Produce vitamin B12 10. The nurse implements which of the following for the client who is starting a Schilling test? 17 1. Administering methylcellulose (Citrucel) 2. Starting a 24- to 48 hour urine specimen collection 3. Maintaining NPO status 4. Starting a 72 hour stool specimen collection 11. A client with pernicious anemia asks why she must take vitamin B12 injections for the rest of her life. What is the nurse’s best response? 1. “The reason for your vitamin deficiency is an inability to absorb the vitamin because the stomach is not producing sufficient acid.” 2. “The reason for your vitamin deficiency is an inability to absorb the vitamin because the stomach is not producing sufficient intrinsic factor.” 3. “The reason for your vitamin deficiency is an excessive excretion of the vitamin because of kidney dysfunction.” 4. “The reason for your vitamin deficiency is an increased requirement for the vitamin because of rapid red blood cell production.” 12. The nurse is assessing a client’s activity intolerance by having the client walk on a treadmill for 5 minutes. Which of the following indicates an abnormal response? 1. Pulse rate increased by 20 bpm immediately after the activity 2. Respiratory rate decreased by 5 breaths/minute 3. Diastolic blood pressure increased by 7 mm Hg 4. Pulse rate within 6 bpm of resting phase after 3 minutes of rest. 13. When comparing the hematocrit levels of a post-op client, the nurse notes that the hematocrit decreased from 36% to 34% on the third day even though the RBC and hemoglobin values remained stable at 4.5 million and 11.9 g/dL, respectively. Which nursing intervention is most appropriate? 1. Check the dressing and drains for frank bleeding 2. Call the physician 3. Continue to monitor vital signs 4. Start oxygen at 2L/min per NC 14. A client is to receive epoetin (Epogen) injections. What laboratory value should the nurse assess before giving the injection? 1. Hematocrit 2. Partial thromboplastin time 3. Hemoglobin concentration 4. Prothrombin time 15. A client states that she is afraid of receiving vitamin B12 injections because of the potential toxic reactions. What is the nurse’s best response to relieve these fears? 1. “Vitamin B12 will cause ringing in the eats before a toxic level is reached.” 2. “Vitamin B12 may cause a very mild skin rash initially.” 3. “Vitamin B12 may cause mild nausea but nothing toxic.” 4. “Vitamin B12 is generally free of toxicity because it is water soluble.” 16. A client with microcytic anemia is having trouble selecting food items from the hospital menu. Which food is best for the nurse to suggest for satisfying the client’s nutritional needs and personal preferences? 1. Egg yolks 2. Brown rice 3. Vegetables 4. Tea 18 17. A client with macrocytic anemia has a burn on her foot and states that she had been watching television while lying on a heating pad. What is the nurse’s first response? 1. Assess for potential abuse 2. Check for diminished sensations 3. Document the findings 4. Clean and dress the area 18. Which of the following nursing assessments is a late symptom of polycythemia vera? 1. Headache 2. Dizziness 3. Pruritus 4. Shortness of breath 19. The nurse is teaching a client with polycythemia vera about potential complications from this disease. Which manifestations would the nurse include in the client’s teaching plan? Select all that apply. 1. Hearing loss 2. Visual disturbance 3. Headache 4. Orthopnea 5. Gout 6. Weight loss 20. When a client is diagnosed with aplastic anemia, the nurse monitors for changes in which of the following physiological functions? 1. Bleeding tendencies 2. Intake and output 3. Peripheral sensation 4. Bowel function 21. Which of the following blood components is decreased in anemia? 1. Erythrocytes 2. Granulocytes 3. Leukocytes 4. Platelets 22. A client with anemia may be tired due to a tissue deficiency of which of the following substances? 1. Carbon dioxide 2. Factor VIII 3. Oxygen 4. T-cell antibodies 23. Which of the following cells is the precursor to the red blood cell (RBC)? 1. B cell 2. Macrophage 3. Stem cell 4. T cell 24. Which of the following symptoms is expected with hemoglobin of 10 g/dl? 1. None 2. Pallor 3. Palpitations 4. Shortness of breath 19 25. Which of the following diagnostic findings are most likely for a client with aplastic anemia? 1. Decreased production of T-helper cells 2. Decreased levels of white blood cells, red blood cells, and platelets 3. Increased levels of WBCs, RBCs, and platelets 4. Reed-Sternberg cells and lymph node enlargement 26. A client with iron deficiency anemia is scheduled for discharge. Which instruction about prescribed ferrous gluconate therapy should the nurse include in the teaching plan? 1. “Take the medication with an antacid.” 2. “Take the medication with a glass of milk.” 3. “Take the medication with cereal.” 4. “Take the medication on an empty stomach.” 27. Which of the following disorders results from a deficiency of factor VIII? 1. Sickle cell disease 2. Christmas disease 3. Hemophilia A 4. Hemophilia B 28. The nurse explains to the parents of a 1-year-old child admitted to the hospital in a sickle cell crisis that the local tissue damage the child has on admission is caused by which of the following? 1. Autoimmune reaction complicated by hypoxia 2. Lack of oxygen in the red blood cells 3. Obstruction to circulation 4. Elevated serum bilirubin concentration. 29. The mothers asks the nurse why her child’s hemoglobin was normal at birth but now the child has S hemoglobin. Which of the following responses by the nurse is most appropriate? 1. “The placenta bars passage of the hemoglobin S from the mother to the fetus.” 2. “The red bone marrow does not begin to produce hemoglobin S until several months after birth.” 3. “Antibodies transmitted from you to the fetus provide the newborn with temporary immunity.” 4. “The newborn has a high concentration of fetal hemoglobin in the blood for some time after birth.” 30. Which of the following would the nurse identify as the priority nursing diagnosis during a toddler’s vaso-occlusive sickle cell crisis? 1. Ineffective coping related to the presence of a life-threatening disease 2. Decreased cardiac output related to abnormal hemoglobin formation 3. Pain related to tissue anoxia 4. Excess fluid volume related to infection 31. A mother asks the nurse if her child’s iron deficiency anemia is related to the child’s frequent infections. The nurse responds based on the understanding of which of the following? 1. Little is known about iron-deficiency anemia and its relationship to infection in children. 2. Children with iron deficiency anemia are more susceptible to infection than are other children. 3. Children with iron-deficiency anemia are less susceptible to infection than are other children. 4. Children with iron-deficient anemia are equally as susceptible to infection as are other children. 32. Which statements by the mother of a toddler would lead the nurse to suspect that the child has iron-deficiency anemia? Select all that apply. 20 1. “He drinks over 3 cups of milk per day.” 2. “I can’t keep enough apple juice in the house; he must drink over 10 ounces per day.” 3. “He refuses to eat more than 2 different kinds of vegetables.” 4. “He doesn’t like meat, but he will eat small amounts of it.” 5. “He sleeps 12 hours every night and take a 2-hour nap.” 33. Which of the following foods would the nurse encourage the mother to offer to her child with iron deficiency anemia? 1. Rice cereal, whole milk, and yellow vegetables 2. Potato, peas, and chicken 3. Macaroni, cheese, and ham 4. Pudding, green vegetables, and rice 34. The physician has ordered several laboratory tests to help diagnose an infant’s bleeding disorder. Which of the following tests, if abnormal, would the nurse interpret as most likely to indicate hemophilia? 1. Bleeding time 2. Tourniquet test 3. Clot retraction test 4. Partial thromboplastin time (PTT) 35. Which of the following assessments in a child with hemophilia would lead the nurse to suspect early hemarthrosis? 1. Child’s reluctance to move a body part 2. Cool, pale, clammy extremity 3. Eccymosis formation around a joint 4. Instability of a long bone in passive movement 36. Because of the risks associated with administration of factor VIII concentrate, the nurse would teach the client’s family to recognize and report which of the following? 1. Yellowing of the skin 2. Constipation 3. Abdominal distention 4. Puffiness around the eyes 37. A child suspected of having sickle cell disease is seen in a clinic, and laboratory studies are performed. A nurse checks the lab results, knowing that which of the following would be increased in this disease? 1. Platelet count 2. Hematocrit level 3. Reticulocyte count 4. Hemoglobin level 38. A clinic nurse instructs the mother of a child with sickle cell disease about the precipitating factors related to pain crisis. Which of the following, if identified by the mother as a precipitating factor, indicates the need for further instructions? 1. Infection 2. Trauma 3. Fluid overload 4. Stress 39. Laboratory studies are performed for a child suspected of having iron deficiency anemia. The nurse reviews the laboratory results, knowing that which of the following results would indicate this type of anemia? 21 1. An elevated hemoglobin level 2. A decreased reticulocyte count 3. An elevated RBC count 4. Red blood cells that are microcytic and hypochromic 40. A pediatric nurse health educator provides a teaching session to the nursing staff regarding hemophilia. Which of the following information regarding this disorder would the nurse plan to include in the discussion? 1. Hemophilia is a Y linked hereditary disorder 2. Males inherit hemophilia from their fathers 3. Females inherit hemophilia from their mothers 4. Hemophilia A results from a deficiency of factor VIII Answers and Rationale 1. Answer: 1. One of the microcytic, hypochromic anemias is iron-deficiency anemia. A rich source of iron is needed in the diet, and eggs are high in iron. Other foods high in iron include organ and muscle (dark) meats; shellfish, shrimp, and tuna; enriched, whole-grain, and fortified cereals and breads; legumes, nuts, dried fruits, and beans; oatmeal; and sweet potatoes. Dark green leafy vegetables and citrus fruits are good sources of vitamin C. Cheese is a good source of calcium. 2. Answer: 3. Good sources of vitamin B12 include meats and dairy products. Whole grains are a good source of thiamine. Green leafy vegetables are good sources of niacin, folate, and carotenoids (precursors of vitamin A). Broccoli and Brussels sprouts are good sources of ascorbic acid (vitamin C). 3. Answer: 4. The normal range of folic acid is 1.8 to 9 ng/mL, and the normal range of vitamin B12 is 200 to 900 pg/mL. A low folic acid level in the presence of a normal vitamin B12 level is indicative of a primary folic acid-deficiency anemia. Factors that affect the absorption of folic acid are drugs such as methotrexate, oral contraceptives, antiseizure drugs, and alcohol. The total bilirubin, serum creatinine, and hemoglobin values are within normal limits. 4. Answer: 2. The defining characteristic of pernicious anemia, a megaloblastic anemia, is lack of the intrinsic factor, which results from atrophy of the stomach wall. Without the intrinsic factor, vitamin B12 cannot be absorbed in the small intestines, and folic acid needs vitamin B12 for DNA synthesis of RBCs. The gastric analysis was done to determine the primary cause of the anemia. An elevated excretion of the injected radioactive vitamin B12, which is protocol for the first and second stage of the Schilling test, indicates that the client has the intrinsic factor and can absorb vitamin B12 into the intestinal tract. A sedimentation rate of 16 mm/hour is normal for both men and women and is a nonspecific test to detect the presence of inflammation. It is not specific to anemias. An RBC value of 5.0 million is a normal value for both men and women and does not indicate anemia. 5. Answer: 2. Clients with aplastic anemia are severely immunocompromised and at risk for infection and possible death related to bone marrow suppression and pancytopenia. Strict aseptic technique and reverse isolation are important measures to prevent infection. Although diet, reduced stress, and rest are valued in supporting health, the potentially fatal consequence of an acute infection places it as a priority for teaching the client about health maintenance. Animal meat and dark green leafy vegetables, good sources of vitamin B12 and folic acid, should be included in the daily diet. Yoga and meditation are good complimentary therapies to reduce stress. Eight hours of rest and naps are good for spacing and pacing activity and rest. 6. Answer: 4. Vitamin B12 combines with intrinsic factor in the stomach and is then carried to the ileum, where it is absorbed in the bloodstream. In this situation, vitamin B12 cannot be absorbed regardless of the amount of oral intake of sources of vitamin B12 such as animal protein or vitamin B12 tablets. Vitamin B12 needs to be injected every month, because the ileum has been surgically removed. Replacement of fluids and electrolytes is important when the client has continuous multiple 22 loose stools on a daily basis. Warm salt water is used to soothe sore mucous membranes. Crohn’s disease and small bowel resection may cause several loose stools a day. 7. Answer: 3. Coffee and tea increase gastrointestinal motility and inhibit the absorption of nonheme iron. Clients are instructed to add dried fruits to dishes at every meal because dried fruits are a nonheme or nonanimal iron source. Cooking in iron cookware, especially acid-based foods such as tomatoes, adds iron to the diet. Clients are instructed to add a rich supply of vitamin C to every meal because the absorption of iron is increased when food with vitamin C or ascorbic acid is consumed. 8. Answer: 1. It is difficult to determine activity intolerance without objectively comparing activities from one time frame to another. Because iron deficiency anemia can occur gradually and individual endurance varies, the nurse can best assess the client’s activity tolerance by asking the client to compare activities 6 months ago and at the present. Asking a client how long a problem has existed is a very open-ended question that allows for too much subjectivity for any definition of the client’s activity tolerance. Also, the client may not even identify that a “problem” exists. Asking the client whether he is staying abreast of usual activities addresses whether the tasks were completed, not the tolerance of the client while the tasks were being completed or the resulting condition of the client after the tasks were completed. Asking the client if he is more tired now than usual does not address his activity tolerance. Tiredness is a subjective evaluation and again can be distorted by factors such as the gradual onset of the anemia or the endurance of the individual. 9. Answer: 3. Pernicious anemia is caused by the body’s inability to absorb vitamin B12. This results in a lack of intrinsic factor in the gastric juices. Schilling’s test helps diagnose pernicious anemia by determining the client’s ability to absorb vitamin B12. 10. Answer: 2. Urinary vitamin B12 levels are measured after the ingestion of radioactive vitamin B12. A 24-to 48- hour urine specimen is collected after administration of an oral dose of radioactively tagged vitamin B12 and an injection of non-radioactive vitamin B12. In a healthy state of absorption, excess vitamin B12 is excreted in the urine; in a malabsorption state or when the intrinsic factor is missing, vitamin B12 is excreted in the feces. Citrucel is a bulk-forming agent. Laxatives interfere with the absorption of vitamin B12. The client is NPO 8 to 12 hours before the test but is not NPO during the test. A stool collection is not part of the Schilling test. If stool contaminates the urine collection, the results will be altered. 11. Answer: 2. Most clients with pernicious anemia have deficient production of intrinsic factor in the stomach. Intrinsic factor attaches to the vitamin in the stomach and forms a complex that allows the vitamin to be absorbed in the small intestine. The stomach is producing enough acid, there is not an excessive excretion of the vitamin, and there is not a rapid production of RBCs in this condition. 12. Answer: 2. The normal physiologic response to activity is an increased metabolic rate over the resting basal rate. The decrease in respiratory rate indicates that the client is not strong enough to complete the mechanical cycle of respiration needed for gas exchange. The post activity pulse is expected to increase immediately after activity but by no more than 50 bpm if it is strenuous activity. The diastolic blood pressure is expected to rise but by no more than 15 mm Hg. The pulse returns to within 6 bpm of the resting pulse after 3 minutes of rest. 13. Answer: 3. The nurse should continue to monitor the client, because this value reflects a normal physiologic response. The physician does not need to be called, and oxygen does not need to be started based on these laboratory findings. Immediately after surgery, the client’s hematocrit reflects a falsely high value related to the body’s compensatory response to the stress of sudden loss of fluids and blood. Activation of the intrinsic pathway and the renin-angiotensin cycle via antidiuretic hormone produces vasoconstriction and retention of fluid for the first 1 to 2 day post-op. By the second to third day, this response decreases and the client’s hematocrit level is more reflective of the amount of RBCs in the plasma. Fresh bleeding is a less likely occurrence on the third post-op day but is not impossible; 23 however, the nurse would have expected to see a decrease in the RBC and hemoglobin values accompanying the hematocrit. 14. Answer: 1. Epogen is a recombinant DNA form of erythropoietin, which stimulates the production of RBCs and therefore causes the hematocrit to rise. The elevation in hematocrit causes an elevation in blood pressure; therefore, the blood pressure is a vital sign that should be checked. The PTT, hemoglobin level, and PT are not monitored for this drug. 15. Answer: 4. Vitamin B12 is a water-soluble vitamin. When water-soluble vitamins are taken in excess of the body’s needs, they are filtered through the kidneys and excreted. Vitamin B12 is considered to be nontoxic. Adverse reactions that have occurred are believed to be related to impurities or to the preservative in B12 preparations. Ringing in the ears, skin rash, and nausea are not considered to be related to vitamin B12 administration. 16. Answer: 2. Brown rice is a source of iron from plant sources (nonheme iron). Other sources of non heme iron are whole-grain cereals and breads, dark green vegetables, legumes, nuts, dried fruits (apricots, raisins, dates), oatmeal, and sweet potatoes. Egg yolks have iron but it is not as well absorbed as iron from other sources. Vegetables are a good source of vitam