LEWIS'S MEDICAL SURGICAL NURSING TEST BANK 11TH EDITION HARDING

Splenectomy increases the risk for septicemia from bacterial infections. The patients protein intake is good and should improve immunefunction. Daily aspirin use does not affect immunefunction. A chest x-ray does not have enough radiation to suppress immunefunction. DIF: Cognitive Level: Apply (application) TOP: NursingProcess: Assessment MSC: NCLEX: Physiological Integrity 12. Which patient should the nurse assess first? a. Patient with urticaria after receiving an IV antibiotic b. Patient who has graft-versus-host disease and severe diarrhea c. Patient who is sneezing after having subcutaneous immunotherapy d. Patient with multiple chemical sensitivities who has muscle stiffness NN Test Bank - Lewis's MedicalSurgical Nursing(11th Edition by Harding) 109 ANS: C Sneezing after subcutaneous immunotherapy may indicate impending anaphylaxis and assessment and emergency measures should be initiated. The other patients also have findingsthat need assessment and intervention by the nurse, but do not have evidence of life-threatening complications. DIF: Cognitive Level: Analyze (analysis) OBJ: Special Questions: Prioritization; Multiple Patients TOP: NursingProcess: Assessment MSC: NCLEX: Safe and Effective Care Environment 13. Ten days after receiving a bone marrow transplant, a patient develops a skin rash. What would the nurse suspect is the cause of this patients skin rash? a. The donor T cells are attacking the patients skin cells. b. The patients antibodies are rejecting the donor bone marrow. c. The patient is experiencing a delayed hypersensitivity reaction. d. The patient will need treatment to prevent hyperacute rejection. ANS: A The patients history and symptoms indicate that the patient is experiencing graft-versus-host disease, in which the donated T cells attack the patients tissues. The history and symptoms are not consistent with rejection or delayed hypersensitivity. DIF: Cognitive Level: Understand (comprehension) TOP: NursingProcess: Evaluation MSC: NCLEX: Physiological Integrity 14. An adolescent patient seeks care in the emergency department after sharing needles for heroin injection with a friend who has hepatitis B. To provide immediate protection from infection, what medication will the nurse administer? a. Corticosteroids b. Gamma globulin c. Hepatitis B vaccine d. Fresh frozen plasma ANS: B The patient should first receive antibodies for hepatitis B from injection of gamma globulin. The hepatitis B vaccination series should be started to provide active immunity. Fresh frozen plasma and corticosteroids will not be effective in preventing hepatitis B in the patient. DIF: Cognitive Level: Apply (application) NN Test Bank - Lewis's MedicalSurgical Nursing(11th Edition by Harding) 110 TOP: NursingProcess: Planning MSC: NCLEX: Physiological Integrity 15. The nurse teaches a patient about drug therapy after a kidney transplant. Which statement by the patient would indicate a need for further instructions? a. After a couple of years, it is likely that I will be able to stop taking the cyclosporine. b. If I develop an acute rejection episode,I will need to have other types of drugs given IV. c. I need to be monitored closely because I have a greater chance of developing malignant tumors. d. The drugs are given in combination because they inhibit different ways the kidney can be rejected. ANS: A Cyclosporine, a calcineurin inhibitor, will need to be continued for life. The other patient statements are accurate and indicate that no further teaching is necessary about those topics. DIF: Cognitive Level: Apply (application) TOP: NursingProcess: Evaluation MSC: NCLEX: Physiological Integrity 16. An older adult patient has a prescription for cyclosporine following a kidney transplant. Which information in the patients health history has the most implications for planning patient teaching about the medication at this time? a. The patient restrictssalt to treat prehypertension. b. The patient drinks 3 to 4 quarts of fluids every day. c. The patient has many concerns about the effects of cyclosporine. d. The patient has a glass of grapefruit juice every day for breakfast. ANS: D Grapefruit juice can increasethe toxicity of cyclosporine. The patient should be taught to avoid grapefruit juice. High fluid intake will not affect cyclosporine levels or renal function. Cyclosporine may cause hypertension, and the patients many concerns should be addressed, but these are not potentially life-threatening problems. DIF: Cognitive Level: Apply (application) TOP: NursingProcess: Planning MSC: NCLEX: Physiological Integrity 17. A patient is admitted to the hospital with acute rejection of a kidney transplant. Which intervention will the nurse prepare for this patient? a. Administration of immunosuppressant medications b. Insertion of an arteriovenous graft for hemodialysis NN Test Bank - Lewis's MedicalSurgical Nursing(11th Edition by Harding) 111 c. Placement of the patient on the transplant waiting list d. A blood draw for human leukocyte antigen (HLA) matching ANS: A Acute rejection is treated with the administration of additional immunosuppressant drugs such as corticosteroids. Because acute rejection is potentially reversible, there is no indication that the patient will require another transplant or hemodialysis. There is no indication for repeat HLA testing. DIF: Cognitive Level: Apply (application) TOP: NursingProcess: Planning MSC: NCLEX: Physiological Integrity 18. The charge nurse is assigning rooms for new admissions. Which patient would be the most appropriate roommate for a patient who has acute rejection of an organ transplant? a. A patient who has viral pneumonia b. A patient with second-degree burns c. A patient who is recovering from an anaphylactic reactionto a bee sting d. A patient with graft-versus-host disease after a recent bone marrow transplant ANS: C Treatment for a patient with acute rejection includes administration of additional immunosuppressants, and the patient should not be exposedto increased risk for infection as would occur from patients with viral pneumonia, graft-versus-host disease, and burns. There is no increased exposure to infection from a patient who had an anaphylactic reaction. DIF: Cognitive Level: Apply (application) OBJ: Special Questions: Multiple Patients TOP: NursingProcess: Planning MSC: NCLEX: Safe and Effective Care Environment 19. A patient who has received allergentesting using the cutaneous scratch method has developed itching and swelling at the skin site. Which action should the nurse take first? a. Administer epinephrine. b. Apply topical hydrocortisone. c. Monitorthe patient for lower extremity edema. d. Ask the patient about exposure to any new lotions or soaps. NN Test Bank - Lewis's MedicalSurgical Nursing(11th Edition by Harding) 112 ANS: A The initial symptoms of anaphylaxis are itching and edema at the site of the exposure. Hypotension, tachycardia, dilated pupils, and wheezes occur later. Rapid administration of epinephrine when excessive itching or swelling at the skin site is observed can prevent the progression to anaphylaxis. Topical hydrocortisone would not deter an anaphylactic reaction. Exposure to lotions and soaps does not address the immediate concern of a possibleanaphylactic reaction. The nurse should not wait and observe for edema. The nurse should act immediately in order to prevent progression to anaphylaxis. DIF: Cognitive Level: Apply (application) OBJ: Special Questions: Prioritization TOP: NursingProcess: Assessment MSC: NCLEX: Physiological Integrity 20. A patient who is anxious and has difficulty breathing seeks treatment after being stung by a wasp. What is the nurses priority action? a. Have the patient lie down. b. Assess the patients airway. c. Administer high-flow oxygen. d. Remove the stinger from the site. ANS: B The initial action with any patient with difficulty breathing is to assess and maintain the airway. The other actions also are part of the emergency management protocol for anaphylaxis, but the priority is airway maintenance. DIF: Cognitive Level: Apply (application) OBJ: Special Questions: Prioritization TOP: NursingProcess: Implementation MSC: NCLEX: Physiological Integrity 21. Immediately after the nurse administers an intracutaneous injection of an allergenon the forearm, a patient complains of itching at the site and of weakness and dizziness. What action should the nurse take first? a. Remind the patient to remain calm. b. Administer subcutaneous epinephrine. c. Apply a tourniquet above the injection site. d. Rub a local antiinflammatory cream on the site. ANS: C Application of a tourniquet will decrease systemic circulation of the allergenand should be the first reaction. A NN Test Bank - Lewis's MedicalSurgical Nursing(11th Edition by Harding) 113 local antiinflammatory cream may be applied to the site of a cutaneous test if the itching persists.Epinephrine will be needed if the allergic reactionprogresses to anaphylaxis. The nurse should assist the patient to remain calm, but this is not an adequate initial nursing action. DIF: Cognitive Level: Apply (application) OBJ: Special Questions: Prioritization TOP: NursingProcess: Implementation MSC: NCLEX: Physiological Integrity 22. A clinic patient is experiencing an allergic reactionto an unknown allergen. Which action is most appropriate for the registered nurse (RN) to delegate to a licensedpractical/vocational nurse (LPN/LVN)? a. Performa focused physical assessment. b. Obtain the health history from the patient. c. Teach the patient about the various diagnostic studies. d. Administer skin testing by the cutaneous scratch method. ANS: D LPN/LVNs are educated and licensedto administer medications under the supervision of an RN. RN-level education and the scope of practice include assessment of health history, focused physical assessment, and patient teaching. DIF: Cognitive Level: Apply (application) OBJ: Special Questions: Delegation TOP: NursingProcess: Planning MSC: NCLEX: Safe and Effective Care Environment 23. The health care provider asks the nurse whether a patients angioedema has responded to prescribed therapies. Which assessment should the nurse perform? a. Ask the patient about any clear nasal discharge. b. Obtain the patients blood pressure and heart rate. c. Check for swelling of the patients lips a