MULTIPLE CHOICE

1. The nurse helps to ambulate a client who has anemia. Which clinical manifestation indicates that the client is not tolerating the activity?

a.            Blood pressure of 120/90 mm Hg

b.            Heart rate of 110 beats/min

c.             Pulse oximetry reading of 95%

d.            Respiratory rate of 20 breaths/min

ANS: B

The red blood cells contain thousands of hemoglobin molecules. The most important feature of hemoglobin is its ability to combine loosely with oxygen. A low hemoglobin level can cause decreased oxygenation to the tissues, thus causing a compensatory increase in heart rate. The other options are close to normal range and are not indicative of not tolerating this activity.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

MSC: Integrated Process: Nursing Process (Analysis)

2. The nurse is assessing a client with liver failure. Which assessment is the highest priority for this client?

a.            Auscultation for bowel sounds

b.            Assessing for deep vein thrombosis

c.             Monitoring of blood pressure hourly

d.            Assessing for signs of bleeding

ANS: D

All these options are important in assessment of the client, but the most important action is assessment for signs of bleeding. The liver is the site of production of prothrombin and most of the blood-clotting factors. Clients with liver failure run a high risk of having problems with bleeding.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Assessment)

3. The nurse observes yellow-tinged sclera in a client with dark skin. Based on this assessment finding, what does the nurse do next?

a.            Assess the client’s pulses.

b.            Examine the soles of the client’s feet.

c.             Inspect the client’s hard palate.

d.            Auscultate the client’s lung sounds.

ANS: C

Jaundice can best be observed in clients with dark skin by inspecting the oral mucosa, especially the hard palate, for yellow discoloration. Because sclera may have subconjunctival fat deposits that show a yellow hue, and because foot calluses may appear yellow, neither of these areas should be used to assess for jaundice. The client’s pulse and lung sounds have no correlation with an assessment of jaundice.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening)

MSC: Integrated Process: Nursing Process (Assessment)

4. The nurse is assessing a client with numerous areas of bruising. Which question does the nurse ask to determine the cause of this finding?

a.            “Do you take aspirin?”

b.            “How often do you exercise?”

c.             “Are you a vegetarian?”

d.            “How often do you take Tylenol?”

ANS: A

Platelet aggregation is essential for blood clotting. An inability to clot blood when an injury occurs can result in bleeding, which would cause bruising. Aspirin is a drug that interferes with platelet aggregation and has the ability to “plug” an extrinsic event, such as trauma. Vitamin K found in green vegetables enhances clotting factors, which would improve the ability to stop bleeding associated with an extrinsic event. Acetaminophen (Tylenol) and exercise do not inhibit clotting factors.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening)

MSC: Integrated Process: Nursing Process (Assessment)

5. A client who has a chronic vitamin B12 deficiency is admitted to the hospital. When obtaining the client’s health history, which priority question does the nurse ask this client?

a.            “Are you having any pain?”

b.            “Are you having blood in your stools?”

c.             “Do you notice any changes in your memory?”

d.            “Do you bruise easily?”

ANS: C

Vitamin B12 deficiency impairs cerebral, olfactory, spinal cord, and peripheral nerve function. Severe chronic deficiency may cause permanent neurologic degeneration. The other options are not symptoms of vitamin B12deficiency.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening)

MSC: Integrated Process: Nursing Process (Assessment)

6. The nurse is planning discharge teaching for a client who has a splenectomy. Which statement does the nurse include in this client’s teaching plan?

a.            “Avoid crowds and people who are sick.”

b.            “Do not eat raw fruits or vegetables.”

c.             “Avoid environmental allergens.”

d.            “Do not play contact sports.”

ANS: A

The spleen is the major site of B-lymphocyte maturation and antibody production. Those who undergo splenectomies for any reason have a decreased antibody-mediated immune response and are particularly susceptible to viral infections. Eating raw fruits and vegetables places the client at risk for bacterial infections. The body responds to environmental allergens with an unspecific inflammatory process. The client is not at risk for bleeding or injury due to contact sports.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Teaching/Learning

7. The nurse is teaching a client who has undergone a bone marrow biopsy. Which instruction does the nurse give the client?

a.            “Wear protective gear when playing contact sports.”

b.            “Monitor the biopsy site for bruising.”

c.             “Remain in bed for at least 12 hours.”

d.            “Use a heating pad for pain at the biopsy site.”

ANS: B

The most important instruction is to have the client monitor the area for external or internal bleeding. Activities such as contact sports should be avoided, and an ice pack can be used to limit bruising.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Diagnostic Tests/Treatments/Procedures)

MSC: Integrated Process: Teaching/Learning

8. The nurse is assessing a 75-year-old male client. Which blood value indicates that the client is experiencing normal changes associated with aging?

a.            Hemoglobin, 13.0 g/dL

b.            Platelet count, 100,000/mm3

c.             Prothrombin time (PT), 14 seconds

d.            White blood cell (WBC) count, 5000/mm3

ANS: A

Hemoglobin levels in men and women fall after middle age. Therefore, this client’s hemoglobin value would be considered part of the aging process. Platelet counts and blood-clotting times are not age related; the client’s platelet count and PT are elevated for some other reason. The WBC count shown is normal.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 860

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Laboratory Values) MSC: Integrated Process: Nursing Process (Assessment)

9. The nurse is planning care for a client who has a platelet count of 30,000/mm3. Which intervention does the nurse include in this client’s plan of care?

a.            Oxygen by nasal cannula

b.            Bleeding Precautions

c.             Isolation Precautions

d.            Vital signs every 4 hours

ANS: B

The normal platelet count ranges between 150,000 and 400,000/mm3. This client is at extreme risk for bleeding. Although it is necessary to notify the provider, the nurse would first protect the client by instituting Bleeding Precautions. The other interventions are not related to the low platelet count.

DIF: Cognitive Level: Application/Applying or higher REF: N/A