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
Category | ATI |
Release date | 2021-09-14 |
Pages | 13 |
Language | English |
Comments | 0 |
Sales | 0 |
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