Pregunta 1
Pregunta
A nurse in a clinic is caring for a client who has suspected anemia. Which of the following laboratory test results should the nurse expect?
Respuesta
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Iron 90 mcg/dL
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RBC 6.5 million/uL
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WBC 4,800 mm3
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Hgb 10 g/dL
Pregunta 2
Pregunta
A nurse is caring for a client who is receiving warfarin for anticoagulation therapy. Which of the following laboratory test results indicates to the nurse that the client needs an increase in the dosage?
Respuesta
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aPTT 38 seconds
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INR 1.1
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PT 22 seconds
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D‑dimer negative
Pregunta 3
Pregunta
A nurse is providing teaching for a client who is scheduled for a bone marrow biopsy of the iliac crest. Which of the following statements made by the client indicates an understanding of the teaching?
Respuesta
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“This test will be performed while I am lying flat on my back.”
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“I will need to stay in bed for about an hour after the test.”
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“This test will determine which antibiotic I should take for treatment.”
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“I will receive general anesthesia for the test.”
Pregunta 4
Pregunta
A nurse is preparing to administer packed RBCs to a client who has a Hgb of 8 g/dL. Which of the following actions should the nurse plan to take during the first 15 min of the transfusion?
Respuesta
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Obtain consent from the client for the transfusion.
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Assess for an acute hemolytic reaction.
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Explain the transfusion procedure to the client.
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Obtain blood culture specimens to send to the lab.
Pregunta 5
Pregunta
A nurse is caring for a client who is receiving a blood transfusion. Which of the following actions should the nurse expect if an allergic transfusion reaction is suspected? (Select all that apply.)
Respuesta
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Stop the transfusion.
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Monitor for hypertension.
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Maintain an IV infusion with 0.9% sodium chloride.
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Position the client in an upright position with the feet lower than the heart.
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Administer diphenhydramine.
Pregunta 6
Pregunta
A nurse is monitoring a client who began receiving a unit of packed RBCs 10 min ago. Which of the following findings should the nurse identify as an indication of a febrile transfusion reaction? (Select all that apply.)
Respuesta
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Temperature change from 37° C (98.6° F) pretransfusion to 37.2° C (99.0° F)
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Current blood pressure 178/90 mm Hg
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Heart rate change from 88/min pretransfusion to 120/min
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Client report of itching
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Client appears flushed
Pregunta 7
Pregunta
A nurse is providing preoperative teaching for a client who requests autologous donation in preparation for a scheduled orthopedic surgical procedure. Which of the following statements should the nurse include in the teaching?
Respuesta
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“you should make an appointment to donate blood 8 weeks prior to the surgery.”
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“If you need an autologous transfusion, the blood your brother donates can be used.”
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“you can donate blood each week if your hemoglobin is stable.”
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“Any unused blood that is donated can be used for other clients.”
Pregunta 8
Pregunta
A nurse preceptor is observing a newly licensed nurse on the unit who is preparing to administer a blood transfusion to an older adult client. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure?
Respuesta
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Inserts an 18‑gauge IV catheter in the client
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Verifies blood compatibility and expiration date of the blood with an assistive personnel (AP)
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Administers dextrose 5% in 0.9% sodium chloride IV with the transfusion
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Obtains vital signs every 15 min throughout the procedure
Pregunta 9
Pregunta
A nurse is planning care for a client who has Hgb 7.5 g/dL and Hct 21.5%. Which of the following actions should the nurse include in the plan of care? (Select all that apply.)
Respuesta
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Provide assistance with ambulation.
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Monitor oxygen saturation.
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Weigh the client weekly.
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Obtain stool specimen for occult blood.
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Schedule daily rest periods.
Pregunta 10
Pregunta
A nurse is teaching a client who has a new prescription for ferrous sulfate. Which of the following information should the nurse include in the teaching?
Pregunta 11
Pregunta
A nurse is providing discharge teaching to a client who had a gastrectomy for stomach cancer. Which of the following information should the nurse include in the teaching? (Select all that apply.)
Respuesta
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“you will need a monthly injection of vitamin B12 for the rest of your life.”
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“Using the nasal spray form of vitamin B12 on a daily basis can be an option.”
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“An oral supplement of vitamin B12 taken on a daily basis can be an option.”
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“you should increase your intake of animal proteins, legumes, and dairy products to increase vitamin B12 in your diet.”
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“Add soy milk fortified with vitamin B12 to your diet to decrease the risk of pernicious anemia.”
Pregunta 12
Pregunta
A nurse is completing an integumentary assessment of a client who has anemia. Which of the following findings should the nurse expect?
Respuesta
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Absent turgor
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Spoon‑shaped nails
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Shiny, hairless legs
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Yellow mucous membranes
Pregunta 13
Pregunta
A nurse in a clinic receives a phone call from a client seeking information about a new prescription for erythropoietin. Which of the following information should the nurse review with the client?
Respuesta
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The client needs an erythrocyte sedimentation rate (ESR) test weekly.
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The client should have his hemoglobin checked twice a week.
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Oxygen saturation levels should be monitored.
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Folic acid production will increase.
Pregunta 14
Pregunta
A nurse is caring for a client who has disseminated intravascular coagulation (DIC). Which of the following laboratory values indicates the client’s clotting factors are depleted? (Select all that apply.)
Respuesta
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Platelets 100,000/mm3
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Fibrinogen levels 57 mg/dL
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Fibrin degradation products 4.3 mcg/mL
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D‑dimer 0.03 mcg/mL
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Sedimentation rate 38 mm/hr
Pregunta 15
Pregunta
A nurse is assessing a client and suspects the client is experiencing DIC. Which of the following physical findings should the nurse anticipate?
Respuesta
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Bradycardia
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Hypertension
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Epistaxis
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Xerostomia
Pregunta 16
Pregunta
A nurse is caring for a client who has idiopathic thrombocytopenic purpura (ITP). The nurse should notify the provider and report possible small‑vessel clotting when which of the following is assessed?
Pregunta 17
Pregunta
A nurse is caring for a client who has DIC. Which of the following medications should the nurse anticipate administering?
Respuesta
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Heparin
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Vitamin K
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Mefoxin
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Simvastatin
Pregunta 18
Pregunta
A nurse is teaching a newly licensed nurse about heparin‑induced thrombocytopenia. Which of the following risk factors for this disorder should the nurse include in the teaching?
Respuesta
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Warfarin therapy for atrial fibrillation
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Placental abruption
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Systemic lupus erythematosus
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Heparin therapy for deep‑vein thrombosis
Pregunta 19
Pregunta
A nurse is admitting a client who reports nausea, vomiting, and weakness. The client has dry oral mucous membranes, temperature 38.5° C (101.3° F), pulse 92/min, respirations 24/min, skin cool with tenting present, and blood pressure 102/64 mm Hg. Urine is concentrated with a high specific gravity. Which of the following are manifestations of fluid volume deficit for which the nurse should monitor? (Select all that apply.)
Respuesta
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Decreased skin turgor
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Concentrated urine
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Bradycardia
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Low‑grade fever
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Tachypnea
Pregunta 20
Pregunta
A nurse is admitting an older adult client who is experiencing dyspnea, weakness, weight gain of 2 lb, and 1+ bilateral edema of the lower extremities. The client has temperature 37.2° C (99° F), pulse 96/min, respirations 26/min, oxygen saturation 94% on 3 L oxygen via nasal cannula, and blood pressure 152/96 mm Hg. Which of the following manifestations of fluid volume excess should the nurse expect? (Select all that apply.)
Respuesta
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Dyspnea
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Edema
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Bradycardia
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Hypertension
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Weakness
Pregunta 21
Pregunta
A nurse is assessing a client who is dehydrated for fluid volume deficit. Which of the following findings should the nurse expect in the client?
Respuesta
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Moist skin
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Distended neck veins
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Increased urinary output
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Tachycardia
Pregunta 22
Pregunta
A nurse is caring for an older adult client in a long‑term care facility. The client has become weak and confused. He ate 40% of his breakfast and lunch. The client’s temperature is 38.3° C (100.9° F), pulse 92/min, respirations 20/min, and blood pressure 108/60 mm Hg. He has lost ¾ lb and reports dizziness when assisted to the bathroom. He also has a nonproductive cough with diminished breath sounds in the right lower lobe. Which of the following actions should the nurse take?
Respuesta
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Initiate fluid restrictions to limit intake.
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Observe for signs of peripheral edema.
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Encourage the client to ambulate to promote oxygenation.
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Monitor for orthostatic hypotension
Pregunta 23
Pregunta
A nurse is caring for a client who has a serum sodium level 133 mEq/L and serum potassium level 3.4 mEq/L. The nurse should recognize that which of the following treatments can result in these laboratory findings?
Pregunta 24
Pregunta
A nurse is caring for a client who has a serum potassium 5.4 mEq/L. The nurse should assess for which of the following manifestations?
Respuesta
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ECG changes
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Constipation
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Polyuria
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Hypotension
Pregunta 25
Pregunta
A nurse is caring for a client who has a nasogastric tube attached to low intermittent suctioning. The nurse should monitor for which of the following electrolyte imbalances?
Respuesta
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Hypercalcemia
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Hyponatremia
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Hyperphosphatemia
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Hypomagnesemia
Pregunta 26
Pregunta
A nurse is assessing a client who has hyperkalemia. The nurse should identify which of the following conditions as being associated with this electrolyte imbalance?
Respuesta
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Diabetic ketoacidosis
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Heart failure
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Cushing’s syndrome
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Thyroidectomy
Pregunta 27
Pregunta
A nurse is assessing a client for Chvostek’s sign. Which of the following techniques should the nurse use to perform this test?
Respuesta
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Apply a blood pressure cuff to the client’s arm.
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Place the stethoscope bell over the client’s carotid artery.
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Tap lightly on the client’s cheek.
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Ask the client to lower her chin to her chest.
Pregunta 28
Pregunta
A nurse is caring for a client admitted with confusion and lethargy. The client was found at home unresponsive with an empty bottle of aspirin lying next to her bed. Vital signs reveal blood pressure 104/72 mm Hg, heart rate 116/min with regular rhythm, and respiratory rate 42/min and deep. Which of the following arterial blood gas findings should the nurse expect?
Respuesta
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pH 7.68 PaO2 96 mm Hg PaCO2 38 mm Hg HCO3− 28 mEq/L
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pH 7.48 PaO2 100 mm Hg PaCO2 28 mm Hg HCO3− 23 mEq/L
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pH 6.98 PaO2 100 mm Hg PaCO2 30 mm Hg HCO3− 18 mEq/L
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pH 7.58 PaO2 96 mm Hg PaCO2 38 mm Hg HCO3− 29 mEq/L
Pregunta 29
Pregunta
A nurse is caring for a client who was in a motor‑vehicle accident. The client reports chest pain and difficulty breathing. A chest x‑ray reveals the client has a pneumothorax. Which of the following arterial blood gas findings should the nurse expect?
Respuesta
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pH 7.06 PaO2 86 mm Hg PaCO2 52 mm Hg HCO3− 24 mEq/L
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pH 7.42 PaO2 100 mm Hg PaCO2 38 mm Hg HCO3− 23 mEq/L
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pH 6.98 PaO2 100 mm Hg PaCO2 30 mm Hg HCO3− 18 mEq/L
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pH 7.58 PaO2 96 mm Hg PaCO2 38 mm Hg HCO3− 29 mEq/L
Pregunta 30
Pregunta
A nurse is obtaining arterial blood gases for a client who has vomited for 24 hr. The nurse should expect which of the following acid‑base imbalances to result from vomiting for 24 hr?
Respuesta
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Respiratory acidosis
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Respiratory alkalosis
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Metabolic acidosis
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Metabolic alkalosis
Pregunta 31
Pregunta
A charge nurse is teaching a group of nurses about conditions related to metabolic acidosis. Which of the following statements by a unit nurse indicates the teaching has been effective?
Respuesta
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“Metabolic acidosis can occur due to diabetic ketoacidosis.”
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“Metabolic acidosis can occur in a client who has myasthenia gravis.”
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“Metabolic acidosis can occur in a client who has asthma.”
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“Metabolic acidosis can occur due to cancer.”
Pregunta 32
Pregunta
A nurse is assessing a client who has pancreatitis. The client’s arterial blood gases reveal metabolic acidosis. Which of the following are expected findings? (Select all that apply.)
Respuesta
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Tachycardia
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Hypertension
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Bounding pulses
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Hyperreflexia
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Dysrhythmia
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Tachypnea