During a routing physical examination, a client reports recent occipital headaches, blurred vision, fatigue, and increasing edemA)  The nurse reports these findings and indicative of.
A) Endocarditis.
B) Hypovolemic shock
C) Hypertension.
D) Ventricular tachycardia
ANSWER: C

A client's parents ask the nurse, "What is the prognosis of myocarditis?" The most appropriate response by the nurse is 
A) A heart transplant would be very promising. "
B) Most often, a person will do well with coronary artery bypass surgery
C) A coronary angioplasty would only involve a one-to three-day hospitalization.
D) Recovery usually happens without any special treatment."
ANSWER: D

The nurse is planning the care for a client in the acute stage of bacterial endocardittis. Which of the following interventions should the nurse include?
A) fluid restriction
B) vitamin K [Aquamephyton]
C) Analgesics
D) physical therapy
ANSWER: C

A client who has hypertension asks the nurse why a urine sample is needed. The nurse informs the client it is to check for. 
A) Protein, which may indicate the kidneys are affected
B) Illegal drugs, which may have caused the hypertension.
C) Infection, which may cause the blood pressure to rise.
D) The appropriate drug level of the antihypertensive medication
ANSWER: C

Which of the following orders should the nurse question in a client who has been admitted with a possible myocardial infarction and active peptic ulcer disease?
A) Nitroglycerin SL
B) Oxygen by nasal cannula
C) Morphine IV
D) Aspirin PO
ANSWER: D

The nurse's client asks, "how did I get rheumatic heart disease?" The most appropriate response by the nurse is that rheumatic heart disease is frequently  result of 
A) hypertension
B) streptococcal infection
C) genetic tendency
D) pregnancy
ANSWER: B 

Which of the following interventions is a priority during exacerbation of left-sided heart failure?
A) metered dose inhaler of albuterol
B) Oxygen
C) IV fluids
D) Incentive inspirometer
ANSWER: B 

The nurse is preparing a client to be discharge after a new diagnosis of heart failure. Which of the following statements by the client shows an appropriate understanding of the nurse's teaching?
A) I will do weekly finger-stick monitoring of my sodium levels
B) I will call my doctor if I gain more than two pounds in a day.
C) I will take my angiotensin-converting enzyme [ACE] inhibitor as needed for shortness of breathe.
D) I will not take my diuretic pill on weekends when I am traveling, in order to avoid incontinence.
ANSWER: B

The nurse should monitor a client after a coronary angioplasty for which of the following clinical manifestations indicating cardiac tamponade?
A) Muffled heart sound
B) headache
C) hypertension
D) Vision changes
ANSWER: A

The nurse is caring for a client who has an allergy to penicillin. Immediately after receiving cefazolin (Ancef) IV for prophylaxis for a pacemaker insertion, the client becomes restless, tachycardic, and hypotensive. Which of the following interventions should the nurse implement as the priority? 
A) Administer epinephrine [adrenaline] 
B) Obtain stat blood culture 
C) Administer thrombolytic therapy 
D) Administer atropine
ANSWER: A

After a myocardial infarction, a client has concerns about when it its safe to resume sexual activity. The most appropriate response by the nurse is. 
A) You should really talk to your doctor about that.
B) Continue with the sexual practice with which you are most comfortable
C) You need to first undergo a cardiac stress test.
D) When you're able to climb two flights of stairs comfortably
ANSWER: D

In preparing a client for a transesophageal echocardiogram (TEE), the nurse should include which of the following in the client education?
A) You will be able to eat only soft foods for the first day after the procedure.
B) You will need a designated driver to take you home.
C) The procedure involves a series of x-rays that may require you to come back.
D) The procedure involves a balloon that will press plaque against the blocked walls of your coronary artery.
ANSWER: B

After receiving a permanent pacemaker, the client asks the nurse if there are any activities to avoid during a vacation scheduled four months after discharge. Which of the following is the most appropriate response by the nurse?
A) There are no restrictions on your activity.
B) You should avoid working over a running engine.
C) Avoid standing in front of microwave ovens.
D) Swimming in the ocean should be avoided. 
ANSWER: B

After a client with coronary artery disease develops heavy, substernal chest pain, which of the following interventions should the nurse do first?
A) Administer 2 puffs of albutero [Proventil] by mouth.
B) Administer 1 table of nitroglycerin under the tongue every 5 minutes; call 911 if no relief after 15 minutes
C) Administer 0.04 mg IV push nitroglycerin slowly over 1 to 2 minutes 
D) Administer immediate synchronized cardioversion
ANSWER: B

The nurse assists the client with coronary artery disease to select which of the following menu choices?
A) Mozzarella cheese.
B) Grilled cheddar cheese sandwich.
C) Tomato juice.
D) Peanut butter sandwich.
ANSWER: A 

In caring for a client with a cardiac history the client has a temperature of 39.4 celsius or 103 farenheit, becomes tachycardic, hypotensive, and short of breath while exhibiting cool, clammy skin and a decreased urine output. The client also has positive blood cultures. The nurse should plan to include which of the following in the plan of care for this client?
A) Assistance with pericardiocentesis.
B) Administration of antihypertensives.
C) Administration of vasopressors.
D) Assistance with defibrillation.
ANSWER: C

Which of the following should the nurse include in the preoperative teaching for a client scheduled for coronary artery bypass graft (CABG) surgery?
A) A liquid diet will be ordered for the first four to five days postoperatively.
B) Coughing is to be avoided in order to protect the sternal incision.
C) The hospital stay is generally about 10 days.
D) High calorie supplements are encouraged in the first few weeks postoperative. 
ANSWER: D

The nurse observes the ECG rhythm of a client who has received a new permanent pacemaker for third-degree heart block. Several spikes are noted on the rhythm, but are not followed by any other waveforms. The nurse recognizes this as.
A) An indication that the pacemaker is adhering to the heart.
B) A normal finding because spikes should never be seen on a pacemaker ECG rhythm strip.
C) The sinoatrial [S-A] node is beating appropriately but may not show up on the rhythm strip.
D) An abnormal finding because every spike on the ECG strip should be followed by a waveform.
ANSWER: D

The nurse assesses the left foot of a client with known coronary artery disease that has become suddenly cold, painful, and pulse less. Which of the following would be the priority intervention for this client? 
A) Notify the physician.
B) Provide education to the client about probable bypass surgery for the client's leg the following week.
C) Instruct the client on importance of daily doses of warfarin [Coumadin]
D) Instruct the client to restrict activity, keeping it warm and elevated until it heals.
ANSWER: A

Plans for nursing interventions for a client in the acute stage of bacterial endocarditis should include which of the following interventions? 
A) Daily ECGs.
B) Administration of analgesics as needed. 
C) Strict fluid restriction.
D) Aggressive physical therapy.
ANSWER: B

Which of the following is priority for the nurse to report when obtaining a history form a client scheduled for a coronary angiogram?
A) A history of rheumatic heart disease.
B) A history of allergy to shellfish.
C) A recent diagnosis of hyperlipidemia.
D) A previous coronary angioplasty to the right coronary artery.
ANSWER: B

Which of the following should the nurse include in the plan of care for a client following a coronary angiogram?
A) Vigorous leg exercises.
B) Immediate cardiac stress test.
C) Encourage fluids.
D) Activity restriction for four to six weeks.
ANSWER: C

The nurse is teaching a class to student nurses or rheumatic fever. Which of the following should the nurse include in the class? Rheumatic fever.
A) Occurs mainly in the elderly.
B) Is more likely to develop after a varicella zoster infection.
C) Is easy to be diagnosed with a throat culture and serum antistreptolysin titer. 
D) May be diagnosed by a series of two-step blood cultures. 
ANSWER: C

Which of the following should the nurse include in the plan of care  fro the client experiencing pain from a deep vein thrombosis (DVT) of the leg who is receiving heparin and warfarin (Coumadin)? Administration of 
A) aspirin 325 mg p.o. every 4 hours
B) Patient controlled analgesic of IV morphine.
C) Meperidien [Demerol] 50 mg IM every 3 hours.
D) Ibuprofen [Motrin] 400 mg p.o. every 6 hours p.r.n. 
ANSWER: B

The client with a recent diagnosis of cardiomyopathy asks the nurse, "What contributed to my getting this illness?" The most appropriate response is to say that the majority of clients with cardiomyopahty also have
A) hypertension.
B) a viral infection.
C) a genetic trait.
D) An unknown cause.
ANSWER: D

The nurse is teaching the client what to expect after coronary artery bypass graft surgery (CABG). Which of the following client statements demonstrates that the client correctly understood the teaching?
A) "I will be given a pen and paper to communicate, because I will still have a breathing tube in my throat."
B) "I will be fed with a tube into my stomach until I can eat again."
C) "Pain medicine is generally not needed after this surgery."
D) "The nurses will be checking on me every four hours."
ANSWER: A

The nurse reports the following ECG strip to be indicative of which of the following dysrhythmias.
A) Ventricular fibrillation.
B) Atrial flutter.
C) Atrial fibrillation.
D) Ventricular tachycardia.
ANSWER: B

28.A client is brought to the emergency room with a third-degree heart block after experiencing an acute anterior myocardial infarction. Which of the following interventions is the priority on an emergency basis?
A) temporary pacemaker
B) administer lidocaine
C) cardioversion
D) administer atropine
ANSWER: A

the nurse should include which of the following in the plan of care of a client after a pacemaker is inserted?
A) Instruct the client to avoid lifting the arm on the pacemaker side above shoulder height.
B) Encourage the client to exercise the shoulder and arm on the side of the pacemaker four times a day.
C) Encourage the client to wash the pacemaker incision with warm soapy water twice a day.
D) Instruct the client to avoid the use of microwave ovens. 
ANSWER: A

Following morning assessment, the registered nurse may delegate which of the following clients with a dysrhythmia to a licensed practical nurse to care for a client with.
A) ventricular tachycardia
B) Sinus bradycardia.
C) Ventricular fibrillation.
D) Sinus thythm with a second degree A-V block type II [Mobitz II]
ANSWER: B

The nurse is monitoring the ECG tracing on the central monitors on a cardiac unit. Which of the following dysrhythmias is a priority for the nurse to report first?
A) sinus rhythm with a first-degree A-V block.
B) supraventricular tachycardia [SVT]
C) Atrial fibrillation.
D) Idioventricular rhythm [ventricular escape rhythm]
ANSWER: D

In caring for a client with atrial flutter, which of the following goals would have priority?
A) reduce the ventricular rate to below 100 beats per minute.
B) identify and treat the underlying cause. 
C) control the heart rate and maintain cardiac output. 
D) Increase the heart rate. 
ANSWER: C

Which of the following should the nurse include in the plan of care for a client wht sinus tachycardia?
A) Administer lidocaine.
B) Assess the client.
C) Administer atropine.
D) Cardioversion.
ANSWER: B

A client is admitted to the intensive care unit 36 hours ago following extensive pulmonary traumA)  Which clinical manifestation would first alert the nurse that the client is experiencing adult respiratory distress syndrome (ARDS)?
A) blood tinged, frothy sputum.
B) dense pulmonary infiltrates with a "whited-out" appearance.
C) an increase in respiratory rate.
D) increasing hypoxemia.
ANSWER: C

A client with a history of asthma presents in the physician's office with complaints of difficulty breathing. While performing the initial assessment, the nurse becomes concerned that the client's respiratory status has worsened based on which of the following? 
A) Wheezing throughout the lung fields.
B) Noticeable diminished breath sounds. 
C) Loud wheezing only on expiration.
D) Mild wheezing on inspiration.
ANSWER: B

A home health nurse is visiting a client with severe chronic obstructive pulmonary disease COPD) who is complaining of increased shortness of air. The client is on home oxygen at 2 L/min via on oxygen concentrator with a respiratory rate of 23 breaths/min. the most appropriate nursing action is to
A) Call emergency services to come to the home.
B) Reassure the client of being unnecessarily anxious.
C) Conduct further assessment of the client's respiratory status.
D) Consider increasing the oxygen to 4 Liter per minute during the home visit.
ANSWER: C

The nurse is admitting a client with suspected tuberculosis [TB] to the acute care unit. The nurse places the client in airborne precautions until a confirmed diagnosis of active TB can be made. Which of the following tests is a priority to confirm the diagnosis?
A) chest x-ray that is positive for lung lesions.
B) Positive purified protein derivative [PPD] test.
C) Sputum positive for blood [hemoptysis]
D) Sputum culture positive for Mycobacterium tuberculosis.
ANSWER: D

A student health nurse is conducting tuberculosis [TB] testing. Students who had the purified protein derivative (PPD) test 48 hours ago have returned to have the results read and documenteD)  The nurse determines that the test is positive if which of the following is present?
A) the client complains of itching at the site.
B) there is a large area of erythema.
C) there is an induration of 10 mm or greater.
D) a bruise is present at the site of injection. 
ANSWER: C

A client is scheduled for computerized axial tomography [CAT] scan with contrast as one of several tests to diagnose a respiratory problem. The priority component of the nurse's assessment in preparation for this test would be to ask the client about _____. 
A) fat intake.
B) allergy.
C) aspirin intake.
D) bleeding disorders.
ANSWER: B

A client with no history of respiratory disease has a sudden onset of dyspnea, chest pain, and tachycardiA)  A pulmonary embolism is therapeutic orders to be prescribed for this client? 
A) Oxygen at 2 Liter per min.
B) High-fowler's position.
C) Oxygen at 4 Liter per min.
D) Meperidine hydrochloride [Demerol] 100 mg intramuscular.
ANSWER: A

A client with pulmonary edema is currently receiving 6 Liter per minute of oxygen per nasal cannula.  The most recent arterial blood gas (ABG) results indicate the following: pH = 7.30, pCO2 = 50 mm Hg, pO2 = 56 mm Hg, HcO3 = 24 mm Hg. The nurse anticpates that the physician will order which of the following?
A) change nasal cannula to face mask at 6 L/min oxygen.
B) add one ampule of sodium bicarbonate to the client's current intravenous fluids.
C) change nasal cannula to partial rebreather mask at 8 L/min oxygen.
D) intubate the client and place on mechanical ventilation.
ANSWER: D

A registered nurse is planning the schedule for the day. Which of the following nursing tasks may the nurse delegate to a licensed practical nurse?
A) develop instructions for the client on pursed lip breathing.
B) clarify an order with the physician.
C) instruct a client on a bronchoscopy.
D) administer a purified protein derivative [PPD] to a client.
ANSWER: D

The nurse is assisting the physician with the removal of a chest tube. How should the nurse tell the client to breathe during the procedure? ____
A) exhale.
B) inhale.
C) hold breath and bear down.
D) inhale exhale.
ANSWER: C

The nurse has just received orders to provide chest physiotherapy for a client two times per day. The nurse evaluates which schedule to be most therapeutic?
A) 7am and 1pm
B) 6am and 4pm 
C) 9am and 5pm
D) 8am and 8pm 
ANSWER: B

The nurse assess fluctuations in the water seal chamber of a client's closed chest drainage system. The nurse evaluates this findings as indicating.
A) the system is functioning properly
B) An air leak is present
C) The tubing is kinked
D) The lung has rexpanded 
ANSWER: A

The nurse assesses a college-age client complaining of shortness of breath after jogging and tightness in his chest. Upon further questioning, the client denies a sore throat, fever, or productive cough. The nurse notifies the physician that this client's clinical manifestations are most likely related to 
A) pneumonia.
B) bronchitis.
C) pneumoconiosis.
D) asthma.
ANSWER: D

Which of the following is a priority to include in the instructions given to a client who has bronchitis?
A) avoid cigarette smoking.
B) decrease overweight status.
C) increase activity.
D) avoid malnutrition. 
ANSWER: A

The nurse is assessing the respiratory status of a client following a thoracentesis. Which finding would indicate further assessment is needed?
A) equal bilateral chest expansion.
B) scattered crackles, unchanged from baseline. 
C) diminished breath sounds on the affected side.
D) respiratory rate of 22 breaths per minute.
ANSWER: C

The nurse is admitting a client who complains of fever, chills, chest pain, and dyspnea.The client has a heart rate of 110, respiratory rate of 28, and a nonproductive hacking cough. A chest x-ray confirms a diagnosis of left lower lobe pneumoniA)  Upon auscultation of the left lower lobe, the nurse documents which of the following breath sounds?
A) bronchial.
B) bronchovesicular.
C) vesicular.
D) Absent breath sounds. 
ANSWER: A

The nurse is preparing a client with empyema for a thoracentesis. Which of the following should the nurse has available in the event tha the procedure is ineffective?
A) a ventilator.
B) a chest tube insertion kit.
C) an intubation tray.
D) a crash cart.
ANSWER: B

A client is admitted to a burn unit with second and third degree burns over 18% of the body. An inhalation injury is also suspecteD)  The nurse should monitor which of the following to determine the extent of carbon monoxide poisoning?
A) pulse oximetry.
B) urine myoglobin.
C) arterial blood gases.
D) serum carboxyhemoglobin levels.
ANSWER: D

Which of the following should the nurse include when suctioning a clients tracheostomy?
A) instill sterile saline down the trachea to stimulate a cough, then suction with continous suctioning.
B) Insertthe catheter until a cough reflex is obtained or until resistance is felt.
C) Adjust he wall suction to150 mm Hg for the procedure.
D) Suction the client's mouth before entering the trachea.
ANSWER: B

The nurse is evaluating the respiratory system of a client who admits to smoking a half pack per day for the last 5 years and 1 pack per day for 10 years prior to that. When evaluating the client's risk of developing a respiratory disease, the nurse calculates that the client has a smoking history of how many packs over the years? 
A) 2.5 pack years.
B) 10 pack years.
C) 12.5 pack years.
D) 15 pack years.
ANSWER: C

A client with pneumonia has a poor appetite, is dyspneic and complains of decreased taste sensation, and is receiving chest physiotherapy treatments and breathing treatments. Which of the following actions should the nurse include to improve the client's appetite?
A) provide three balanced meals each day.
B) Provide juice and fluids at the bedside. 
D) increase fluid intake to 3 L a day.
ANSWER: A

A client with left-sided heart failure is progressing to pulmonary edemA)  The nurse assesses the client and reports which of the following manifestations?
A) Dry, hacking cough.
B) Bilateral crackles.
C) Fever above 36.8 celsius or 101.5 farenheit
D) Peripheral pitting edema.
ANSWER: B

The nurse is performing a respiratory assessment of a client with pleurisy and compares the assessment findings with the previous days assessment. Currently there is no friction rub, but one was auscultated the previous day. The nurse evaluates this finding as the result of
A) the client taking more shallow breaths
B) A decreased inflammatory response. 
C) The effectiveness of the antibiotics. 
D) An accumualtionof pleural fluid in the inflamed are. 
ANSWER: D

The nurse is caring for a client following a cardiac bypass surgery. The nurse note that in the first hour the chest tube drainage measured 90 ml. during the second hour the drainage dropped to 5 ml. the nurse suspects that 
A) the chest tube may be clotted.
B) the lungs have fully inflated.
C) the client is recovering normally.
D) the physician should be notified.
ANSWER: A

The nurse should monitor a client admitted with a suspected diagnosis of pulmonary emphysema for which of the following clinical manifestations?
A) copious sputum production.
B) lateral wheezing.
C) prolonged aspiratory phase.
D) barrel chest appearance.
ANSWER: D

The nurse is preparing to delegate which of the following nursing tasks to a licensed practical nurse?
A) administer morphine IV to a client experiencing a pulmonary embolism.
B) monitor a client's chest tube fro bubbling.
C) assess a client for tactile fremitus.
D) perform a sputum culture for a client. 
ANSWER: D

The nurse is reviewing the normal limits for a head and neck assessment. Which of the following findings would indicate the need for additional investigations?
A) a small, discrete, movable lymph node.
B) the trachea is to the right of the suprasternal notch.
C) a thyroid gland that is not visible or palpable.
D) the muscles of the neck are symmetrical.
ANSWER: B

The nurse is performing an assessment of the thorax and lungs on a 30-year-old client. Which of the following assessments does the nurse evaluate to be a normal adult finding?
A) the thorax is barrel shaped.
B) the costal margin is greater than 90º.
C) the accessory muscles are used during inspiration.
D) the ribs articulate at a 45º angle with the sternum.
ANSWER: 4

The nurse correctly documents moist, low-pitched, gurgling breath sounds as.
A) Sonorous wheezes.
B) Coarse crackles.
C) Sibilant wheezes.
D) Pleural friction rub
ANSWER: B

When preparing a client to collect a sputum specimen, it would be essential for the nurse to explain which of the following aspects of the procedure? 
A) avoid mouth care prior to collecting the specimen
B) breathe deeply followed by coughing up sputum
C) collect the specimen before bedtime
D) restrict fluids prior to expectorating sputum 
ANSWER: B

The nurse is admitting client suspected of having sickle cell anemia. The client has a fever of 38.9 celsius or 102 farenheit, faint yellow tinged sclera, and is complaining of abdominal pain, which of the following clinical manifestations further support this diagnosis?
A) rapid but regular breathing
B) pale, dilute urine
C) skin ulcers on the lower extremities
D) cyanotic fingers
ANSWER: C

The nurse making a care plan for a client with sever thrombocytopenia should include which of the following?
A) careful examination of spinal fluid obtained by lumbar puncture.
B) a private room with reverse isolation precautions. 
C) avoid intramuscular administration of medications.
D) careful monitoring of urinary output while titrating the dosage of furosemide [Lasix].
ANSWER: C

A client with lung cancer is admitted with a new diagnosis of acute disseminated intravascular coagulation [DIC]. Which of the following actions is a priority?
A) obtain a diet history from the client for the last three days.
B) assess the client for any indications of internal or external bleeding. 
C) take the family to the family lounge and discuss home care for a client with DIC. 
D) Call the dialysis unit to determine when the client may be transferreD).
ANSWER: B

The nurse has instructed a client with a hematological disorder about the functions of the hematologic system. The client indicates a need for further teaching by describing the function of the hematologic system as 
A) "The coagulation and clotting of blood".
B) "The exchange of oxygen and carbon dioxide at the alveoli.".
C) "The transportation of oxygen and carbon dioxide to cells of the body.".
D) "To fight infection.".
ANSWER: B

Nurse is admitting a client with severe shortness of breath. The nurse assesses which of the following clinical manifestations to be present in the client with pernicious anemia?Select all that apply:
A) oral temperature greater than 38 celsius or 100.5 farenheit
B) dark brown urine.
C) paresthesia.
D) white and yellow patches on the tongue.
E) mental confusion.
F) muscle weakness.
ANSWER: CEF

The nurse is discharging a client with aplastic anemiA)  Which of the following statements made by the client would demonstrate the need for additional teaching by the nurse?
A) "I'm a little nervous about the side effects of my medicines and will call if I have questions.".
B) "I have a lot of sisters and brothers. I hope one of them will match for my bone marrow transplant.".
C) "I'm going back to my job in the toddler room at a day care center tomorrow.".
D) "Diabetes runs in my family so we will be checking my glucose levels while I am a prednisone.".
ANSWER: C

A client with a chronic bleeding duodenal ulcer is admitted to the hospital. What clinical manifestations should the nurse assess for in a client with a 30% blood volume loss?Select all that apply:
A) posture hypotension.
B)  Dizziness.
C) tachycardia with activity.
D) swelling. 
E) blood pressure below normal at rest. 
F) pain.
ANSWER: AC

Which of the following should the nurse include in the instructions provided to a client with sickle cell anemia?Select all that apply:
A) administer pain medications.
B) encourage fluids.
C) treat the presence of infection.
D) avoid informing others of the condition.
E) vigorous exercise is permitted.
F) inform the client that the disorder is not hereditary.
ANSWER: ABC

The nurse is evaluating a client with an enlarged spleen. Which of the following diagnostic tests would confirm the diagnosis?
A) urinalysis.
B) CAT scan of the chest.
C) Blood cultures.
D) CAT scan of the abdomen.
ANSWER: D

The nurse has started a transfusion of packed red blood cells. The nurse should immediately strop the transfusion when which of the following occurs?
A) fever and back pain.
B) dry mouth.
C) hypothermia and pallor.
D) heart rate of 74 beats per minute.
ANSWER: A

The nurse is caring for a client with neutropenia.  Which of the following blood tests would indicate to the nurse the desired response to treatment?
A) increased granulocytes.
B) decrease in platelet count.
C) normal hemoglobin.
D) liver functions above normal.
ANSWER: A

The nurse is preparing to administer a red blood cell transfusion to a client. The client tells the nurse of being terrified of contracting HIV fro the transfusion. Which of the following statements is the most appropriate by the nurse?
A) "Don't worry. I've give a lot of transfusions and I've never had a client got HIV, yet.".
B) "I understand your concerns. The blood supply is not 100% safe. Why don't you get someone in your family to donate blood for you?".
C) "This blood was given by screened donors and tested for HIV. The chances of getting HIV for a blood transfusion are very small.".
D) "You are much more likely to die if you don't get this transfusion than if you do.".
ANSWER: C

Which of the following is essential for the nurse to assess in the health history of a client with a hematologic disorder?
A) the client's occupation.
B) the client's recreational activities.
C) the client's menstrual history.
D) the client's recent trip to Canada. 
ANSWER: C

A student nurse is reviewing the chart of a client with a long-standing anemia.The student asks the nurse what the term koilonychias means. The nurse should inform the student that koilonychias means the
A) fingernails are spoon shaped.
B) skin is flushed.
C) mucous membranes are pink and moist. 
D) white count is elevateD.
ANSWER: A

A client returns to the clinic after a procedure complaining of pain in the left lower back. The nurse suspects the client most likely is experiencing.
A) a hematoma from a bone marrow biopsy and aspiration performed two days ago. 
B) Splenomegaly following a schilling test.
C) Viral hepatitis B infection from a blood transfusion.
D) Folic acid deficiency.
ANSWER: A

A client with an enlarge lymph node in the neck is scheduled to have an open biopsy of the node. Which of the following client statements would alert the nurse to an inadequate understanding of the procedure?
A) "I have to go to the hospital really early in the morning and I can't drink or eat anything after midnight.
B) "My husband will have to drive me home after the biopsy.".
C) "They are going to find cancer and I have to stay in the hospital overnight.".
D) "I will know the result of my biopsy within a couple of days.".
ANSWER: C

The nurse is admitting a client with a hematologic disorder. During the dietary history, the client states eating clay regularly. The nurse reports this client as exhibiting what clinical manifestation of anemia? _______.
A) pica.
B) sickle cell crisis.
C) anemic crisis.
D) obssessive crisis.
ANSWER: A

The admitting nurse is making room assignments for a client admitted with aplastic anemiA)  The nurse appropriately selects which of the following room assignments for this client?
A) Semiprivate room with strict hand washing.
B) Private room, protective isolation, and HEPA filtration.
C) Semiprivate room with no special precautions.
D) Private room with ECG monitoring on a cardiac care unit.
ANSWER: B

During an IV antibiotic administration, the nurse inspects a 2-day-old IV site on a client who is neutropenic and observes redness without swelling. The client complains of tenderness. Which of the following interventions is the priority for the nurse to implement?
A) check the client's vital signs before going to care for another client.
B) inform the client that the IV will need to be changed to a new site.
C) administer prescribed pain medications.
D) Inform the client that medication is causing a rash.
ANSWER: B

A client with iron deficiency anemia is very pale, has shortness of breath, and records a hemoglobin level of 7.5 grams. Which of the following is a priority for the nurse to implement?
A) administer an iron supplement.
B) instruct the client on a diet high in iron.
C) administer packed red cells.
D) Instruct the client to conserve energy.
ANSWER: C

During a therapeutic phlebotomy of a client with hemochromatosis, the nurse explains the rationale for the procedure by telling the client 
A) "You may need several phlebotomies during your lifetime to keep the iron form damaging your pancreas and heart.".
B) "The blood is being removed so your blood is available for future transfusions.".
C) "If you hadn't been a vegetarian you wouldn't have gotten this disease.". 
D) "You have too much blood and some of it has to be removed to make you less prone to infections.".
ANSWER: A

Which of the following should the nurse include in the plan of care for a client scheduled for a bone marrow biopsy?
A) assist the client on the abdomen with arms toward the head preprocedure.
B) place  the client NPO preprocedure.
C) position the client on the abdomen for one hour postprocedure. 
D) place a light gauze dressing on the insertion site.
ANSWER: A

A nurse caring for a client with acute disseminated intravascular coagulation (DIC) should monitor the client for which of the following clinical manifestations?Select all that apply:
A) bleeding from the nose and mouth.
B) hypertension.
C) jaundiced sclera.
D) elevated platelet count.
E) Liguria.
F) dizziness.
ANSWER: AFC

The nurse should monitor a client with a blood type A who received a transfusion form a type O donor for which of the following?
A) A febrile reaction because of the blood type mismatch.
B) An expected rise in hemoglobin and hematocrit.
C) A conversion from Rh negative to Rh positive because of the mismatched blood type.
D) Fluid overload symptoms.
ANSWER: B

The nurse is caring for a client with a severe anemia. A transfusion of two units of packed red blood cells has been ordered.  The nurse should start an infusion of which solution prior to hanging the blood?  
A) D5NSS
B) D5Normosol M
C) D5.3 percent NaCL
D) pNSS
ANSWER: D