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1. A nurse is administering IV furosemide to a patient admitted with congestive heart failure. After the
infusion, which of the following symptoms is NOT expected?

A. Increased urinary output.


B. Decreased edema.
C. Decreased pain.
D. Decreased blood pressure.

2. There are a number of risk factors associated with coronary artery disease. Which of the following is a
modifiable risk factor?

A. Obesity.
B. Heredity.
C. Gender.
D. Age.

3. Tissue plasminogen activator (t-PA) is considered for treatment of a patient who arrives in the emergency
department following onset of symptoms of myocardial infarction. Which of the following is a
contraindication for treatment with t-PA?

A. Worsening chest pain that began earlier in the evening.


B. History of cerebral hemorrhage.
C. History of prior myocardial infarction.
D. Hypertension.

4. Following myocardial infarction, a hospitalized patient is encouraged to practice frequent leg exercises
and ambulate in the hallway as directed by his physician. Which of the following choices reflects the purpose
of exercise for this patient?

A. Increases fitness and prevents future heart attacks.


B. Prevents bedsores.
C. Prevents DVT (deep vein thrombosis).
D. Prevent constipations.

5. A patient arrives in the emergency department with symptoms of myocardial infarction, progressing to
cardiogenic shock. Which of the following symptoms should the nurse expect the patient to exhibit with
cardiogenic shock?

A. Hypertension.
B. Bradycardia.
C. Bounding pulse.
D. Confusion.

6. A patient with a history of congestive heart failure arrives at the clinic complaining of dyspnea. Which of
the following actions is the first the nurse should perform?

A. Ask the patient to lie down on the exam table.


B. Draw blood for chemistry panel and arterial blood gas (ABG).
C. Send the patient for a chest x-ray.
D. Check blood pressure.

7. A clinic patient has recently been prescribed nitroglycerin for treatment of angina. He calls the nurse
complaining of frequent headaches. Which of the following responses to the patient is correct?

A. Stop taking the nitroglycerin and see if the headaches improve.


B. Go to the emergency department to be checked because nitroglycerin can cause bleeding in the brain.
C. Headaches are a frequent side effect of nitroglycerine because it causes vasodilation.
D. The headaches are unlikely to be related to the nitroglycerin, so you should see your doctor for further
investigation.

8. A patient received surgery and chemotherapy for colon cancer, completing therapy 3 months previously,
and she is now in remission. At a follow-up appointment, she complains of fatigue following activity and
difficulty with concentration at her weekly bridge games. Which of the following explanations could account
for her symptoms?

A. The symptoms may be the result of anemia caused by chemotherapy.


B. The patient may be immunosuppressed.
C. The patient may be depressed.
D. The patient may be dehydrated.

9. A clinic patient has a hemoglobin concentration of 10.8 g/dL and reports sticking to a strict vegetarian diet.
Which of the follow nutritional advice is appropriate?

A. The diet is providing adequate sources of iron and requires no changes.


B. The patient should add meat to her diet; a vegetarian diet is not advised.
C. The patient should use iron cookware to prepare foods, such as dark green, leafy vegetables and legumes, which
are high in iron.
D. A cup of coffee or tea should be added to every meal.

10. A hospitalized patient is receiving packed red blood cells (PRBCs) for treatment of severe anemia. Which
of the following is the most accurate statement?

A. Transfusion reaction is most likely immediately after the infusion is completed.


B. PRBCs are best infused slowly through a 20g. IV catheter.
C. PRBCs should be flushed with a 5% dextrose solution.
D. A nurse should remain in the room during the first 15 minutes of infusion.

11. A patient who has received chemotherapy for cancer treatment is given an injection of Epoetin. Which of
the following should reflect the findings in a complete blood count (CBC) drawn several days later?

A. An increase in neutrophil count.


B. An increase in hematocrit.
C. An increase in platelet count.
D. An increase in serum iron.

12. A patient is admitted to the hospital with suspected polycythemia vera. Which of the following symptoms
is consistent with the diagnosis? Select all that applies.

A. Weight loss.
B. Increased clotting time.
C. Hypertension.
D. Headaches.

13. A nurse is caring for a patient with a platelet count of 20,000/microliter. Which of the following is an
important intervention?

A. Observe for evidence of spontaneous bleeding.


B. Limit visitors to family only.
C. Give aspirin in case of headaches.
D. Impose immune precautions.

14. A nurse in the emergency department assesses a patient who has been taking long-term corticosteroids
to treat renal disease. Which of the following is a typical side effect of corticosteroid treatment? Note: More
than one answer may be correct.

A. Hypertension.
B. Cushingoid features.
C. Hyponatremia.
D. Low serum albumin.

15. A nurse is caring for patients in the oncology unit. Which of the following is the most important nursing
action when caring for a neutropenic patient?

A. Change the disposable mask immediately after use.


B. Change gloves immediately after use.
C. Minimize patient contact.
D. Minimize conversation with the patient.

16. A patient is undergoing the induction stage of treatment for leukemia. The nurse teaches family members
about infectious precautions. Which of the following statements by family members indicates that the family
needs more education?

A. We will bring in books and magazines for entertainment.


B. We will bring in personal care items for comfort.
C. We will bring in fresh flowers to brighten the room.
D. We will bring in family pictures and get well cards.

17. A nurse is caring for a patient with acute lymphoblastic leukemia (ALL). Which of the following is the
most likely age range of the patient?

A. 3-10 years.
B. 25-35 years.

C. 45-55 years.
D. over 60 years.

18. A patient is admitted to the oncology unit for diagnosis of suspected Hodgkins disease. Which of the
following symptoms is typical of Hodgkins disease?

A. Painful cervical lymph nodes.


B. Night sweats and fatigue.
C. Nausea and vomiting.
D. Weight gain.

19. The Hodgkins disease patient described in the question above undergoes a lymph node biopsy for
definitive diagnosis. If the diagnosis of Hodgkins disease were correct, which of the following cells would
the pathologist expect to find?

A. Reed-Sternberg cells.
B. Lymphoblastic cells.
C. Gauchers cells.
D. Rieders cells

20. A patient is about to undergo bone marrow aspiration and biopsy and expresses fear and anxiety about
the procedure. Which of the following is the most effective nursing response?

A. Warn the patient to stay very still because the smallest movement will increase her pain.
B. Encourage the family to stay in the room for the procedure.
C. Stay with the patient and focus on slow, deep breathing for relaxation.
D. Delay the procedure to allow the patient to deal with her feelings.

21. A 43-year-old African American male is admitted with sickle cell anemia. The nurse plans to assess
circulation in the lower extremities every 2 hours. Which of the following outcome criteria would the nurse
use?

A. Body temperature of 99F or less


B. Toes moved in active range of motion
C. Sensation reported when soles of feet are touched
D. Capillary refill of < 3 seconds

22. A 30-year-old male from Haiti is brought to the emergency department in sickle cell crisis. What is the
best position for this client?

A. Side-lying with knees flexed


B. Knee-chest
C. High Fowlers with knees flexed
D. Semi-Fowlers with legs extended on the bed

23. A 25-year-old male is admitted in sickle cell crisis. Which of the following interventions would be of
highest priority for this client?

A. Taking hourly blood pressures with mechanical cuff


B. Encouraging fluid intake of at least 200mL per hour
C. Position in high Fowlers with knee gatch raised
D. Administering Tylenol as ordered

24. Which of the following foods would the nurse encourage the client in sickle cell crisis to eat?

A. Peaches
B. Cottage cheese
C. Popsicle
D. Lima beans

25. A newly admitted client has sickle cell crisis. The nurse is planning care based on assessment of the
client. The client is complaining of severe pain in his feet and hands. The pulse oximetry is 92. Which of the
following interventions would be implemented first? Assume that there are orders for each intervention.

A. Adjust the room temperature


B. Give a bolus of IV fluids
C. Start O2
D. Administer meperidine (Demerol) 75 mg IV push

26. The nurse is instructing a client with iron-deficiency anemia. Which of the following meal plans would the
nurse expect the client to select?

A. Roast beef, gelatin salad, green beans, and peach pie


B. Chicken salad sandwich, coleslaw, French fries, ice cream
C. Egg salad on wheat bread, carrot sticks, lettuce salad, raisin pie
D. Pork chop, creamed potatoes, corn, and coconut cake

27. Clients with sickle cell anemia are taught to avoid activities that cause hypoxia and hypoxemia. Which of
the following activities would the nurse recommend?

A. A family vacation in the Rocky Mountains


B. Chaperoning the local boys club on a snow-skiing trip
C. Traveling by airplane for business trips
D. A bus trip to the Museum of Natural History

28. The nurse is conducting an admission assessment of a client with vitamin B12 deficiency. Which of the
following would the nurse include in the physical assessment?

A. Palpate the spleen


B. Take the blood pressure
C. Examine the feet for petechiae
D. Examine the tongue

29. An African American female comes to the outpatient clinic. The physician suspects vitamin B12
deficiency anemia. Because jaundice is often a clinical manifestation of this type of anemia, what body part
would be the best indicator?

A. Conjunctiva of the eye


B. Soles of the feet
C. Roof of the mouth
D. Shins

30. The nurse is conducting a physical assessment on a client with anemia. Which of the following clinical
manifestations would be most indicative of the anemia?

A. BP 146/88
B. Respirations 28 shallow

C. Weight gain of 10 pounds in 6 months


D. Pink complexion

31. The nurse is teaching the client with polycythemia vera about prevention of complications of the disease.
Which of the following statements by the client indicates a need for further teaching?

A. I will drink 500mL of fluid or less each day.


B. I will wear support hose when I am up.
C. I will use an electric razor for shaving.
D. I will eat foods low in iron.

32. A 33-year-old male is being evaluated for possible acute leukemia. Which of the following would the nurse
inquire about as a part of the assessment?

A. The client collects stamps as a hobby.


B. The client recently lost his job as a postal worker.
C. The client had radiation for treatment of Hodgkins disease as a teenager.
D. The clients brother had leukemia as a child.

33. An African American client is admitted with acute leukemia. The nurse is assessing for signs and
symptoms of bleeding. Where is the best site for examining for the presence of petechiae?

A. The abdomen
B. The thorax
C. The earlobes
D. The soles of the feet

34. A client with acute leukemia is admitted to the oncology unit. Which of the following would be most
important for the nurse to inquire?

A. Have you noticed a change in sleeping habits recently?


B. Have you had a respiratory infection in the last 6 months?
C. Have you lost weight recently?
D. Have you noticed changes in your alertness?

35. Which of the following would be the priority nursing diagnosis for the adult client with acute leukemia?

A. Oral mucous membrane, altered related to chemotherapy


B. Risk for injury related to thrombocytopenia
C. Fatigue related to the disease process
D. Interrupted family processes related to life-threatening illness of a family member

36. A 21-year-old male with Hodgkins lymphoma is a senior at the local university. He is engaged to be
married and is to begin a new job upon graduation. Which of the following diagnoses would be a priority for
this client?

A. Sexual dysfunction related to radiation therapy


B. Anticipatory grieving related to terminal illness
C. Tissue integrity related to prolonged bed rest
D. Fatigue related to chemotherapy

37. A client has autoimmune thrombocytopenic purpura. To determine the clients response to treatment, the
nurse would monitor:

A. Platelet count
B. White blood cell count
C. Potassium levels
D. Partial prothrombin time (PTT)

38. The home health nurse is visiting a client with autoimmune thrombocytopenic purpura (ATP). The clients
platelet count currently is 80, It will be most important to teach the client and family about:

A. Bleeding precautions
B. Prevention of falls
C. Oxygen therapy
D. Conservation of energy

39. A client with a pituitary tumor has had a transsphenoidal hypophysectomy. Which of the following
interventions would be appropriate for this client?

A. Place the client in Trendelenburg position for postural drainage


B. Encourage coughing and deep breathing every 2 hours

C. Elevate the head of the bed 30


D. Encourage the Valsalva maneuver for bowel movements

40. The client with a history of diabetes insipidus is admitted with polyuria, polydipsia, and mental confusion.
The priority intervention for this client is:

A. Measure the urinary output


B. Check the vital signs
C. Encourage increased fluid intake
D. Weigh the client

41. A client with hemophilia has a nosebleed. Which nursing action is most appropriate to control the
bleeding?

A. Place the client in a sitting position with the head hyperextended


B. Pack the nares tightly with gauze to apply pressure to the source of bleeding
C. Pinch the soft lower part of the nose for a minimum of 5 minutes
D. Apply ice packs to the forehead and back of the neck

42. A client has had a unilateral adrenalectomy to remove a tumor. To prevent complications, the most
important measurement in the immediate postoperative period for the nurse to take is:

A. Blood pressure
B. Temperature
C. Output
D. Specific gravity

43. A client with Addisons disease has been admitted with a history of nausea and vomiting for the past 3
days. The client is receiving IV glucocorticoids (Solu-Medrol). Which of the following interventions would the
nurse implement?

A. Glucometer readings as ordered


B. Intake/output measurements
C. Sodium and potassium levels monitored
D. Daily weights

44. A client had a total thyroidectomy yesterday. The client is complaining of tingling around the mouth and
in the fingers and toes. What would the nurses next action be?

A. Obtain a crash cart


B. Check the calcium level
C. Assess the dressing for drainage
D. Assess the blood pressure for hypertension

45. A 32-year-old mother of three is brought to the clinic. Her pulse is 52, there is a weight gain of 30 pounds
in 4 months, and the client is wearing two sweaters. The client is diagnosed with hypothyroidism. Which of
the following nursing diagnoses is of highest priority?

A. Impaired physical mobility related to decreased endurance


B. Hypothermia r/t decreased metabolic rate
C. Disturbed thought processes r/t interstitial edema
D. Decreased cardiac output r/t bradycardia

Answers and Rationale


1. Answer: C. Decreased pain.

Furosemide, a loop diuretic, does not alter pain. Furosemide acts on the kidneys to increase urinary output. Fluid may
move from the periphery, decreasing edema. Fluid load is reduced, lowering blood pressure.

2. Answer: A. Obesity.

Obesity is an important risk factor for coronary artery disease that can be modified by improved diet and weight loss.
Family history of coronary artery disease, male gender, and advancing age increase risk but cannot be modified.

3. Answer: B. History of cerebral hemorrhage.

A history of cerebral hemorrhage is a contraindication to tPA because it may increase the risk of bleeding. TPA acts
by dissolving the clot blocking the coronary artery and works best when administered within 6 hours of onset of
symptoms. Prior MI is not a contraindication to tPA. Patients receiving tPA should be observed for changes in blood
pressure, as tPA may cause hypotension.

4. Answer: C. Prevents DVT (deep vein thrombosis).

Exercise is important for all hospitalized patients to prevent deep vein thrombosis. Muscular contraction promotes
venous return and prevents hemostasis in the lower extremities. This exercise is not sufficiently vigorous to increase
physical fitness, nor is it intended to prevent bedsores or constipation.

5. Answer: D. Confusion.

Cardiogenic shock severely impairs the pumping function of the heart muscle, causing diminished blood flow to the
organs of the body. This results in diminished brain function and confusion, as well as hypotension, tachycardia, and
weak pulse. Cardiogenic shock is a serious complication of myocardial infarction with a high mortality rate.

6. Answer: D. Check blood pressure.

A patient with congestive heart failure and dyspnea may have pulmonary edema, which can cause severe
hypertension. Therefore, taking the patients blood pressure should be the first action. Lying flat on the exam table
would likely worsen the dyspnea, and the patient may not tolerate it. Blood draws for chemistry and ABG will be
required, but not prior to the blood pressure assessment.

7. Answer: C. Headaches are a frequent side effect of nitroglycerine because it causes vasodilation.

Nitroglycerin is a potent vasodilator and often produces unwanted effects such as headache, dizziness, and
hypotension. Patients should be counseled, and the dose titrated, to minimize these effects. In spite of the side
effects, nitroglycerin is effective at reducing myocardial oxygen consumption and increasing blood flow. The patient
should not stop the medication. Nitroglycerine does not cause bleeding in the brain.

8. Answer: A. The symptoms may be the result of anemia caused by chemotherapy.

Three months after surgery and chemotherapy the patient is likely to be feeling the after-effects, which often includes
anemia because of bone-marrow suppression. There is no evidence that the patient is immunosuppressed, and
fatigue is not a typical symptom of immunosuppression. The information given does not indicate that depression or
dehydration is a cause of her symptoms.

9. Answer: C. The patient should use iron cookware to prepare foods, such as dark green, leafy vegetables
and legumes, which are high in iron.

Normal hemoglobin values range from 11.5-15.0. This vegetarian patient is mildly anemic. When food is prepared in
iron cookware its iron content is increased. In addition, dark green leafy vegetables, such as spinach and kale, and
legumes are high in iron. Mild anemia does not require that animal sources of iron be added to the diet. Many nonanimal sources are available. Coffee and tea increase gastrointestinal activity and inhibit absorption of iron.

10. Answer: D. A nurse should remain in the room during the first 15 minutes of infusion.

Transfusion reaction is most likely during the first 15 minutes of infusion, and a nurse should be present during this
period. PRBCs should be infused through a 19g or larger IV catheter to avoid slow flow, which can cause clotting.
PRBCs must be flushed with 0.45% normal saline solution. Other intravenous solutions will hemolyze the cells.

11. Answer: B. An increase in hematocrit.

Epoetin is a form of erythropoietin, which stimulates the production of red blood cells, causing an increase in
hematocrit. Epoetin is given to patients who are anemic, often as a result of chemotherapy treatment. Epoetin has no
effect on neutrophils, platelets, or serum iron.

12. Answers: B, C, and D.

Polycythemia vera is a condition in which the bone marrow produces too many red blood cells. This causes an
increase in hematocrit and viscosity of the blood. Patients can experience headaches, dizziness, and visual
disturbances. Cardiovascular effects include increased blood pressure and delayed clotting time. Weight loss is not a
manifestation of polycythemia vera.

13. Answer: A. Observe for evidence of spontaneous bleeding.

Platelet counts under 30,000/microliter may cause spontaneous petechiae and bruising, particularly in the extremities.
When the count falls below 15,000, spontaneous bleeding into the brain and internal organs may occur. Headaches
may be a sign and should be watched for. Aspirin disables platelets and should never be used in the presence of
thrombocytopenia. Thrombocytopenia does not compromise immunity, and there is no reason to limit visitors as long
as any physical trauma is prevented.

14. Answers: A, B, and D.

Side effects of corticosteroids include weight gain, fluid retention with hypertension, Cushingoid features, a low serum
albumin, and suppressed inflammatory response. Patients are encouraged to eat a diet high in protein, vitamins, and
minerals and low in sodium. Corticosteroids cause hypernatremia and not hyponatremia.

15. Answer: B. Change gloves immediately after use.

The neutropenic patient is at risk of infection. Changing gloves immediately after use protects patients from
contamination with organisms picked up on hospital surfaces. This contamination can have serious consequences for
an immunocompromised patient. Changing the respiratory mask is desirable, but not nearly as urgent as changing
gloves. Minimizing contact and conversation are not necessary and may cause nursing staff to miss changes in the
patients symptoms or condition.

16. Answer: C. We will bring in fresh flowers to brighten the room.

During induction chemotherapy, the leukemia patient is severely immunocompromised and at risk of serious infection.
Fresh flowers, fruit, and plants can carry microbes and should be avoided. Books, pictures, and other personal items
can be cleaned with antimicrobials before being brought into the room to minimize the risk of contamination.

17. Answer: A. 3-10 years.

The peak incidence of ALL is at 4 years (range 3-10). It is uncommon after the mid-teen years. The peak incidence of
chronic myelogenous leukemia (CML) is 45-55 years. The peak incidence of acute myelogenous leukemia (AML)
occurs at 60 years. Two-thirds of cases of chronic lymphocytic leukemia (CLL) occur after 60 years.

18. Answer: B. Night sweats and fatigue.

Symptoms of Hodgkins disease include night sweats, fatigue, weakness, and tachycardia. The disease is
characterized by painless, enlarged cervical lymph nodes. Weight loss occurs early in the disease. Nausea and
vomiting are not typically symptoms of Hodgkins disease.

19. Answer: A. Reed-Sternberg cells.

A definitive diagnosis of Hodgkins disease is made if Reed-Sternberg cells are found on pathologic examination of
the excised lymph node. Lymphoblasts are immature cells found in the bone marrow of patients with acute
lymphoblastic leukemia. Gauchers cells are large storage cells found in patients with Gauchers disease. Rieders
cells are myeloblasts found in patients with acute myelogenous leukemia.

20. Answer: C. Stay with the patient and focus on slow, deep breathing for relaxation.

Slow, deep breathing is the most effective method of reducing anxiety and stress. It reduces the level of carbon
dioxide in the brain to increase calm and relaxation. Warning the patient to remain still will likely increase her anxiety.
Encouraging family members to stay with the patient may make her worry about their anxiety as well as her own.
Delaying the procedure is unlikely to allay her fears.

21. Answer: D. Capillary refill of < 3 seconds

It is important to assess the extremities for blood vessel occlusion in the client with sickle cell anemia because a
change in capillary refill would indicate a change in circulation. Body temperature, motion, and sensation would not
give information regarding peripheral circulation; therefore, answers A, B, and C are incorrect.

22. Answer: D. Semi-Fowlers with legs extended on the bed

Placing the client in semi-Fowlers position provides the best oxygenation for this client. Flexion of the hips and knees,
which includes the knee-chest position, impedes circulation and is not correct positioning for this client. Therefore,
answers A, B, and C are incorrect.

23. Answer: B. Encouraging fluid intake of at least 200mL per hour

It is important to keep the client in sickle cell crisis hydrated to prevent further sickling of the blood. Answer A is
incorrect because a mechanical cuff places too much pressure on the arm. Answer C is incorrect because raising the
knee gatch impedes circulation. Answer D is incorrect because Tylenol is too mild an analgesic for the client in crisis.

24. Answer: C. Popsicle

Hydration is important in the client with sickle cell disease to prevent thrombus formation. Popsicles, gelatin, juice,
and pudding have high fluid content. The foods in answers A, B, and D do not aid in hydration and are, therefore,
incorrect.

25. Answer: C. Start O2

The most prominent clinical manifestation of sickle cell crisis is pain. However, the pulse oximetry indicates that
oxygen levels are low; thus, oxygenation takes precedence over pain relief. Answer A is incorrect because although a
warm environment reduces pain and minimizes sickling, it would not be a priority. Answer B is incorrect because

although hydration is important, it would not require a bolus. Answer D is incorrect because Demerolis acidifying to
the blood and increases sickling.

26. Answer: C. Egg salad on wheat bread, carrot sticks, lettuce salad, raisin pie

Egg yolks, wheat bread, carrots, raisins, and green, leafy vegetables are all high in iron, which is an important mineral
for this client. Roast beef, cabbage, and pork chops are also high in iron, but the side dishes accompanying these
choices are not; therefore, answers A, B, and D are incorrect.

27. Answer: D. A bus trip to the Museum of Natural History

Taking a trip to the museum is the only answer that does not pose a threat. A family vacation in the Rocky Mountains
at high altitudes, cold temperatures, and airplane travel can cause sickling episodes and should be avoided;
therefore, answers A, B, and C are incorrect.

28. Answer: D. Examine the tongue

The tongue is smooth and beefy red in the client with vitamin B12 deficiency, so examining the tongue should be
included in the physical assessment. Bleeding, splenomegaly, and blood pressure changes do not occur, making
answers A, B, and C incorrect.

29. Answer: C. Roof of the mouth

The oral mucosa and hard palate (roof of the mouth) are the best indicators of jaundice in dark-skinned persons. The
conjunctiva can have normal deposits of fat, which give a yellowish hue; thus, answer A is incorrect. The soles of the
feet can be yellow if they are calloused, making answer B incorrect; the shins would be an area of darker pigment, so
answer D is incorrect.

30. Answer: B. Respirations 28 shallow

When there are fewer red blood cells, there is less hemoglobin and less oxygen. Therefore, the client is often short of
breath, as indicated in answer B. The client with anemia is often pale in color, has weight loss, and may be
hypotensive. Answers A, C, and D are within normal and, therefore, are incorrect.

31. Answer: A. I will drink 500mL of fluid or less each day.

The client with polycythemia vera is at risk for thrombus formation. Hydrating the client with at least 3L of fluid per day
is important in preventing clot formation, so the statement to drink less than 500mL is incorrect. Answers B, C, and D
are incorrect because they all contribute to the prevention of complications. Support hose promotes venous return, the
electric razor prevents bleeding due to injury, and a diet low in iron is essential to preventing further red cell formation.

32. Answer: C. The client had radiation for treatment of Hodgkins disease as a teenager.

Radiation treatment for other types of cancer can result in leukemia. Some hobbies and occupations involving
chemicals are linked to leukemia, but not the ones in these answers; therefore, answers A and B are incorrect.
Answer D is incorrect because the incidence of leukemia is higher in twins than in siblings.

33. Answer: D. The soles of the feet

Petechiae are not usually visualized on dark skin. The soles of the feet and palms of the hand provide a lighter
surface for assessing the client for petechiae. Answers A, B, and C are incorrect because the skin might be too dark
to make an assessment.

34. Answer: B. Have you had a respiratory infection in the last 6 months?

The client with leukemia is at risk for infection and has often had recurrent respiratory infections during the previous 6
months. Insomnolence, weight loss, and a decrease in alertness also occur in leukemia, but bleeding tendencies and
infections are the primary clinical manifestations; therefore, answers A, C, and D are incorrect.

35. Answer: B. Risk for injury related to thrombocytopenia

The client with acute leukemia has bleeding tendencies due to decreased platelet counts, and any injury would
exacerbate the problem. The client would require close monitoring for hemorrhage, which is of higher priority than the
diagnoses in answers A, C, and D, which are incorrect.

36. Answer: A. Sexual dysfunction related to radiation therapy

Radiation therapy often causes sterility in male clients and would be of primary importance to this client. The
psychosocial needs of the client are important to address in light of the age and life choices. Hodgkins disease,
however, has a good prognosis when diagnosed early. Answers B, C, and D are incorrect because they are of lesser
priority.

37. Answer: A. Platelet count

Clients with autoimmune thrombocytopenic purpura (ATP) have low platelet counts, making answer A the correct
answer. White cell counts, potassium levels, and PTT are not affected in ATP; thus, answers B, C, and D are
incorrect.

38. Answer: A. Bleeding precautions

The normal platelet count is 120,000400, Bleeding occurs in clients with low platelets. The priority is to prevent and
minimize bleeding. Oxygenation in answer C is important, but platelets do not carry oxygen. Answers B and D are of
lesser priority and are incorrect in this instance.

39. Answer: C. Elevate the head of the bed 30

Elevating the head of the bed 30 avoids pressure on the sella turcica and alleviates headaches. Answers A, B, and D
are incorrect because Trendelenburg, Valsalva maneuver, and coughing all increase the intracranial pressure.

40. Answer: B. Check the vital signs

The large amount of fluid loss can cause fluid and electrolyte imbalance that should be corrected. The loss of
electrolytes would be reflected in the vital signs. Measuring the urinary output is important, but the stem already says
that the client has polyuria, so answer A is incorrect. Encouraging fluid intake will not correct the problem, making
answer C incorrect. Answer D is incorrect because weighing the client is not necessary at this time.

41. Answer: C. Pinch the soft lower part of the nose for a minimum of 5 minutes

The client should be positioned upright and leaning forward, to prevent aspiration of blood. Answers A, B, and D are
incorrect because direct pressure to the nose stops the bleeding, and ice packs should be applied directly to the nose
as well. If a pack is necessary, the nares are loosely packed.

42. Answer: A. Blood pressure

Blood pressure is the best indicator of cardiovascular collapse in the client who has had an adrenal gland removed.
The remaining gland might have been suppressed due to the tumor activity. Temperature would be an indicator of
infection, decreased output would be a clinical manifestation but would take longer to occur than blood pressure
changes, and specific gravity changes occur with other disorders; therefore, answers B, C, and D are incorrect.

43. Answer: A. Glucometer readings as ordered

IV glucocorticoids raise the glucose levels and often require coverage with insulin. Answer B is not necessary at this
time, sodium and potassium levels would be monitored when the client is receiving mineralocorticoids, and daily
weights is unnecessary; therefore, answers B, C, and D are incorrect.

44. Answer: B. Check the calcium level

The parathyroid glands are responsible for calcium production and can be damaged during a thyroidectomy. The
tingling is due to low calcium levels. The crash cart would be needed in respiratory distress but would not be the next
action to take; thus, answer A is incorrect. Hypertension occurs in thyroid storm and the drainage would occur in
hemorrhage, so answers C and D are incorrect.

45. Answer: D. Decreased cardiac output r/t bradycardia

The decrease in pulse can affect the cardiac output and lead to shock, which would take precedence over the other
choices; therefore, answers A, B, and C are incorrect.