Ca 4%

Created by johnbell 

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1. A patient with a history of iron-deficiency anemia who has not taken iron supplements for several years is experiencing increased fatigue and occasional palpitations. The nurse would expect the patient's laboratory findings to include
a. hematocrit (Hct) 38%.
b. red blood cell count (RBC) 4,500,000/l.
c. hemoglobin (Hb) 8.6 g/dl (86 g/L).
d. normal RBC indices.

C
Rationale: The patient's clinical manifestations indicate moderate anemia, which is consistent with a Hb of 6 to 10 g/dl. The other values are all within the range of low-normal to normal.

Cognitive Level: Comprehension Text Reference: pp. 686, 690
Nursing Process: Assessment NCLEX: Physiological Integrity

2. When discussing appropriate food choices with a patient who has iron-deficiency anemia and follows a low-cholesterol diet, the nurse will encourage the patient to increase the dietary intake of
a. eggs and muscle meats.
b. nuts and cornmeal.
c. milk and milk products.
d. legumes and dried fruits.

D
Rationale: Legumes and dried fruits are high in iron and low in fat and cholesterol. Eggs and muscle meats are high in iron but also high in fat and cholesterol. Nuts and milk products will improve amino acid intake but are not high in iron. Cornmeal would be an appropriate choice for a vitamin B6 deficiency.

Cognitive Level: Application Text Reference: p. 689
Nursing Process: Implementation NCLEX: Physiological Integrity

3. A patient has a folic acid deficiency related to chronic alcohol abuse. The nurse would expect a complete blood cell count (CBC) to reveal
a. macrocytic, normochromic red cells.
b. normocytic, normochromic red cells.

c. microcytic, hypochromic red cells.
d. microcytic, normochromic red cells.

A
Rationale: With folic acid deficiency, the cells are larger than normal, but the iron levels are normal or elevated, leading to findings of a macrocytic, normochromic anemia. Microcytic anemia, hypochromic anemia is more typical of iron deficiency. Normocytic, normochromic RBC indicate that the patient does not have anemia or may occur in patients with anemia-related chronic disease.

Cognitive Level: Comprehension Text Reference: pp. 686, 690
Nursing Process: Assessment NCLEX: Physiological Integrity

4. A 52-year-old patient has a new diagnosis of pernicious anemia. After teaching the patient about pernicious anemia, the nurse determines that the patient understands the disorder when the patient states,
a. "I will need to have cobalamin (B12) injections regularly for the rest of my life."
b. "I will stop having a glass of wine with dinner."
c. "The numbness in my feet will go away once my hemoglobin level returns to normal."
d. "My diet should include more red meat or liver."

A
Rationale: Pernicious anemia prevents the absorption of vitamin B12, and the patient requires injections or intranasal administration of cobalamin. Alcohol use does not cause cobalamin deficiency. Neurologic symptoms may not resolve with treatment. Eating more foods rich in B12 is not helpful because the lack of intrinsic factor prevents absorption of the vitamin.

Cognitive Level: Application Text Reference: p. 692
Nursing Process: Evaluation NCLEX: Physiological Integrity

5. A patient with chronic lymphocytic leukemia is hospitalized for treatment of severe hemolytic anemia. An appropriate nursing intervention for the patient is to
a. provide a diet high in vitamin K.
b. isolate the patient from visitors.
c. plan care to alternate periods of rest and activity.
d. encourage increased intake of fluid and fiber in the diet.

C
Rationale: Nursing care for patients with anemia should alternate periods of rest and activity to maintain patient mobility without causing undue fatigue. High vitamin K diets might be used for a patient with a bleeding disorder. There is no indication that the patient is neutropenic, so isolation is not needed. Increased intake of fluid and fiber will not improve the anemia.

Cognitive Level: Application Text Reference: p. 688
Nursing Process: Implementation NCLEX: Physiological Integrity

6. After teaching the patient about taking oral iron preparations for a moderate iron-deficiency anemia, the nurse determines that additional instruction is needed when the patient says,
a. "I will call the doctor if my stools start to turn black."
b. "I will take a stool softener if I feel constipated occasionally."
c. "I will increase my fluid and fiber intake while I am taking the iron tablets."
d. "I should take the iron with orange juice about an hour before eating."

A
Rationale: It is normal for the stools to appear black when a patient is taking iron and the patient should not call the doctor about this. The other patient statements are correct.

Cognitive Level: Application Text Reference: p. 690
Nursing Process: Evaluation NCLEX: Physiological Integrity

7. A patient is admitted to the hospital with idiopathic aplastic anemia. An appropriate collaborative problem for the nurse to identify for the patient is
a. potential complication: hemorrhage.
b. potential complication: neurogenic shock.
c. potential complication: pulmonary edema.
d. potential complication: seizures.

A
Rationale: Because the patient with aplastic anemia has pancytopenia, the patient is at risk for bleeding and infection. There is no increased risk for seizures, neurogenic shock, or pulmonary edema.

Cognitive Level: Application Text Reference: p. 694
Nursing Process: Diagnosis NCLEX: Physiological Integrity

8. A patient with sickle cell anemia is admitted to the hospital with a sickle cell crisis. While caring for the patient during the crisis, it is important for the nurse to
a. limit the patient's intake of oral and IV fluids.
b. evaluate the effectiveness of opioid analgesics.
c. encourage the patient to ambulate as much as tolerated.
d. teach the patient about high-protein, high-calorie foods.

B
Rationale: Pain is the most common clinical manifestation of a crisis and usually requires large doses of continuous opioids for control. Fluid intake should be increased to reduce blood viscosity and improve perfusion. Rest is usually ordered to decrease metabolic requirements. Patients are instructed about the need for dietary folic acid, but high-protein, high-calorie diets are not emphasized.

Cognitive Level: Application Text Reference: pp. 696, 698
Nursing Process: Implementation NCLEX: Physiological Integrity

9. A patient who is having a sickle cell crisis asks the nurse why the sickling causes such pain. The nurse explains that the pain of sickling is caused by
a. spasms of the blood cells as they change shape.
b. deposition of sickled red cells in the bone marrow.
c. tissue hypoxia caused by small blood vessel occlusion.
d. infectious processes in organs affected by the sickling.

C
Rationale: The pain associated with a sickle cell crisis is caused by ischemia as the sickled cells occlude small blood vessels and capillaries. Blood vessels do not change shape during the crisis. Sickled red cells are not deposited in the bone marrow. Infection may precipitate sickling but is not the cause of the pain.

Cognitive Level: Application Text Reference: pp. 696-697
Nursing Process: Implementation NCLEX: Physiological Integrity

10. When planning discharge teaching for the patient who was admitted with a sickle cell crisis, which information will the nurse include?
a. Drink only one or two caffeinated beverages daily.
b. Take a daily multivitamin with iron.
c. Limit fluids to 2 to 3 quarts a day.
d. Avoid exposure to crowds as much as possible.

D
Rationale: Exposure to crowds increases the patient's risk for infection, the most common cause of sickle cell crisis. There is no restriction on caffeine use. Iron supplementation is generally not recommended. A high-fluid intake is recommended.

Cognitive Level: Application Text Reference: p. 697
Nursing Process: Planning NCLEX: Physiological Integrity

11. Which of these assessment data obtained by the nurse when caring for a patient with thrombocytopenia should be immediately communicated to the health care provider?
a. Platelet count is 52,000/l.
b. There are bullae on the oral mucosa.
c. The patient is difficult to arouse.
d. There are large bruises on the back.

C
Rationale: Difficulty in arousing the patient may indicate a cerebral hemorrhage, which is life threatening and requires immediate action. The other information should be documented and reported, but they are not urgent.

Cognitive Level: Application Text Reference: pp. 703, 705, 707
Nursing Process: Assessment NCLEX: Physiological Integrity

12. During the admission assessment of a patient who has an Hb of 7.6 g/dl (76 g/L), the nurse notes jaundice of the sclera. The nurse will plan to check the laboratory results for
a. the stool occult blood test.
b. the bilirubin level.
c. the gastric analysis testing.
d. the Schilling test.

B
Rationale: Jaundice is caused by the elevation of bilirubin level associated with RBC hemolysis. The presence of jaundice suggests a hemolytic anemia, rather than gastrointestinal bleeding or cobalamin deficiency, as the cause of the anemia.

Cognitive Level: Application Text Reference: p. 686
Nursing Process: Assessment NCLEX: Physiological Integrity

13. The health care provider orders transfusion with packed RBCs for a patient who is hospitalized with severe anemia. The most important action by the nurse to prevent a transfusion reaction when administering the blood is to
a. verify the patient identification according to hospital policy.
b. administer the blood as soon as it arrives on the nursing unit.
c. initiate the blood transfusion at a rate of no more than 2 ml/min.
d. stay with the patient during the first 15 minutes of the transfusion.

A
Rationale: Improper identification is responsible 90% of hemolytic transfusion reactions. The nurse should also administer the blood within 30 minutes of its arrival on the unit, transfuse the blood at 2 ml/min during the first 15 minutes, and stay with the patient during the first 15 minutes; however, these measures will not prevent a transfusion reaction if the person is receiving the wrong blood.

Cognitive Level: Comprehension Text Reference: p. 731
Nursing Process: Implementation
NCLEX: Safe and Effective Care Environment

14. A patient receiving a whole-blood transfusion develops chills and fever, headache, and anxiety 30 minutes after the transfusion is started. After stopping the transfusion, the nurse will plan to
a. send a urine specimen to the laboratory.
b. administer acetaminophen (Tylenol).
c. give diphenhydramine (Benadryl).
d. draw blood for a new cross-match.

B
Rationale: The patient's clinical manifestations are consistent with a febrile, nonhemolytic transfusion reaction. The transfusion should be stopped and antipyretics administered for the fever as ordered. A urine specimen is needed if an acute hemolytic reaction is suspected. Diphenhydramine (Benadryl) is used for allergic reactions. This type of reaction does not indicate incorrect crossmatching.

Cognitive Level: Application Text Reference: p. 733
Nursing Process: Planning NCLEX: Physiological Integrity

15. Fifteen minutes after a transfusion of packed red cells is started, a patient develops tachycardia and tachypnea and complains of back pain and feeling warm. The nurse first action should be to
a. disconnect the transfusion and infuse normal saline.
b. obtain a urine specimen to send to the laboratory.
c. administer oxygen therapy at a high flow rate.
d. notify the health care provider about the transfusion reaction.

A
Rationale: The first action should be to disconnect the transfusion and infuse normal saline to keep the line open and maintain the patient's BP. The other actions are also needed but are not the highest priority.

Cognitive Level: Application Text Reference: pp. 732-733
Nursing Process: Implementation NCLEX: Physiological Integrity

16. A patient who has been receiving a heparin infusion and warfarin (Coumadin) for a deep vein thrombosis (DVT) is diagnosed with heparin-induced thrombocytopenia and thrombosis syndrome (HITTS). The nurse will anticipate a health care provider order to
a. use saline for flushing IV lines.
b. give low-molecular-weight (LMW) heparin.
c. discontinue the warfarin.
d. administer platelet transfusions.

A
Rationale: All heparin is discontinued when the HITTS is diagnosed. The patient should be instructed to never receive heparin or LMW heparin. Warfarin will be continued because it does not induce thrombocytopenia. The platelet count does not drop low enough in HITTS for a platelet transfusion, and a transfusion will increase the risk for thrombosis

Cognitive Level: Application Text Reference: p. 704
Nursing Process: Planning NCLEX: Physiological Integrity

17. During treatment of the patient with an acute exacerbation of polycythemia vera, a critical action by the nurse is to
a. check oxygen saturation q4hr.
b. monitor fluid intake and output.
c. place the patient on bed rest.
d. administer iron supplements.

B
Rationale: Monitoring hydration status is important during an acute exacerbation because the patient is at risk for fluid overload or underhydration. Problems with tissue oxygenation in polycythemia vera are due to increased blood viscosity and poor perfusion, not to poor oxygen saturation. (Oxygen is useful in secondary polycythemia.) The patient should be encouraged to ambulate to prevent DVT. Iron is contraindicated for polycythemia vera.

Cognitive Level: Application Text Reference: p. 701
Nursing Process: Planning NCLEX: Physiological Integrity

18. A patient admitted to the hospital in preparation for a splenectomy for treatment of immune thrombocytopenia purpura (ITP) asks the nurse about the benefits of the splenectomy. The nurse explains that the expected effect of the splenectomy is
a. reduced destruction of platelets by macrophages.
b. promotion of platelet sequesterization and release by the liver.
c. increased production of platelets by the bone marrow.
d. increased RBC production to compensate for blood loss.

A
Rationale: Because sequesterization of platelets and platelet destruction by macrophages occurs in the spleen, splenectomy will increase the platelet count. Splenectomy does not promote sequesterization or release of platelets by the liver, increase platelet production, or increase RBC production.

Cognitive Level: Application Text Reference: p. 703
Nursing Process: Implementation NCLEX: Physiological Integrity

19. All of the following patients are waiting to be admitted by the emergency department nurse. Which one requires the most rapid assessment and care by the nurse?
a. The patient with a history of sickle cell anemia who has had nausea and diarrhea for 24 hours
b. The patient who has chemotherapy-induced neutropenia and has a temperature of 100.8° F
c. The patient with thrombocytopenia who has oozing after having a tooth extracted
d. The patient with hemophilia A who has ankle swelling after twisting the ankle

B
Rationale: A neutropenic patient with a fever is assumed to have an infection and is at risk for rapidly developing sepsis. Rapid assessment, cultures, and initiation of antibiotic therapy are needed. The other patients also require rapid assessment and care but not so urgently as the neutropenic patient.

Cognitive Level: Analysis Text Reference: p. 714
Nursing Process: Assessment
NCLEX: Safe and Effective Care Environment

20. The nurse is caring for a patient ITP who has an order for a platelet transfusion. Which patient information indicates that the nurse should consult with the health care provider before administering platelets?
a. Petechiae are present on the chest and back.
b. Blood pressure (BP) is 94/56 mm Hg.
c. Platelet count is 42,000/l.
d. Blood is oozing from the venipuncture site.

C
Rationale: Platelet transfusions are not usually indicated until the platelet count is below 20,000/l unless the patient is actively bleeding, so the nurse should clarify the order with the health care provider before giving the transfusion. The other data all indicate that bleeding caused by ITP may be occurring and indicate that the platelet transfusion is appropriate.

Cognitive Level: Application Text Reference: p. 704
Nursing Process: Assessment NCLEX: Physiological Integrity

21. Which nursing intervention will be included in the care plan for a patient with ITP?
a. Use rinses rather than a toothbrush for oral care.
b. Restrict activity to passive and active range of motion.
c. Place patient in a private room.
d. Avoid intramuscular (IM) and subcutaneous injections.

D
Rationale: IM or subcutaneous injections should be avoided because of the risk for bleeding. A soft toothbrush can be used for oral care. There is no need to restrict activity or place the patient in a private room.

Cognitive Level: Application Text Reference: pp. 705-706
Nursing Process: Planning
NCLEX: Safe and Effective Care Environment

22. The nurse suspects the development of heparin-induced thrombocytopenia and thrombosis syndrome (HITTS) when a patient receiving heparin
a. develops a pancytopenia.
b. has a platelet count of 200,000/l.
c. develops a spiking temperature and chills.
d. has decreasing activated partial thromboplastin times.

D
Rationale: Platelet aggregation in HITTS causes neutralization of heparin so that the activated partial thromboplastin times will be shorter and more heparin will be needed to maintain therapeutic levels. Decreases in WBCs and RBCs are not seen with HITTS. A platelet count of 200,000/l is normal. A spiking temperature and chills indicate infection or sepsis, not HITTS.

Cognitive Level: Application Text Reference: p. 704
Nursing Process: Assessment NCLEX: Physiological Integrity

23. A patient with type A hemophilia has been admitted to the hospital with severe pain and swelling in the right knee. During the initial care of the patient, the nurse should
a. immobilize the knee.
b. apply heat to the joint.
c. perform passive range of motion (ROM) to the knee.
d. assist the patient with light weight-bearing.

A
Rationale: The initial action should be total rest of the knee to minimize bleeding. Ice packs are used to decrease bleeding. ROM and weight-bearing exercise are contraindicated initially, but after the bleeding stops, ROM and physical therapy are started.

Cognitive Level: Application Text Reference: p. 709
Nursing Process: Implementation NCLEX: Physiological Integrity

24. A patient with von Willebrand's disease is admitted to the hospital for minor knee surgery. The nurse will review the coagulation survey to check the
a. bleeding time.
b. platelet count.
c. prothrombin time.
d. thrombin time.

A
Rationale: The bleeding time is affected by von Willebrand's disease. Platelet count, prothrombin time, and thrombin time are normal in von Willebrand's disease.

Cognitive Level: Application Text Reference: p. 709
Nursing Process: Implementation NCLEX: Physiological Integrity

25. The nurse caring for a patient with hemophilia teaches the patient to seek immediate medical attention upon experiencing
a. sore throat.
b. skin abrasions.
c. bleeding gums.
d. dark tarry stools.

D
Rationale: Melena is a sign of gastrointestinal bleeding and requires further assessment. A sore throat does not indicate bleeding, although neck swelling requires rapid medical care. The patient can apply pressure to abrasions or gum bleeding rather than immediately seeking medical attention.

Cognitive Level: Application Text Reference: pp. 708, 710
Nursing Process: Implementation
NCLEX: Health Promotion and Maintenance

26. A patient's family member asks the nurse what caused the patient to develop disseminated intravascular coagulation (DIC). The nurse tells the family member that DIC
a. is caused by an abnormal activation of clotting.
b. occurs when the immune system attacks platelets.
c. is a complication of cancer chemotherapy.
d. is caused when hemolytic processes destroy erythrocytes.

A
Rationale: DIC is an abnormal response of the clotting cascade stimulated by a variety of disease or disorders. ITP is caused by platelet destruction by the immune system. Various cancers are associated with DIC, but cancer chemotherapy is not a cause. Destruction of RBCs does not occur in DIC.

Cognitive Level: Application Text Reference: p. 710
Nursing Process: Assessment NCLEX: Physiological Integrity

27. During treatment of the patient who has sepsis-induced DIC with moderate bleeding, the nurse will expect that the initial collaborative care will focus on
a. administration of heparin to reduce intravascular clotting.
b. treatment of the infectious process with IV antibiotics.
c. infusion of whole blood to replace clotting factors and RBCs.
d. supportive management of symptoms until the DIC is resolved.

B
Rationale: Treatment of the acute sepsis is essential to resolving the DIC and will be the major focus of collaborative care. Heparin administration is controversial in DIC, although it may be used if the DIC does not resolve and clotting factors continue to decrease. Selected blood components may be infused, but whole blood is not used. Supportive care will be given, but treatment of the sepsis is essential.

Cognitive Level: Application Text Reference: p. 712
Nursing Process: Planning NCLEX: Physiological Integrity

28. A patient with myelodysplastic syndrome (MDS) is receiving chemotherapy. Which of these laboratory values will be of most concern to the nurse?
a. RBC 4,800,000/l
b. Monocytes 560/l
c. Neutrophils 2600/l
d. WBC 2800/L

D
Rationale: The low WBC level indicates a risk for infection; the nurse should notify the health care provider and expect an order to check the differential. The other values are normal and do not require any immediate action by the nurse except ongoing monitoring.

Cognitive Level: Application Text Reference: p. 717
Nursing Process: Assessment NCLEX: Physiological Integrity

29. The most appropriate nursing intervention to include in the care plan for a patient with neutropenia is to
a. omit fresh fruits or vegetables from the diet.
b. check the temperature q4hr.
c. avoid any IM or subcutaneous injections.
d. assess all wounds for redness and drainage.

B
Rationale: The earliest sign of infection in a neutropenic patient is an elevation in temperature. Fruits and vegetables that are peeled are acceptable. Injections may be required for administration of medications such as filgrastim (Neupogen). Redness and drainage may not occur even with severe wound infections because these symptoms of infections are dependent on neutrophils.

Cognitive Level: Application Text Reference: pp. 714-716
Nursing Process: Assessment NCLEX: Physiological Integrity

30. A patient receiving chemotherapy for acute lymphocytic leukemia has pancytopenia, and filgrastim (Neupogen) is prescribed. The nurse teaches the patient that the reason for the use of the medication is
a. to help promote remission of the acute leukemia.
b. to improve the number and function of neutrophils.
c. replacement of abnormal stem cells in the bone marrow with normal cells.
d. prevention of hemorrhage complications in patients with thrombocytopenia.

B
Rationale: Filgrastim increases the neutrophil count and function in neutropenic patients. It does not cause remission of the leukemia or cause changes in the bone marrow stem cells. Thrombocytopenic patients may receive oprelvekin (Neumega) to increase platelet count and decrease bleeding risk.

Cognitive Level: Application Text Reference: p. 715
Nursing Process: Planning NCLEX: Physiological Integrity

31. A 64-year-old patient with newly diagnosed acute myelogenous leukemia (AML) who is undergoing induction therapy with chemotherapeutic agents tells the nurse, "I feel so sick that I don't know if the treatment is worth completing." The nurse's best response to the patient is
a. "I know you feel really ill right now, but after this therapy your disease will go into a remission and you will feel normal again."
b. "Induction therapy is very aggressive and causes the most side effects, so when this phase is completed you won't feel so ill."
c. "Your type of leukemia has an 80% survival rate if aggressive therapy is started, so the effects of treatment will be worth it to you."
d. "The chemotherapy is difficult, but it is necessary to put the disease into remission and give you time to make choices about your life."

D
Rationale: AML is very aggressive, and survival after diagnosis is short without treatment. Induction therapy is followed by more chemotherapy, so the nurse should not tell the patient that he or she will feel normal or not so ill. The survival with AML is not 80%.

Cognitive Level: Application Text Reference: p. 720
Nursing Process: Implementation NCLEX: Psychosocial Integrity

32. Which of these nursing actions included in the care plan for a patient with neutropenia is appropriate for the RN to delegate to an LPN/LVN who is assisting with patient care?
a. Teaching the patient the purpose of neutropenic precautions
b. Assessing the patient for signs and symptoms of infection
c. Developing a discharge teaching plan for the patient and family
d. Administer the ordered subcutaneous filgrastim (Neupogen) injection

D
Rationale: Administration of medications is included in LPN/LVN education and scope of practice. Patient education, assessment, and developing the plan of care require RN level education and scope of practice.

Cognitive Level: Application Text Reference: pp. 714-716
Nursing Process: Implementation
NCLEX: Safe and Effective Care Environment

33. A patient with newly diagnosed leukemia is receiving chemotherapy. Which intervention will the nurse include in the plan of care?
a. Avoid the intake of fresh fruits and vegetables.
b. Administer oral prophylactic antibiotics.
c. Teach visitors hand washing techniques.
d. Place the patient in a laminar airflow room.

C
Rationale: Infection-control measures such as handwashing are necessary for the patient receiving chemotherapy. Restrictions of fresh fruits and vegetables, prophylactic antibiotics, and laminar airflow rooms are used for patients who are neutropenic, but not for all patients receiving chemotherapy.

Cognitive Level: Application Text Reference: p. 716
Nursing Process: Planning
NCLEX: Safe and Effective Care Environment

34. A 45-year-old patient with chronic myelogenous leukemia (CML) is considering the possibility of treatment with a hematopoietic stem cell transplant (HSCT) from an HLA-matched sibling. To assist the patient with treatment decisions, the best approach for the nurse to use is to
a. emphasize the positive outcomes of a bone marrow transplant.
b. ask the patient whether there are any questions or concerns about HSCT.
c. explain that a cure is not possible with any other treatment except HSCT.
d. discuss the need for adequate insurance to cover post-HSCT care.

B
Rationale: Offering the patient an opportunity to ask questions or discuss concerns about HSCT will encourage the patient to voice concerns about this treatment and will also allow the nurse to assess whether the patient needs more information about the procedure. Treatment of CML using chemotherapy is another option for the patient. It is not appropriate for the nurse to ask the patient to consider insurance needs in making this decision.

Cognitive Level: Application Text Reference: pp. 721-722
Nursing Process: Implementation NCLEX: Psychosocial Integrity

35. During care of the patient with multiple myeloma, an important nursing intervention is
a. limiting weight-bearing and ambulation.
b. maintaining a fluid intake of 3 to 4 L/day.
c. assessing lymph nodes for enlargement.
d. administration of calcium supplements.

B
Rationale: A high fluid intake and urine output helps to prevent the complications of kidney stones caused by hypercalcemia and renal failure caused by deposition of Bence-Jones protein in the renal tubules. Weight-bearing and ambulation are encouraged to help bone retain calcium. Lymph nodes are not enlarged with multiple myeloma. Calcium supplements will further increase the patient's calcium level and are not used.

Cognitive Level: Application Text Reference: pp. 728-729
Nursing Process: Planning NCLEX: Physiological Integrity

36. A patient with non-Hodgkin's lymphoma develops a platelet count of 10,000/l during chemotherapy. An appropriate nursing intervention for the patient, based on this finding, is to
a. encourage fluids to 3000 ml/day.
b. provide oral hygiene q2hr.
c. check the temperature q4hr.
d. check all stools for occult blood.

D
Rationale: Because the patient is at risk for spontaneous bleeding, the nurse should check stools for occult blood. A low platelet count does not require an increased fluid intake. Oral hygiene is important, but it is not necessary to provide oral care every 2 hours. The low platelet count does not increase risk for infection, so frequent temperature monitoring is not indicated.

Cognitive Level: Application Text Reference: p. 706
Nursing Process: Planning NCLEX: Physiological Integrity

37. A 26-year-old patient with stage II Hodgkin's lymphoma asks the nurse, "How long do I have to live?" The nurse's best response to the patient is
a. "Since no one can predict how long someone will live, try to focus on the present."
b. "It will depend on how your disease responds to radiation, but most patients do well."
c. "With ongoing maintenance chemotherapy, the 10-year survival rate is very good."
d. "Most patients with your stage of Hodgkin's disease are treated successfully."

D
Rationale: The survival rate is almost 90% in patients with the early stages of Hodgkin's lymphoma. The response beginning, "Since no one can predict" is nontherapeutic because the patient is likely to feel that the nurse is avoiding the question. Chemotherapy, rather than radiation, is the major treatment for Hodgkin's lymphoma. Maintenance chemotherapy is not used for Hodgkin's lymphoma.

Cognitive Level: Application Text Reference: p. 724
Nursing Process: Implementation NCLEX: Psychosocial Integrity

38. A 22-year-old patient with acute myelogenous leukemia develops neutropenia after receiving outpatient chemotherapy. Which action by the nurse in the outpatient clinic is most appropriate?
a. Plan to admit the patient to the hospital for treatment of the neutropenia.
b. Schedule the patient to come into the hospital daily for filgrastim (Neupogen) injections.
c. Teach the patient or family how to administer filgrastim (Neupogen) injections at home.
d. Obtain a high-efficiency particulate-air (HEPA) filter for the patient to use at home.

C
Rationale: The patient or family may be taught to self-administer filgrastim injections. Patients with neutropenia are at higher risk for infection when exposed to other patients in the hospital. HEPA filters are expensive and are used in the hospital, where the number of pathogens is much higher than in the patient's home environment.

Cognitive Level: Application Text Reference: p. 715
Nursing Process: Implementation
NCLEX: Safe and Effective Care Environment

MULTIPLE RESPONSE

1. A patient recently diagnosed with Hodgkin's lymphoma undergoes extensive testing for staging of the disease and decisions regarding treatment. The nurse will plan to teach the patient about (Select all that apply.)
a. angiography.
b. lymph node biopsy.
c. radiographic studies.
d. peripheral blood analysis.
e. bone marrow examination.
f. laparotomy and splenectomy.

B, C, D, E
Rationale: Lymph node biopsy, radiographic studies, blood analysis, and bone marrow biopsy are used in staging Hodgkin's lymphoma and choosing treatment. Angiography, laparotomy, and splenectomy are not part of the diagnostic process.

Cognitive Level: Comprehension Text Reference: p. 724
Nursing Process: Implementation NCLEX: Physiological Integrity

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