NUR 2502 / NUR2502 Final Exam (Latest 2024 / 2025): Multidimensional Care III / MDC 3 – Rasmussen
NUR 2502 Multidimensional Care III
NUR 2502 MDC 3 Final Exam
A patient admitted for sickle cell crisis is distraught after learning her child
also has the disease. What response by the nurse is best?
A. “Both you and the father are equally responsible for passing it on.”
B. “I can see you are upset. I can stay here with you a while if you like.”
C. “It’s not your fault; there is no way to know who will have this disease.”
D. “There are many good treatments for sickle cell disease these days.”
Correct Answer:
B. “I can see you are upset. I can stay here with you a while if you like.”
A nurse is caring for a client diagnosed with multiple myeloma. Which of the
following signs and symptoms are not consistent with early stages of the
disease?
a. Fatigue
b. Bruising
c. Bone pain
d. Hypertension
Correct Answer:
d. Hypertension
Which of the following assessment findings are common with autoimmune
thrombocytopenic purpura?
a. Bruising
b. Fatigue
c. Confusion
d. Fever
Correct Answer:
a. Bruising
A nurse is caring for a client who was recently diagnosed with hemophilia.
Which of the following laboratory test is consistent with that diagnosis?
a. Prolonged bleeding time
b. Prolonged activated partial thromboplastin time
c. Prolonged prothrombin time
d. Decreased platelet count
Correct Answer:
b. Prolonged activated partial thromboplastin time
A client is receiving treatment for the diagnosis of hemophilia A. Which of
the following is the most appropriate to include in the assessment of this
client?
a. Appetite
b. Urine output
c. Joint pain and bruising
d. Respiratory rate
Correct Answer:
c. Joint pain and bruising
The nurse knows that hemolytic reactions to blood transfusions occur most
often within the first _____mL of the infusion.
a. 5
b. 50
c. 100
d. 150
Correct Answer:
b. 50
Which of the following is the priority nursing intervention for a client
experiencing a transfusion reaction?
a. Stop transfusion immediately
b. Notify the provider
c. Flush the IV line
d. Check vital signs
Correct Answer:
*a. Stop transfusion immediately
Which of the following assessment findings is a priority during a blood
transfusion?
a. Chest pain
b. Headache
c. Joint pain
d. Fatigue
Correct Answer:
Chest pain
Which patient is not at risk for iron-deficiency anemia?
a. 24-year-old female with heavy menses
b. 64-year-old male diabetic with chronic kidney disease
c. 72-year old male with osteoarthritis
d. 32-year-old female with ulcerative colitis exacerbation
Correct Answer:
*b. 64-year-old male diabetic with chronic kidney disease
A 78-year-old female presented to the emergency department with
shortness of breath. Her daughter is at the bedside and shares that the
client has a history of heart failure. You place the client on the cardiac
monitor and find that the client is in atrial fibrillation at a rate of 180 beats
per minute. Which of the following are your concerns regarding this rhythm?
(Select all that apply)
a. Potential for embolic event
b. Hypotension due to elevated heart rate
c. Worsening heart failure
d. Increased confusion
e. Cerebral edema
Correct Answer:
a. Potential for embolic event
b. Hypotension due to elevated heart rate
c. Worsening heart failure
d. Increased confusion
Which of the following is a priority nursing intervention for a client in atrial fibrillation with a rate of 180 beats per minute?
a. Apply oxygen
b. Administer anticoagulants
c. Administer medications to slow the rate
d. Monitor urine output
c. Administer medications to slow the rate
A nurse is caring for a client who was recently diagnosed with left ventricular heart failure. What is an early sign the client is most likely to report? a. Nocturia b. Weight gain c. Swollen legs d. Nocturnal coughing
d. Nocturnal coughing
A nurse is performing discharge teaching for a patient who was recently diagnosed with heart failure. Which of the following should be included in the patient and family teaching? (SATA)
a. Medication teaching
b. Low sodium diet
c. Fluid restriction
d. Daily weights
e. what their S/S are for CHF
*a. Medication teaching
*b. Low sodium diet
*c. Fluid restriction
*d. Daily weights
*e. what their S/S are for CHF
Which of the following would be a sign of improvement in heart failure symptoms after an exacerbation?
a. Weight gain of 3 lb in a week
b. Excessive awakening at night to urinate
c. Decreased swelling in the feet, ankles, or hands
d. Decrease in exercise tolerance
c. Decreased swelling in the feet, ankles, or hands
A 56-year-old female presented to the emergency department with complaints of fatigue and dyspnea on exertion. Physical assessment reveals jugular vein distention, pitting edema of the lower extremities, and irregular heart rhythm. Which of the following tests would you anticipate to be ordered as priority?
a. B-type natriuretic peptide
b. Complete blood count
c. Complete metabolic panel
d. Arterial blood gas
a. B-type natriuretic peptide
The nurse is caring for a 65-year-old female who presented to the emergency department with shortness of breath and chest discomfort. The client has not been feeling well for the past few days and complains of a productive cough of blood-tinged sputum. Laboratory tests reveal an elevated BNP, and chest x-ray reveals pulmonary congestion. Based on the assessment findings, which of the following diagnosis are consistent with these findings?
a. Heart failure (left-sided)
b. Pulmonary embolism
c. Heart failure (right-sided)
d. Lung cancer
a. Heart failure (left-sided)
The nurse educates the client on which of the following tests as the best tool for diagnosing heart failure?
a. Echocardiography
b. Pulmonary artery catheter
c. Radionuclide studies
d. Multigated angiographic (MUGA) scan
a. Echocardiography
A client presents with pink, frothy sputum. What is the most appropriate nursing action?
a. Hold the next routine dose of diuretic
b. Assess respiratory status
c. Insert an IV line
d. Insert a nasogastric tube
b. Assess respiratory status
A nurse is caring for a patient who was diagnosed with heart failure. Which of the following should the nurse include in the patient education regarding causes of heart failure? (Select all that apply)
a. Smoking
b. Hypertension
c. Anorexia
d. Diet
e. Sleep Apnea
a. Smoking
b. Hypertension d. Diet
Which of the following is the treatment of choice for end-stage heart failure?
a. Heart transplant
b. Coronary artery bypass grafting
c. Percutaneous angiogram
d. Medications
a. Heart transplant
Which statement to the nurse by a client being treated for heart failure is the best indicator of hope and well-being as a desired psychological outcome?
a. “I’m taking the medication and following the doctor’s orders.”
b. “I’m looking forward to dancing with my wife on our wedding anniversary.”
c. “I’m planning to go on a long trip. I’ll never go back to the hospital again.”
d. “I want to thank you for all that you have done. I know you did your best.”
b. “I’m looking forward to dancing with my wife on our wedding anniversary.”
A client is at risk for heart failure but currently has no official medical diagnosis.
While assessing the client’s lungs, the nurse hears fine profuse crackles. What does the nurse do next?
a. Report the finding to the health care provider
b. Document the finding as a baseline for later comparison
c. Give the client low-flow supplemental oxygen
d. Ask the client to cough and re-auscultate the lungs
d. Ask the client to cough and re-auscultate the lungs
A 65-year-old female presented to the emergency room with complaints of progressively worsening fatigue, shortness of breath, and palpitations. Upon assessment, heart rate is 130 beats per minute and irregular, and there is positive jugular vein distention. Heart tones reveal a high-pitched holosystolic murmur. Which of the following disorders are consistent with these findings?
a. Mitral regurgitation
b. Mitral stenosis
c. Aortic regurgitation
d. Aortic stenosis
a. Mitral regurgitation
Which of the following medications are appropriate for the treatment of heart failure related to mitral regurgitation? (Select all that apply)
a. Antibiotics
b. Diuretics
c. Beta-blockers
d. Anticoagulants
e. Brochodilators
b. Diuretics
c. Beta-blockers D. Anticoagulants
The nurse is caring for a 60-year-old female who was recently diagnosed with mitral valve stenosis. Which of the following is a common assessment findings for a client with this disorder?
a. Increased cardiac output
b. Weight gain
c. Platypnea
d. Fatigue
Fatigue
The nurse is caring for an 89-year-old female client diagnosed with mitral valve stenosis. Which of the following are possible treatment options? (Select all that apply)
a. Coronary artery bypass grafting
b. Ventricular assist device
c. Percutaneous balloon valvuloplasty
d. Mitral valve replacement
e. Permanent pacemaker
c. Percutaneous balloon valvuloplasty
d. Mitral valve replacement
Which of the following would predispose a patient to mitral stenosis?
a. Obesity
b. Rheumatic fever
c. Diabetes
d. IV drug use
b. Rheumatic fever
The patient with a mechanical prosthetic valve replacement must understand that post-operative care will include lifelong therapy for which type of medication?
a. Daily antibiotics
b. Anticoagulants
c. Immunosuppressants
d. Pain medication
Anticoagulants
A nurse is providing discharge teaching to a client who recently underwent a mechanical valve replacement. Which of the following statements by the client would validate the need for further discharge teaching regarding anticoagulation therapy?
a. “I do not need to take my prescribed medication for the rest of my life.”
b. “Additional monitoring is not required while on the anticoagulant.”
c. “I can lead a normal life while on anticoagulants, no restrictions are required.”
d. “I will need to modify my diet while on this medication.”
a. “I do not need to take my prescribed medication for the rest of my life.”
A nurse is caring for a 29-year-old male client who has recently been diagnosed with mitral valve prolapse. Which of the following conditions is associated with this disorder?
a. Endocarditis
b. Marfan syndrome
c. Sickle Cell Disorder
d. Papillary muscle rupture
b. Marfan syndrome
Which of the following assessment findings is consistent with mitral valve prolapse?
a. Systolic click
b. Urinary frequency
c. Atrial fibrillation
d. Claudication
a. Systolic click
A nurse is caring for a 60-year-old female presented to her family doctor for her annual physical. She communicated to her provider that she has been experiencing chest discomfort and shortness of breath. Upon assessment, the provider auscultated a harsh, systolic crescendo-decrescendo murmur. Based on the client’s symptoms and physical, which of the following conditions could the client be exhibiting?
a. Mitral stenosis
b. Mitral valve prolapse
c. Aortic regurgitation
d. Aortic stenosis
d. Aortic stenosis
Which of the following assessment findings are consistent with aortic regurgitation?
Atrial fibrillation
Systolic click
c. Pitting edema
d. Blowing, decrescendo diastolic murmur
d. Blowing, decrescendo diastolic murmur
The nurse knows that which of the following is the most common problem for a client with valvular heart disease?
a. Decreased cardiac output
b. Difficulty coping
c. Shortness of breath
d. Altered body image
a. Decreased cardiac output
Which of the following is the noninvasive diagnostic testing of choice to evaluate valve disease?
a. Electrocardiogram
b. Cardiac catheterization
c. Echocardiogram
d. Stress test
Echocardiogram
A nurse is caring for a 65-year-old male who recently underwent an aortic valve replacement. Which of the following is a post-operative nursing care priority?
a. Temperature monitoring
b. Advance diet as tolerated
c. Assess for bleeding
d. Dressing change
c. Assess for bleeding
Which of the following clients is most at risk for developing endocarditis?
a. A client who recently underwent a valve replacement
b. A client with Marfan’s syndrome
c. A client recently diagnosed with mitral stenosis
d. A client who recently had a valve replacement and had dental work recently performed
d. A client who recently had a valve replacement and had dental work recently performed
A nurse is caring for a client who was recently diagnosed with infective endocarditis. Upon assessment, you note small non-tender erythematous lesions on the palms and soles. Based on your knowledge of the disease process, what are these lesions called?
a. Hives
b. Osler’s nodes
c. Janeway lesions
d. Trousseau’s sign
c. Janeway lesions
A client experiencing infective endocarditis may have all of the following signs and symptoms except:
a. Fever
b. Cardiac murmur
c. Osler’s nodes
d. Weight gain
d. Weight gain
Which of the following is a treatment option for a client with infective endocarditis?
a. Antimicrobials
b. Anticoagulants
c. Diet modification
d. Bedrest
a. Antimicrobials
A nurse is providing discharge instructions to a client who was diagnosed with endocarditis. Which of the following statements validates the client’s understanding?
a. “I will continue my antibiotics until they are gone.”
b. “I am not required any follow-up care.”
c. “I have no restrictions on my activity or future procedures.”
d. “I must remain on daily antibiotics for the rest of my life.”
a. “I will continue my antibiotics until they are gone.”
A nurse is caring for a client recently diagnosed with pericarditis. Which of the following is a common assessment finding with this disorder?
a. ST-segment depression
b. Pericardial friction rub
c. Elevated troponin
d. Heart failure
b. Pericardial friction rub
You are caring for a client recently diagnosed with acute pericarditis who has pain that is unresolved by NSAID administration. Which of the following positions is most likely to provide the most comfort to this patient?
a. Trendelenburg
b. Sitting upright
c. Left-side lying
d. Low fowlers
b. Sitting upright
You are providing care to a client with pericarditis. If left untreated, which of the following is the client at risk of developing?
a. Cardiac tamponade
b. Pneumonia
c. Pulmonary embolism
d. Deep vein thrombosis
a. Cardiac tamponade
Which of the following procedures are performed for a client with a pericardial effusion?
a. Coronary artery bypass graft
b. Thoracotomy
c. Pericardiocentesis
d. Thoracentesis
Pericardiocentesis
A nurse is caring for a client who presented to the emergency department with complaints of fatigue, palpitations, and chest pain. Upon assessment, the provider notes an S3 and S4 gallop, weak peripheral pulses, and tachycardia. The provider orders a chest x-ray and echocardiogram, which reveal left ventricular dilation. Which of the following disorders is consistent with these findings?
a. Dilated cardiomyopathy
b. Restrictive cardiomyopathy
c. Pericarditis
d. Cardiac tamponade
a. Dilated cardiomyopathy
Which of the following is a treatment option for a client with severe dilated cardiomyopathy?
a. Ventricular assistive device
b. Percutaneous alcohol septal ablation
c. Heart transplant
d. Myomectomy
c. Heart transplant
A nurse is caring for a client who recently underwent a heart transplant. Which of the following post-operative nursing interventions is the highest priority?
a. Assess for signs and symptoms of rejection
b. Advance diet as tolerated
c. Auscultate bowel sounds
d. Maintain strict bedrest
a. Assess for signs and symptoms of rejection
You are caring for a client diagnosed with atherosclerosis. Which of the following is considered a risk factor for the development of this disorder?
a. High HDL-C / Low LDL -C
b. Vegan diet
c. Low HDL-C/High LDL-C
d. Diet high in vitamin K
c. Low HDL-C/High LDL-C
Which of the following interventions should be included in the nutrition care plan of the patient with atherosclerosis?
a. Increase saturated fats
b. Increase daily intake of vegetables, fruits, and whole grains
c. Limit sodium intake to 6 g per day
d. Increase full-fat dairy products
b. Increase daily intake of vegetables, fruits, and whole grains
A nurse is caring for a client diagnosed with peripheral artery disease. Which of the following is a common assessment findings?
a. 3+ pedal pulses
*b. 1+ pedal pulses
c. 4+ pedal pulses
d. Bounding pulses in all 4 extremities
b. 1+ pedal pulses
Which of the following medications are utilized to treat PAD?
a. Antiplatelet drugs
b. Antibiotics
c. Nitroglycerin
d. Diuretics
a. Antiplatelet drugs
A nurse is caring for a client recently diagnosed with hypertension. Which of the following should be included in the discharge teaching?
a. Only check your blood pressure at a clinic or pharmacy
b. Diet changes are not recommended
c. Decrease physical activity to avoid spikes in blood pressure.
d. Adhere to prescribed medications
d. Adhere to prescribed medications
A 48-year-old male presents to the emergency department with complaints of abdominal and back pain for the past few days. The client has a history of hypertension, smoking, and atherosclerosis. The client’s heart rate is 130 bpm, and blood pressure is 80/50 mm/Hg. The provider orders a CT of the chest and abdomen, which reveal a dissecting abdominal aneurysm. Which of the following is a priority treatment for this disorder?
a. Control blood pressure
b. Immediate surgical intervention
c. Fluid resuscitation
d. Blood transfusion
b. Immediate surgical intervention
Which of the following intervention is included for a client with an aortic dissection?
a. Palpate abdomen
b. Vasoconstrictive agents
c. Anticoagulants
d. Management of blood pressure
d. Management of blood pressure
A 65-year-old male client is brought via EMS to the emergency department with chest pain. He rates the pain as a “10” on a scale from 0-10the pain is located mid-sternum and radiates to his left arm. His heart rate is 126 bpm, and blood pressure is 96/60 mm Hg. A 12-lead electrocardiogram is performed and reveals ST-segment elevation. Which of the following interventions does the nurse anticipate performing immediately? (Select all that apply)
a. Administer oxygen
b. Administer nitroglycerin
c. Administer a beta-blocker
d. Administer morphine
a. Administer oxygen
b. Administer nitroglycerin d. Administer morphine
What is the treatment for a client with a STEMI?
a. Coronary bypass surgery
b. Percutaneous coronary intervention
c. Heart transplant
d. Cardiac ablation
b. Percutaneous coronary intervention
Which of the following clients would not be a candidate for thrombolytic therapy?
a. Blood pressure 100/60 mm Hg
b. Patient with NSTEMI
c. History of hemorrhagic stroke one month ago
d. Client age 65
c. History of hemorrhagic stroke one month ago
A patient diagnosed with stable angina is complaining of sub-sternal chest discomfort rating the pain 5 out of 10. What would be the priority action by the nurse?
a. Administer nitroglycerin 1 tablet sublingual immediately
b. Administer 81mg of aspirin immediately
c. Administer the patients prescribed beta blocker
d. Notify the physician of changes in patient condition
a. Administer nitroglycerin 1 tablet sublingual immediately
A patient is presenting with radiating chest pain. Which of the following would the nurse recognize as indicators that an Acute Myocardial Infarction is occurring? (Select all that Apply)
a. Positive Troponin Markers
b. ST elevation on EKG on two contiguous leads
c. History of Atherosclerosis
d. Pain radiating in jaw, back, shoulder or abdomen
e.Pain relieved with rest
a. Positive Troponin Markers
b. ST elevation on EKG on two contiguous leads
c. History of Atherosclerosis
d. Pain radiating in jaw, back, shoulder or abdomen
When educating a female patient on the risk factors of Acute Coronary Syndrome, the nurse recognizes that which of the following should be included in teaching.
a. Any pain typically resolves with rest
b. Women often present with atypical signs and symptoms of CAD
c. Women with CAD have a lower probability of death then men
d. Age is not a risk factor for women who develop CAD
b. Women often present with atypical signs and symptoms of CAD
Which risk factor does the nurse assess for to determine a client’s cause of anemia?
a. Antacid therapy
b. Chronic alcoholism
c. Congestive heart failure
d. Type 2 diabetes
b. Chronic alcoholism
The nurse is assessing a client with anemia. Which clinical manifestation does the nurse expect to see in this client?
a. Dyspnea with activity
b. Hypertension
c. Bradycardia
d. Warm, flushed skin
a. Dyspnea with activity
A nurse is planning a diet for a client who is iron deficient. Which of the following foods high in iron should the nurse include in the plan?
a. Oranges
b. Cashews
c. Red meat
d. Yogurt
c. Red meat
A nurse is caring for four patients. After reviewing today’s laboratory results, which patient should the nurse see first?A. Patient with an international normalized ratio of 2.8
B. Patient with a platelet count of 128,000/mm3 (128 × 109/L).
C. Patient with a prothrombin time (PT) of 28 seconds
D. Patient with a red blood cell count of 5.1 million/mcL (5.1 × 1012/L)
C. Patient with a prothrombin time (PT) of 28 seconds
Which information is most important for the nurse to provide to the client to prevent sickle cell crisis?
a. Avoid exercising.
b. Avoid planes with pressurized cabins.
c. Maintain a diet high in iron.
d. Maintain an oral fluid intake of at least 4500 mL/day.
d. Maintain an oral fluid intake of at least 4500 mL/day.
A female patient is being treated for a deep-vein thrombus she developed post-operatively about one week ago and was treated with unfractionated heparin. Today presents to the clinic with petechiae on bilateral hands and feet. Laboratory results show a platelet count of 42,000/mm3 (42 × 109/L). The nurse is concerned about a drug reaction and anticipates the patient has which of the following?
A. Heparin-induced thrombocytopenia (HIT)
B. Hemophilia A (classic hemophilia)
C. Thrombotic thrombocytopenic purpura (TTP)
D. Sickle cell crisis
A. Heparin-induced thrombocytopenia (HIT)
Which of the following is not a common assessment finding consistent with a diagnosis of hereditary hemochromatosis?
a. Abdominal pain
b. Fever
c. Hyperglycemia
d. Liver enlargement
b. Fever
A nurse is caring for a client recently diagnosed with leukemia. Which of the following signs and symptoms are not consistent with this diagnosis?
a. Bleeding gums
b. Bone pain
c. Weight gain
d. Hematuria
c. Weight gain
A nurse is caring for a 19-year-old male recently diagnosed with leukemia. Which of the following nursing interventions are appropriate for the care of this client? (Select all that apply)
a. Strict hand hygiene to prevent infection
b. Provide emotional support
c. Restrict fluid and dietary intake
d. Protect from injury due to thrombocytopenia
a. Strict hand hygiene to prevent infection
b. Provide emotional support d. Protect from injury due to thrombocytopenia
Which of the following is not a possible treatment plan for a client diagnosed with leukemia?
a. Induction and consolidation therapy
b. Surgical intervention
c. Stem cell transplant
d. Blood product transfusion
b. Surgical intervention
A nursing student is caring for a patient with leukemia. The student asks why the patient is still at risk for infection when the patient’s white blood cell count (WBC) is high. What response by the registered nurse is best?
A. “If the WBCs are high, there already is an infection present.”
B. “The patient is in a blast crisis and has too many WBCs.”
C. “There must be a mistake the WBCs should be very low.”
D. “Those WBCs are abnormal and don’t provide protection.”
D. “Those WBCs are abnormal and don’t provide protection.”
A nurse is caring for four patients with leukemia. After hand-off report, which patient should the nurse see first?
A. Patient who had two bloody diarrhea stools this morning
B. Patient who has been premedicated for nausea prior to chemotherapy
C. Patient with a respiratory rate change from 15 to 20 breaths/min
D. Patient with an unchanged lesion to the lower right lateral malleolus
A. Patient who had two bloody diarrhea stools this morning
A nurse is caring for a client who recently underwent an allogeneic stem cell transplant. Which of the following is not a potential complication related to the transplant?
a. Failure to engraft
b. Hypertension
c. Graft versus host disease
d. Veno-occlusive disease
b. Hypertension
A nursing student is struggling to understand the process of graft-versus-host disease. What explanation by the nurse instructor is best?
A. “Because of immunosuppression, the donor cells take over.”
B. “It’s like a transfusion reaction because no perfect matches exist.”
C. “The patient’s cells are fighting donor cells for dominance.”
D. “The donor’s cells are actually attacking the patient’s cells.”
D. “The donor’s cells are actually attacking the patient’s cells.”
Hematopoietic stem cell transplantation, sometimes called bone marrow transplantation, is standard treatment for the patient with leukemia who has a closely matched donor and who is in temporary remission after induction therapy.
o It is also used for lymphoma, multiple myeloma, aplastic anemia, sickle cell disease, and many solid tumors.
o Transplantation has five phases: stem cell obtainment, conditioning regimen, transplantation, engraftment, and post-transplantation recovery.
The nurse questions which order for a client with thrombocytopenia?
a. Avoid IM injections.
b. Administer enemas.
c. Apply ice to areas of trauma.
d. Test all urine and stool for the presence of occult blood.
b. Administer enemas.
A patient has thrombocytopenia. What patient statement indicates that the patient understands self-management of this condition?
A. “I brush and use dental floss every day.”
B. “I chew hard candy for my dry mouth.”
C. “I usually put ice on bumps or bruises.”
D. “Nonslip socks are best when I walk.”
C. “I usually put ice on bumps or bruises.”
A patient admitted for sickle cell crisis is distraught after learning her child also has the disease. What response by the nurse is best?
A. “Both you and the father are equally responsible for passing it on.”
B. “I can see you are upset. I can stay here with you a while if you like.”
C. “It’s not your fault; there is no way to know who will have this disease.”
D. “There are many good treatments for sickle cell disease these days.”
B. “I can see you are upset. I can stay here with you a while if you like.”
A nurse is caring for a client diagnosed with multiple myeloma. Which of the following signs and symptoms are not consistent with early stages of the disease?
a. Fatigue
b. Bruising
c. Bone pain
d. Hypertension
d. Hypertension
Which of the following assessment findings are common with autoimmune thrombocytopenic purpura?
a. Bruising
b. Fatigue
c. Confusion
d. Fever
a. Bruising
A nurse is caring for a client who was recently diagnosed with hemophilia. Which of the following laboratory test is consistent with that diagnosis?
a. Prolonged bleeding time
b. Prolonged activated partial thromboplastin time
c. Prolonged prothrombin time
d. Decreased platelet count
b. Prolonged activated partial thromboplastin time
A client is receiving treatment for the diagnosis of hemophilia A. Which of the following is the most appropriate to include in the assessment of this client?
a. Appetite
b. Urine output
c. Joint pain and bruising
d. Respiratory rate
c. Joint pain and bruising
The nurse knows that hemolytic reactions to blood transfusions occur most often within the first _____mL of the infusion.
a. 5
b. 50
c. 100
d. 150
b. 50
Which of the following is the priority nursing intervention for a client experiencing a transfusion reaction?
a. Stop transfusion immediately
b. Notify the provider
c. Flush the IV line
d. Check vital signs
*a. Stop transfusion immediately
Which of the following assessment findings is a priority during a blood transfusion?
Chest pain
Headache
c. Joint pain
d. Fatigue
Chest pain
Which patient is not at risk for iron-deficiency anemia?
a. 24-year-old female with heavy menses
b. 64-year-old male diabetic with chronic kidney disease
c. 72-year old male with osteoarthritis
d. 32-year-old female with ulcerative colitis exacerbation
*b. 64-year-old male diabetic with chronic kidney disease
A 78-year-old female presented to the emergency department with shortness of breath. Her daughter is at the bedside and shares that the client has a history of heart failure. You place the client on the cardiac monitor and find that the client is in atrial fibrillation at a rate of 180 beats per minute. Which of the following are your concerns regarding this rhythm? (Select all that apply)
a. Potential for embolic event
b. Hypotension due to elevated heart rate
c. Worsening heart failure
d. Increased confusion
e. Cerebral edema
a. Potential for embolic event
b. Hypotension due to elevated heart rate
c. Worsening heart failure
d. Increased confusion
A nurse is caring for a client who was received in the emergency department with a heart rate of 220 beats per minute. The client’s cardiac monitor displayed SVT. Which of the following interventions should the nurse implement?
a. Apply oxygen
b. Check blood glucose
c. Draw labs
d. Vagal maneuver
d. Vagal maneuver
Which of the following are considered treatment options for a client with recurrent atrial fibrillation? (Select all that apply)
a. Synchronized cardioversion
b. Radiofrequency catheter ablation
c. Defibrillation
d. Heart transplant
e. Heart catheterization
*a. Synchronized cardioversion
*b. Radiofrequency catheter ablation
You are caring for a client who presented to the emergency department in pulmonary edema. The client is hypotensive with a pulse oximeter of 85% on room air. Which of the following is a nursing priority? a. Administer diuretics b. Administer IV fluids c. Administer oxygen d. Obtain a chest x-ray :
c. Administer oxygen