1.

helps correct the problem.

d. The client is hyperventilating because of anxiety and we will have to stay alert for
development of a respiratory acidosis.

a. Administer IV fluids as prescribed by the physician.

b. Provide straws and offer fluids between meals.
c. Develop plan for added fluid intake over 24 hours
d. Teach family members to assist client with fluid intake

1. A female client is admitted with a diagnosis of acute renal failure. She is awake, alert, oriented,
and complaining of severe back pain, nausea and vomiting and abdominal cramps. Her vital
signs are blood pressure 100/70 mm Hg, pulse 110, respirations 30, and oral temperature
100.4F (38C). Her electrolytes are sodium 120 mEq/L, potassium 5.2 mEq/L; her urinary output
for the first 8 hours is 50 ml. The client is displaying signs of which electrolyte imbalance?

A clients nursing diagnosis is Deficient Fluid Volume related to excessive fluid loss. Which
action related to the fluid management should be delegated to a nursing assistant?

2. The client also has the nursing diagnosis Decreased Cardiac Output related to decrease
plasma volume. Which finding on assessment supports this nursing diagnosis?
a. Flattened neck veins when client is in supine position
b. Full and bounding pedal and post-tibial pulses
c. Pitting edema located in feet, ankles, and calves
d. Shallow respirations with crackles on auscultation
3. The nursing care plan for the client with dehydration includes interventions for oral health.
Which interventions are within the scope of practice for the LPN/LVN being supervised by the
nurse? (Choose all that apply.)
a. Remind client to avoid commercial mouthwashes.
b. Encourage mouth rinsing with warm saline.
c. Assess lips, tongue, and mucous membranes
d. Provide mouth care every 2 hours while client is awake
e. Seek dietary consult to increase fluids on meal trays.
4. The physician has written the following orders for the client with Excess Fluid volume. The
clients morning assessment includes bounding peripheral pulses, weight gain of 2 pounds, pitting
ankle edema, and moist crackles bilaterally. Which order takes priority at this time?
a. Weight client every morning.
b. Maintain accurate intake and output.
c. Restrict fluid to 1500 mL per day
d. Administer furosemide (Lasix) 40 mg IV push
5. You have been pulled to the telemetry unit for the day. The monitor informs you that the client
has developed prominent U waves. Which laboratory value should you check immediately?
a. Sodium
b. Potassium
c. Magnesium
d. Calcium
6. The clients potassium level is 6.7 mEq/L. Which intervention should you delegate to the
student nurse under your supervision?
a. Administer Kayexalate 15 g orally
b. Administer spironolactone 25 mg orally
c. Assess WCG strip for tall T waves
d. Administer potassium 10 mEq orally
7. A client is admitted to the unit with a diagnosis of syndrome of inappropriate antidiuretic
hormone secretion (SIADH). For which electrolyte abnormality will you be sure to monitor?
a. Hypokalemia
b. Hyperkalemia
c. Hyponatremia
d. Hypernatremia
8. The charge nurse assigned in the care for a client with acute renal failure and hypernatremia to
you, a newly graduated RN. Which actions can you delegate to the nursing assistant?
a. Provide oral care every 3-4 hours
b. Monitor for indications of dehydration
c. Administer 0.45% saline by IV line
d. Assess daily weights for trends
9. The experienced LPN/LVN reports that a clients blood pressure and heart rate have
decreased and that when the face is assessed, one side twitches. What action should you take at
this time?
a. Reassess the clients blood pressure and heart rate
b. Review the clients morning calcium level
c. Request a neurologic consult today
d. Check the clients papillary reaction to light
10.You are preparing to discharge a client whose calcium level was low but is now just slightly
within the normal range (9-10.5 mg/dL). Which statement by the client indicates the need for
additional teaching?
a. I will call my doctor if I experience muscle twitching or seizures.
b. I will make sure to take my vitamin D with my calcium each day.
c. I will take my calcium pill every morning before breakfast.
d. I will avoid dairy products, broccoli, and spinach when I eat.
11.A nursing assistant asks why the client with a chronically low phosphorus level needs so much
assistance with activities of daily living. What is your best response?
a. The clients low phosphorus is probably due to malnutrition.
b. The client is just worn out form not getting enough rest.
c. The clients skeletal muscles are weak because of the low phosphorus.
d. The client will do more for herself when her phosphorus is normal
12.You are reviewing a clients morning laboratory results. Which of these results is of most
concern?
a. Serum potassium 5.2 mEq/L
b. Serum sodium 134 mEq/L
c. Serum calcium 10.6 mg/dL
d. Serum magnesium 0.8 mEq/L

13. You are the charge nurse. Which client is most appropriate to assign to the step-down unit
nurse pulled to the intensive care unit for the day?
a. A 68-year-old client on ventilator with acute respiratory failure and respiratory acidosis
b. A 72-year-old client with COPD and normal arterial blood gases (ABGs) who is ventilatordependent
c. A 56-year-old new admission client with diabetic ketoacidosis (DKA) on a n insulin drip
d. A 38-year-old client on a ventilator with narcotic overdose and respiratory alkalosis
14.A client with respiratory failure is receiving mechanical ventilation and continues to produce
ABG results indicating respiratory acidosis. Which action should you expect to correct this
problem?
a. Increase the ventilator rate from 6 to 10 per minute
b. Decrease the ventilator rate from 10 to 6 per minute
c. Increase the oxygen concentration fro 30% to 40%
d. Decrease the oxygen concentration fro 40% to 30%
15.Which action should you delegate to the nursing assistant for the client with diabetic
ketoacidosis? (Choose all that apply.)
a. Check fingerstick glucose every hour.
b. Record intake and output every hour.
c. Check vital signs every 15 minutes.
d. Assess for indicators of fluid imbalance.
16.You are admitting an elderly client to the medical unit. Which factor indicates that this client
has a risk for acid-base imbalances?
a. Myocardial infarction 1 year ago
b. Occasional use of antacids
c. Shortness of breath with extreme exertion
d. Chronic renal insufficiency
17.A client with lung cancer has received oxycodone 10 mg orally for pain. When the student
nurse assesses the client, which finding should you instruct the student to report immediately?
a. Respiratory rate of 8 to 10 per minute
b. Pain level decreased from 6/10 to 2/10
c. Client requests room door be closed.
d. Heart rate 90-100 per minute
18.The nursing assistant reports to you that a client seems very anxious and that vital signs
included a respiratory rate of 38 per minute. Which acid-base imbalance should you suspect?
a. Respiratory acidosis
b. Respiratory alkalosis
c. Metabolic acidosis
d. Metabolic alkalosis
19.A client is admitted to the unit for chemotherapy. To prevent an acid-base problem, which of
the following would you instruct the nursing assistant to report?
a. Repeated episodes of nausea and vomiting
b. Complaints of pain associated with exertion
c. Failure to eat all food on breakfast tray
d. Client hair loss during morning bath
20.A client has a nasogastric tube connected to intermittent wall suction. The student nurse asks
why the clients respiratory rate has increased. What your best response?
a. Its common for clients with uncomfortable procedures such as nasogastric tubes to have a
higher rate to breathing.
b. The client may have a metabolic alkalosis due to the NG suctioning and the increased
respiratory rate is a compensatory mechanism.
c. Whenever a client develops a respiratory acid-base problem, increasing the respiratory rate

A. Hyponatremia
B. Hyperkalemia
C. Hyperphosphatemia
D. Hypercalcemia
2. Assessing the laboratory findings, which result would the nurse most likely expect to find in a
client with chronic renal failure?

A. BUN 10 to 30 mg/dl, potassium 4.0 mEq/L, creatinine 0.5 to 1.5 mg/dl

B. Decreased serum calcium, blood pH 7.2, potassium 6.5 mEq/L
C. BUN 15 mg/dl, increased serum calcium, creatinine l.0 mg/dl
D. BUN 35 to 40 mg/dl, potassium 3.5 mEq/L, pH 7.35, decreased serum calcium
3. Treatment with hemodialysis is ordered for a client and an external shunt is created. Which
nursing action would be of highest priority with regard to the external shunt?

A. Heparinize it daily.
B. Avoid taking blood pressure measurements or blood samples from the affected arm.
C. Change the Silastic tube daily.
D. Instruct the client not to use the affected arm.
4. Romeo Diaz, age 78, is admitted to the hospital with the diagnosis of benign prostatic
hyperplasia (BPH). He is scheduled for a transurethral resection of the prostate (TURP). It would
be inappropriate to include which of the following points in the preoperative teaching?

A. TURP is the most common operation for BPH.

B. Explain the purpose and function of a two-way irrigation system.
C. Expect bloody urine, which will clear as healing takes place.
D. He will be pain free.
5. Roxy is admitted to the hospital with a possible diagnosis of appendicitis. On physical
examination, the nurse should be looking for tenderness on palpation at McBurneys point, which
is located in the

A. left lower quadrant

B. left upper quadrant
C. right lower quadrant
D. right upper quadrant
6. Mr. Valdez has undergone surgical repair of his inguinal hernia. Discharge teaching should
include

A. telling him to avoid heavy lifting for 4 to 6 weeks

B. instructing him to have a soft bland diet for two weeks
C. telling him to resume his previous daily activities without limitations
D. recommending him to drink eight glasses of water daily
7. A 30-year-old homemaker fell asleep while smoking a cigarette. She sustained severe burns of
the face,neck, anterior chest, and both arms and hands. Using the rule of nines, which is the best
estimate of total body-surface area burned?

A. 18%
B. 22%
C. 31%
D. 40%
8. Nursing care planning is based on the knowledge that the first 24-48 hours post-burn are
characterized by:

A. An increase in the total volume of intracranial plasma

B. Excessive renal perfusion with diuresis
C. Fluid shift from interstitial space
D. Fluid shift from intravascular space to the interstitial space
9. If a client has severe bums on the upper torso, which item would be a primary concern?

A. Debriding and covering the wounds

B. Administering antibiotics
C. Frequently observing for hoarseness, stridor, and dyspnea
D. Establishing a patent IV line for fluid replacement
10. Contractures are among the most serious long-term complications of severe burns. If a burn
is located on the upper torso, which nursing measure would be least effective to help prevent
contractures?

A. Changing the location of the bed or the TV set, or both, daily

B. Encouraging the client to chew gum and blow up balloons
C. Avoiding the use of a pillow for sleep, or placing the head in a position of hyperextension
D. Helping the client to rest in the position of maximal comfort
11. An adult is receiving Total Parenteral Nutrition (TPN). Which of the following assessment is
essential?

A. evaluation of the peripheral IV site

B. confirmation that the tube is in the stomach
C. assess the bowel sound
D. fluid and electrolyte monitoring
12. Which drug would be least effective in lowering a clients serum potassium level?

A. Glucose and insulin

B. Polystyrene sulfonate (Kayexalate)
C. Calcium glucomite
D. Aluminum hydroxide
13. A nurse is directed to administer a hypotonic intravenous solution. Looking at the following
labeled solutions, she should choose

A. 0.45% NaCl
B. 0.9% NaCl
C. D5W
D. D5NSS
14. A patient is hemorrhaging from multiple trauma sites. The nurse expects that compensatory
mechanisms associated with hypovolemia would cause all of the following symptoms EXCEPT

A. hypertension
B. oliguria
C. tachycardia
D. tachypnea
15. Maria Sison, 40 years old, single, was admitted to the hospital with a diagnosis of Breast
Cancer. She was scheduled for radical mastectomy. Nursing care during the preoperative period
should consist of

A. assuring Maria that she will be cured of cancer

B. assessing Marias expectations and doubts
C. maintaining a cheerful and optimistic environment
D. keeping Marias visitors to a minimum so she can have time for herself

16. Maria refuses to acknowledge that her breast was removed. She believes that her breast is
intact under the dressing. The nurse should

C. Flushing of the lids, conjunctiva and cornea with tap or preferably sterile water
D. cleansing the conjunctiva with a small cotton-tipped applicator
32. The Heimlich maneuver (abdominal thrust), for acute airway obstruction, attempts to:

A. call the MD to change the dressing so Kathy can see the incision
B. recognize that Kathy is experiencing denial, a normal stage of the grieving process
C. reinforce Kathys belief for several days until her body can adjust to stress of surgery.
D. remind Kathy that she needs to accept her diagnosis so that she can begin rehabilitation
exercises.
17. A chemotherapeutic agent 5FU is ordered as an adjunct measure to surgery. Which of the ff.
statements about chemotherapy is true?

A. it is a local treatment affecting only tumor cells

B. it affects both normal and tumor cells
C. it has been proven as a complete cure for cancer
D. it is often used as a palliative measure.
18. Which is an incorrect statement pertaining to the following procedures for cancer
diagnostics?

A. Biopsy is the removal of suspicious tissue and the only definitive method to diagnose cancer
B. Ultrasonography detects tissue density changes difficult to observe by X-ray via sound waves.
C. CT scanning uses magnetic fields and radio frequencies to provide cross-sectional view of
tumor
D. Endoscopy provides direct view of a body cavity to detect abnormality.
19. A post-operative complication of mastectomy is lymphedema. This can be prevented by

A. ensuring patency of wound drainage tube

B. placing the arm on the affected side in a dependent position
C. restricting movement of the affected arm
D. frequently elevating the arm of the affected side above the level of the heart.
20. Which statement by the client indicates to the nurse that the patient understands precautions
necessary during internal radiation therapy for cancer of the cervix?

A. I should get out of bed and walk around in my room.

B. My 7 year old twins should not come to visit me while Im receiving treatment.
C. I will try not to cough, because the force might make me expel the application.
D. I know that my primary nurse has to wear one of those badges like the people in the x-ray
department, but they are not necessary for anyone else who comes in here.
21. High uric acid levels may develop in clients who are receiving chemotherapy. This is caused
by:

A. Force air out of the lungs

B. Increase systemic circulation
C. Induce emptying of the stomach
D. Put pressure on the apex of the heart
33. John, 16 years old, is brought to the ER after a vehicular accident. He is pronounced dead on
arrival. When his parents arrive at the hospital, the nurse should:

A. ask them to stay in the waiting area until she can spend time alone with them
B. speak to both parents together and encourage them to support each other and express their
emotions freely
C. Speak to one parent at a time so that each can ventilate feelings of loss without upsetting the
other
D. ask the MD to medicate the parents so they can stay calm to deal with their sons death.
34. An emergency treatment for an acute asthmatic attack is Adrenaline 1:1000 given
hypodermically. This is given to:

A. increase BP
B. decrease mucosal swelling
C. relax the bronchial smooth muscle
D. decrease bronchial secretions
35. A nurse is performing CPR on an adult patient. When performing chest compressions, the
nurse understands the correct hand placement is located over the

A. upper half of the sternum

B. upper third of the sternum
C. lower half of the sternum
D. lower third of the sternum
36. The nurse is performing an eye examination on an elderly client. The client states My vision
is blurred, and I dont easily see clearly when I get into a dark room. The nurse best response is:

A. You should be grateful you are not blind.

B. As one ages, visual changes are noted as part of degenerative changes. This is normal.
C. You should rest your eyes frequently.
D. You maybe able to improve you vision if you move slowly.
37. Which of the following activities is not encouraged in a patient after an eye surgery?

A. The inability of the kidneys to excrete the drug metabolites

B. Rapid cell catabolism
C. Toxic effect of the antibiotic that are given concurrently
D. The altered blood ph from the acid medium of the drugs

22. Which of the following interventions would be included in the care of plan in a client with
cervical implant?

A. Frequent ambulation
B. Unlimited visitors
C. Low residue diet
D. Vaginal irrigation every shift

A. sneezing, coughing and blowing the nose

B. straining to have a bowel movement
C. wearing tight shirt collars
D. sexual intercourse
38. Which of the following indicates poor practice in communicating with a hearing-impaired
client?

A. Use appropriate hand motions

B. Keep hands and other objects away from your mouth when talking to the client
C. Speak clearly in a loud voice or shout to be heard
D. Converse in a quiet room with minimal distractions
39. A client is to undergo lumbar puncture. Which is least important information about LP?

23. Which nursing measure would avoid constriction on the affected arm immediately after
mastectomy?

A. Avoid BP measurement and constricting clothing on the affected arm

B. Active range of motion exercises of the arms once a day.
C. Discourage feeding, washing or combing with the affected arm
D. Place the affected arm in a dependent position, below the level of the heart
24. A client suffering from acute renal failure has an unexpected increase in urinary output to
150ml/hr. The nurse assesses that the client has entered the second phase of acute renal failure.
Nursing actions throughout this phase include observation for signs and symptoms of

A. Hypervolemia, hypokalemia, and hypernatremia.

B. Hypervolemia, hyperkalemia, and hypernatremia.
C. Hypovolemia, wide fluctuations in serum sodium and potassium levels.
D. Hypovolemia, no fluctuation in serum sodium and potassium levels.
25. An adult has just been brought in by ambulance after a motor vehicle accident. When
assessing the client, the nurse would expect which of the following manifestations could have
resulted from sympathetic nervous system stimulation?

A. Specimens obtained should be labeled in their proper sequence.

B. It may be used to inject air, dye or drugs into the spinal canal.
C. Assess movements and sensation in the lower extremities after the
D. Force fluids before and after the procedure.
40. A client diagnosed with cerebral thrombosis is scheduled for cerebral angiography. Nursing
care of the client includes the following EXCEPT

A. Inform the client that a warm, flushed feeling and a salty taste may be
B. Maintain pressure dressing over the site of puncture and check for
C. Check pulse, color and temperature of the extremity distal to the site of
D. Kept the extremity used as puncture site flexed to prevent bleeding.
41. Which is considered as the earliest sign of increased ICP that the nurse should closely
observed for?
A. abnormal respiratory pattern
B. rising systolic and widening pulse pressure
C. contralateral hemiparesis and ipsilateral dilation of the pupils
D. progression from restlessness to confusion and disorientation to lethargy
42. Which is irrelevant in the pharmacologic management of a client with CVA?

A. A rapid pulse and increased RR

B. Decreased physiologic functioning
C. Rigid posture and altered perceptual focus
D. Increased awareness and attention
26. Ms. Sy undergoes surgery and the abdominal aortic aneurysm is resected and replaced with
a graft. When she arrives in the RR she is still in shock. The nurses priority should be :

A. Osmotic diuretics and corticosteroids are given to decrease cerebral edema

B. Anticonvulsants are given to prevent seizures
C. Thrombolytics are most useful within three hours of an occlusive CVA
D. Aspirin is used in the acute management of a completed stroke.
43. What would be the MOST therapeutic nursing action when a clients expressive aphasia is
severe?

A. placing her in a trendeleburg position

B. putting several warm blankets on her
C. monitoring her hourly urine output
D. assessing her VS especially her RR

27. A major goal for the client during the first 48 hours after a severe bum is to prevent
hypovolemic shock. The best indicator of adequate fluid balance during this period is

A. Elevated hematocrit levels.

B. Urine output of 30 to 50 ml/hr.
C. Change in level of consciousness.
D. Estimate of fluid loss through the burn eschar.
28. A thoracentesis is performed on a chest-injured client, and no fluid or air is found. Blood and
fluids is administered intravenously (IV), but the clients vital signs do not improve. A central
venous pressure line is inserted, and the initial reading is 20 cm H^O. The most likely cause of
these findings is which of the following?

A. Spontaneous pneumothorax
B. Ruptured diaphragm
C. Hemothorax
D. Pericardial tamponade
29. Intervention for a pt. who has swallowed a Muriatic Acid includes all of the following except;

A. administering an irritant that will stimulate vomiting

B. aspirating secretions from the pharynx if respirations are affected
C. neutralizing the chemical
D. washing the esophagus with large volumes of water via gastric lavage
30. Which initial nursing assessment finding would best indicate that a client has been
successfully resuscitated after a cardio-respiratory arrest?

A. Skin warm and dry

B. Pupils equal and react to light
C. Palpable carotid pulse
D. Positive Babinskis reflex
31. Chemical burn of the eye are treated with

A. local anesthetics and antibacterial drops for 24 36 hrs.

B. hot compresses applied at 15-minute intervals

A. Anticipate the client wishes so she will not need to talk

B. Communicate by means of questions that can be answered by the client shaking the head
C. Keep us a steady flow rank to minimize silence
D. Encourage the client to speak at every possible opportunity.
44. A client with head injury is confused, drowsy and has unequal pupils. Which of the following
nursing diagnosis is most important at this time?
A. altered level of cognitive function
B. high risk for injury
C. altered cerebral tissue perfusion
D. sensory perceptual alteration
45. Which nursing diagnosis is of the highest priority when caring for a client with myasthenia
gravis?

A. Pain
B. High risk for injury related to muscle weakness
C. Ineffective coping related to illness
D. Ineffective airway clearance related to muscle weakness
46. The client has clear drainage from the nose and ears after a head injury. How can the nurse
determine if the drainage is CSF?

A. Measure the ph of the fluid

B. Measure the specific gravity of the fluid
C. Test for glucose
D. Test for chlorides
47. The nurse includes the important measures for stump care in the teaching plan for a client
with an amputation. Which measure would be excluded from the teaching plan?

A. Wash, dry, and inspect the stump daily.

B. Treat superficial abrasions and blisters promptly.
C. Apply a "shrinker" bandage with tighter arms around the proximal end of the affected limb.
D. Toughen the stump by pushing it against a progressively harder substance (e.g., pillow on a
foot-stool).
48. A 70-year-old female comes to the clinic for a routine checkup. She is 5 feet 4 inches tall and
weighs 180 pounds. Her major complaint is pain in her joints. She is retired and has had to give
up her volunteer work because of her discomfort. She was told her diagnosis was osteoarthritis
about 5 years ago. Which would be excluded from the clinical pathway for this client?
A. Decrease the calorie count of her daily diet.
B. Take warm baths when arising.
C. Slide items across the floor rather than lift them.
D. Place items so that it is necessary to bend or stretch to reach them.

49. A client is admitted from the emergency department with severe-pain and edema in the right
foot. His diagnosis is gouty arthritis. When developing a plan of care, which action would have the
highest priority?

A. Apply hot compresses to the affected joints.

B. Stress the importance of maintaining good posture to prevent deformities.
C. Administer salicylates to minimize the inflammatory reaction.
D. Ensure an intake of at least 3000 ml of fluid per day.

ANSWER KEY
RATIONALE
FLUID, ELECTROLYTE, AND ACID-BASE PROBLEMS
1. ANSWER B The nursing assistant can reinforce additional fluild intake once it is part of the
care plan. Administering IV fluids, developing plans, and teaching families require additional
education and skills that are within the scope of practice for the RN.
2. ANSWER A Normally, neck veins are distended when the client is in the supine position. The
veins flatten as the client moves to a sitting position. The other three responses are characteristic
of Excess Fluid Volume.
3. ANSWER A, B, C, D - The LPN/LVNs scope of practice and educational preparation includes
oral care and routine observation. State practice acts vary as to whether LPN/LVNs are permitted
to perform assessment. The client should be reminded to avoid most commercial mouthwashes
that contain alcohol, a drying agent. Initiating a dietary consult is within the purview of the RN or
physician.
4. ANSWER D Bilateral moist crackles indicate fluid-filled alveoli, which interferes with gas
exchange. Furosemide is a potent loop diuretic that will help mobilize the fluid in the lungs. The
other orders are important but not urgent.
5. ANSWER B Suspect hypokalemia and check the clients potassium level. Common ECG
changes with hypokalemia include ST depression, inverted T waves, and prominent U waves.
Client with hypokalemia may also develop heart block.
6. ANSWER A The clients potassium level is high (normal range 3.5-5.0). Kayexalate removes
potassium from the body through the gastrointestinal system. Spironolactone is a potassiumsparing diuretic that may cause the clients potassium level to go even higher. The nursing
student may not have the skill to assess ECG strips and this should be done by the RN.
7. ANSWER C - SIADH causes a relative sodium deficit due to excessive retention of water.
8. ANSWER A Providing oral care is within the scope of practice for the nursing assistant.
Monitoring and assessing clients, as well as administering IV fluids, require the additional
education and skill of the RN.
9. ANSWER B A positive Chvosteks sign (facial twitching of one side of the mouth, nose, and
cheek in response to tapping the face just below and in front of the ear) is a neurologic
manifestation of hypocalcemia. The LPN/LVN is experienced and possesses the skills to take
accurate vital signs.
10. ANSWER D Clients with low calcium levels should be encouraged to consume dairy
products, seafood, nuts, broccoli, and spinach. Which are all good sources of dietary calcium.
11. ANSWER C A musculoskeletal manifestation of low phosphorous is generalized muscle
weakness that may lead to acute muscle breakdown (rhabdomyolysis). Even though the other
statements are true, they do not answer the nursing assistants question.
12. ANSWER D While all of these laboratory values are outside of the normal range, the
magnesium is most outside of normal. With a magnesium level this low, the client is at risk for
ECG changes and life-threatening ventricular dysrhythmias.
13. ANSWER B The client with COPD, although ventilator dependent, is the most stable of this
group. Clients with acid-base imbalances often require frequent laboratory assessment and
changes in therapy to correct their disorders. In addition, the client with DKA is a new admission
and will require an in-depth admission assessment. All three of these clients need care from an
experienced critical care nurse.
14. ANSWER A the blood gas component responsible for respiratory acidosis is CO2 (Carbon
dioxide). Increasing the ventilator rate will blow off more CO2 and decrease the acidosis.
Changes in the oxygen setting may improve oxygenation but will not affect respiratory acidosis.
15. ANSWER B, C The nursing assistants training and education include how to take vital
signs and record intake and output. The need to take vital signs this frequently indicates that the
client maybe unstable. The nurse should give the nursing assistant reporting parameters when
delegating this action, should also check the vital signs for indications in instability. Performing
fingerstick glucose checks and assessing clients require additional education and skill that are
appropriate to licensed nurses. Some facilities may train experienced nursing assistants to
perform fingerstick glucose checks and change their role descriptions to designate their new
skills, but this is beyond the normal scope of practice for a nursing assistant.

16. ANSWER D Risk factors for acid-base imbalances in the older adult include chronic renal
disease and pulmonary disease. Occasional antacid use will not cause imbalances, although
antacid abuse is a risk factor for metabolic alkalosis.

17. ANSWER A A decreased respiratory rate indicates respiratory depression which also puts
the client at risk for respiratory acidosis, All of the other findings are important and should be
reported to the RN, but the respiratory rate is urgent.

18. ANSWER B The client is most likely hyperventilating and blowing off CO2. This decrease in
CO2 will lead to an increase in pH, causing respiratory alkalosis. Respiratory acidosis results
from respiratory depression and retained CO2. Metabolic acidosis and alkalosis result from
problems related to renal acid-base control.
19. ANSWER A Prolonged nausea and vomiting can result in acid deficit that can lead to
metabolic alkalosis. The other findings are important and need to be assessed but are not related
to acid-base imbalances.

20. ANSWER B Nasogastric suctioning can result in a decrease in acid components and
metabolic alkalosis. The clients increase in rate and depth of ventilation is an attempt to
compensate by blowing off CO2. the first response maybe true but does not address all the
components of the question. The third and fourth answers are inaccurate.
1.
Answer: (A) Hyponatremia
The normal serum sodium level is 135 145 mEq/L. The clients serum sodium is below normal.
Hyponatremia also manifests itself with abdominal cramps and nausea and vomiting
2.
Answer: (B) Decreased serum calcium, blood pH 7.2, potassium 6.5 mEq/L
Chronic renal failure is usually the end result of gradual tissue destruction and loss of renal
function. With the loss of renal function, the kidneys ability to regulate fluid and electrolyte and
acid base balance results. The serum Ca decreases as the kidneys fail to excrete phosphate,
potassium and hydrogen ions are retained.
3.
Answer: (B) Avoid taking blood pressure measurements or blood samples from the
affected arm.
In the client with an external shunt, dont use the arm with the vascular access site to take blood
pressure readings, draw blood, insert IV lines, or give injections because these procedures may
rupture the shunt or occlude blood flow causing damage and obstructions in the shunt.
4.
Answer: (D) He will be pain free.
Surgical interventions involve an experience of pain for the client which can come in varying
degrees. Telling the pain that he will be pain free is giving him false reassurance.
5.
Answer: (C) right lower quadrant
To be exact, the appendix is anatomically located at the Mc Burneys point at the right iliac area of
the right lower quadrant.
6.
Answer: (A) telling him to avoid heavy lifting for 4 to 6 weeks
The client should avoid lifting heavy objects and any strenuous activity for 4-6 weeks after
surgery to prevent stress on the inguinal area. There is no special diet required. The fluid intake
of eight glasses a day is good advice but is not a priority in this case.
7.
Answer: (C) 31%
Using the Rule of Nine in the estimation of total body surface burned, we allot the following: 9%
head; 9% each upper extremity; 18%- front chest and abdomen; 18% entire back; 18%
each lower extremity and 1% perineum.
8.
Answer: (D) Fluid shift from intravascular space to the interstitial space
This period is the burn shock stage or the hypovolemic phase. Tissue injury causes vasodilation
that results in increase capillary permeability making fluids shift from the intravascular to the
interstitial space. This can lead to a decrease in circulating blood volume or hypovolemia which
decreases renal perfusion and urine output.
9.
Answer: (C) Frequently observing for hoarseness, stridor, and dyspnea
Burns located in the upper torso, especially resulting from thermal injury related to fires can lead
to inhalation burns. This causes swelling of the respiratory mucosa and blistering which can lead
to airway obstruction manifested by hoarseness, noisy and difficult breathing. Maintaining a
patent airway is a primary concern.
10. Answer: (D) Helping the client to rest in the position of maximal comfort
Mobility and placing the burned areas in their functional position can help prevent contracture
deformities related to burns. Pain can immobilize a client as he seeks the position where he finds
less pain and provides maximal comfort. But this approach can lead to contracture deformities
and other complications.
11. Answer: (D) fluid and electrolyte monitoring
Total parenteral nutrition is a method of providing nutrients to the body by an IV route. The
admixture is made up of proteins, carbohydrates, fats, electrolytes, vitamins, trace minerals and
sterile water based on individual client needs. It is intended to improve the clients nutritional

50. A client had a laminectomy and spinal fusion yesterday. Which statement is to be excluded
from your plan of care?

A. Before log rolling, place a pillow under the clients head and a pillow between the clients legs.
B. Before log rolling, remove the pillow from under the clients head and use no pillows between
the clients legs.
C. Keep the knees slightly flexed while the client is lying in a semi-Fowlers position in bed.
D. Keep a pillow under the clients head as needed for comfort.

status. Because of its composition, it is important to monitor the clients fluid intake and output
including electrolytes, blood glucose and weight.
12. Answer: (D) Aluminum hydroxide
Aluminum hydroxide binds dietary phosphorus in the GI tract and helps treat hyperphosphatemia.
All the other medications mentioned help treat hyperkalemia and its effects.
13. Answer: (A) 0.45% NaCl
Hypotonic solutions like 0.45% NaCl has a lower tonicity that the blood; 0.9% NaCl and D5W are
isotonic solutions with same tonicity as the blood; and D5NSS is hypertonic with a higher tonicity
thab the blood.
14. Answer: (A) hypertension
In hypovolemia, one of the compenasatory mechanisms is activation of the sympathetic nervous
system that increases the RR & PR and helps restore the BP to maintain tissue perfusion but not
cause a hypertension. The SNS stimulation constricts renal arterioles that increases release of
aldosterone, decreases glomerular filtration and increases sodium & water reabsorption that
leads to oliguria.
15. Answer: (B) assessing Marias expectations and doubts
Assessing the clients expectations and doubts will help lessen her fears and anxieties. The nurse
needs to encourage the client to verbalize and to listen and correctly provide explanations when
needed.
16. Answer: (B) recognize that Kathy is experiencing denial, a normal stage of the
grieving process
A person grieves to a loss of a significant object. The initial stage in the grieving process is denial,
then anger, followed by bargaining, depression and last acceptance. The nurse should show
acceptance of the patients feelings and encourage verbalization.
17. Answer: (B) it affects both normal and tumor cells
Chemotherapeutic agents are given to destroy the actively proliferating cancer cells. But these
agents cannot differentiate the abnormal actively proliferating cancer cells from those that are
actively proliferating normal cells like the cells of the bone marrow, thus the effect of bone marrow
depression.
18. Answer: (C) CTscanning uses magnetic fields and radio frequencies to provide
cross-sectional view of tumor
CT scan uses narrow beam x-ray to provide cross-sectional view. MRI uses magnetic fields and
radio frequencies to detect tumors.
19. Answer: (D) frequently elevating the arm of the affected side above the level of the
heart.
Elevating the arm above the level of the heart promotes good venous return to the heart and
good lymphatic drainage thus preventing swelling.
20. Answer: (B) My 7 year old twins should not come to visit me while Im receiving
treatment.
Children have cells that are normally actively dividing in the process of growth. Radiation acts not
only against the abnormally actively dividing cells of cancer but also on the normally dividing cells
thus affecting the growth and development of the child and even causing cancer itself.
21. Answer: (B) Rapid cell catabolism
One of the oncologic emergencies, the tumor lysis syndrome, is caused by the rapid destruction
of large number of tumor cells. . Intracellular contents are released, including potassium and
purines, into the bloodstream faster than the body can eliminate them. The purines are converted
in the liver to uric acid and released into the blood causing hyperuricemia. They can precipitate in
the kidneys and block the tubules causing acute renal failure.
22. Answer: (C) Low residue diet
It is important for the nurse to remember that the implant be kept intact in the cervix during
therapy. Mobility and vaginal irrigations are not done. A low residue diet will prevent bowel
movement that could lead to dislodgement of the implant. Patient is also strictly isolated to protect
other people from the radiation emissions
23. Answer: (A) Avoid BP measurement and constricting clothing on the affected arm
A BP cuff constricts the blood vessels where it is applied. BP measurements should be done on
the unaffected arm to ensure adequate circulation and venous and lymph drainage in the affected
arm
24. Answer: (C) Hypovolemia, wide fluctuations in serum sodium and potassium levels.
The second phase of ARF is the diuretic phase or high output phase. The diuresis can result in
an output of up to 10L/day of dilute urine. Loss of fluids and electrolytes occur.
25. Answer: (A) A rapid pulse and increased RR
The fight or flight reaction of the sympathetic nervous system occurs during stress like in a motor
vehicular accident. This is manifested by increased in cardiovascular function and RR to provide
the immediate needs of the body for survival.
26. Answer: (D) assessing her VS especially her RR
Shock is characterized by reduced tissue and organ perfusion and eventual organ dysfunction
and failure. Checking on the VS especially the RR, which detects need for oxygenation, is a
priority to help detect its progress and provide for prompt management before the occurrence of
complications.
27. Answer: (B) Urine output of 30 to 50 ml/hr.
Hypovolemia is a decreased in circulatory volume. This causes a decrease in tissue perfusion to
the different organs of the body. Measuring the hourly urine output is the most quantifiable way of
measuring tissue perfusion to the organs. Normal renal perfusion should produce 1ml/kg of
BW/min. An output of 30-50 ml/hr is considered adequate and indicates good fluid balance.
28. Answer: (D) Pericardial tamponade
Pericardial tamponade occurs when there is presence of fluid accumulation in the pericardial
space that compresses on the ventricles causing a decrease in ventricular filling and stretching
during diastole with a decrease in cardiac output. . This leads to right atrial and venous
congestion manifested by a CVP reading above normal.
29. Answer: (A) administering an irritant that will stimulate vomiting
Swallowing of corrosive substances causes severe irritation and tissue destruction of the mucous
membrane of the GI tract. Measures are taken to immediately remove the toxin or reduce its
absorption. For corrosive poison ingestion, such as in muriatic acid where burn or perforation of
the mucosa may occur, gastric emptying procedure is immediately instituted, This includes gastric
lavage and the administration of activated charcoal to absorb the poison. Administering an irritant
with the concomitant vomiting to remove the swallowed poison will further cause irritation and
damage to the mucosal lining of the digestive tract. Vomiting is only indicated when non-corrosive
poison is swallowed.
30. Answer: (C) Palpable carotid pulse
Presence of a palpable carotid pulse indicates the return of cardiac function which, together with
the return of breathing, is the primary goal of CPR. Pulsations in arteries indicates blood flowing
in the blood vessels with each cardiac contraction. Signs of effective tissue perfusion will be
noted after.
31. Answer: (C) Flushing of the lids, conjunctiva and cornea with tap or preferably sterile
water
Prompt treatment of ocular chemical burns is important to prevent further damage. Immediate
tap-water eye irrigation should be started on site even before transporting the patient to the
nearest hospital facility. In the hospital, copious irrigation with normal saline, instillation of local
anesthetic and antibiotic is done.
32. Answer: (A) Force air out of the lungs
The Heimlich maneuver is used to assist a person choking on a foreign object. The pressure from
the thrusts lifts the diaphragm, forces air out of the lungs and creates an artificial cough that
expels the aspirated material.
33. Answer: (B) speak to both parents together and encourage them to support each
other and express their emotions freely
Sudden death of a family member creates a state of shock on the family. They go into a stage of
denial and anger in their grieving. Assisting them with information they need to know, answering
their questions and listening to them will provide the needed support for them to move on and be
of support to one another.
34. Answer: (C) relax the bronchial smooth muscle
Acute asthmatic attack is characterized by severe bronchospasm which can be relieved by the
immediate administration of bronchodilators. Adrenaline or Epinephrine is an adrenergic agent
that causes bronchial dilation by relaxing the bronchial smooth muscles.
35. Answer: (C) lower half of the sternum
The exact and safe location to do cardiac compression is the lower half of the sternum. Doing it at
the lower third of the sternum may cause gastric compression which can lead to a possible
aspiration.
36. Answer: (B) As one ages, visual changes are noted as part of degenerative changes.
This is normal.
Aging causes less elasticity of the lens affecting accommodation leading to blurred vision. The
muscles of the iris increase in stiffness and the pupils dilate slowly and less completely so that it
takes the older person to adjust when going to and from light and dark environment and needs
brighter light for close vision.
37. Answer: (D) sexual intercourse
To reduce increases in IOP, teach the client and family about activity restrictions. Sexual
intercourse can cause a sudden rise in IOP.
38. Answer: (C) Speak clearly in a loud voice or shout to be heard
Shouting raises the frequency of the sound and often makes understanding the spoken words
difficult. It is enough for the nurse to speak clearly and slowly.
39. Answer: (D) Force fluids before and after the procedure.
LP involves the removal of some amount of spinal fluid. To facilitate CSF production, the client is
instructed to increase fluid intake to 3L, unless contraindicated, for 24 to 48 hrs after the
procedure.
40. Answer: (D) Kept the extremity used as puncture site flexed to prevent bleeding.
Angiography involves the threading of a catheter through an artery which can cause trauma to
the endothelial lining of the blood vessel. The platelets are attracted to the area causing thrombi
formation. This is further enhanced by the slowing of blood flow caused by flexion of the affected
extremity. The affected extremity must be kept straight and immobilized during the duration of the
bedrest after the procedure. Ice bag can be applied intermittently to the puncture site.

41. Answer: (D) progression from restlessness to confusion and disorientation to

lethargy
The first major effect of increasing ICP is a decrease in cerebral perfusion causing hypoxia that
produces a progressive alteration in the LOC. This is initially manifested by restlessness.
42. Answer: (D) Aspirin is used in the acute management of a completed stroke.
The primary goal in the management of CVA is to improve cerebral tissue perfusion. Aspirin is a
platelet deaggregator used in the prevention of recurrent or embolic stroke but is not used in the
acute management of a completed stroke as it may lead to bleeding.
43. Answer: (D) Encourage the client to speak at every possible opportunity.
Expressive or motor aphasia is a result of damage in the Brocas area of the frontal lobe. It is
amotor speech problem in which the client generally understands what is said but is unable to
communicate verbally. The patient can best he helped therefore by encouraging him to
communicate and reinforce this behavior positively.
44. Answer: (C) altered cerebral tissue perfusion
The observations made by the nurse clearly indicate a problem of decrease cerebral perfusion.
Restoring cerebral perfusion is most important to maintain cerebral functioning and prevent
further brain damage.
45. Answer: (D) Ineffective airway clearance related to muscle weakness
Myasthenia gravis causes a failure in the transmission of nerve impulses at the neuromuscular
junction which may be due to a weakening or decrease in acetylcholine receptor sites. This leads
to sporadic, progressive weakness or abnormal fatigability of striated muscles that eventually
causes loss of function. The respiratory muscles can become weak with decreased tidal volume
and vital capacity making breathing and clearing the airway through coughing difficult. The
respiratory muscle weakness may be severe enough to require and emergency airway and
mechanical ventilation.

1. You are reviewing the complete blood count (CBC)

for a client who has been admitted for knee
arthroscopy. Which value is most important to report
to the physician prior to surgery?
a. White blood cell count 16,000/mm3
b. Hematocrit 33%
c. Platelet count 426,000/ mm3
d. Hemoglobin 10.9 g/dL
2. A new RN is preparing to administer packed red
blood cells (PRBCs) to a client whose anemia was
caused by blood loss after surgery. Which action by
the new RN requires that you, as charge nurse,
intervene immediately?
a. The new RN waits 20 minutes after obtaining the
PRBCs before starting the infusion.
b. The new RN starts an intravenous line for the
transfusion using a 22-gauge catheter.
c. The new RN primes the transfusion set using 5%
dextrose in lactated Ringers solution.
d. The new RN tells the client that the PRBCs may
cause a serious transfusion reaction.
3. A 32-year-old client with a history of sickle cell
anemia is admitted to the hospital during a sickle
cell crisis. The physician orders all of these
interventions. Which order will you implement first?
a. Give morphine sulfate 4-8 mg IV every hour as
needed.
b. Start a large-gauge IV line and infuse normal
saline at 200 mL/hour.
c. Immunize with Pneumovax and Haemophilus
influenzae vaccines.
d. Administer oxygen at an F102 of 100% per nonrebreather mask.
4. A 78-year-old client admitted to the hospital with
chronic anemia caused by possible gastrointestinal
bleeding has all of these activities included in the
care plan. Which activity is best delegated to an
experienced nursing assistant (NA)?
a. Use Hemoccult slides to obtain stool specimens.
b. Have the client sign a colonoscopy consent form.
c. Administer PEG-ES (GoLYTELY) bowel preparation.
d. Check for allergies to contrast dye or shellfish.
5. As charge nurse, you are making the daily
assignments on the medical-surgical unit. Which
client is best assigned to a nurse who has floated
from the post-anesthesia care unit (PACU)?
a. A 30-year-old client with thalassemia major who
has an order for subcutaneous infusion of
deferoxamine (Desferal)
b. A 43-year-old client with multiple myeloma who
needs discharge teaching
c. A 52-year-old client with chronic gastrointestinal
bleeding who has returned to the unit after a
colonoscopy
d. A 65-year-old client with pernicious anemia who
has just been admitted to the unit
6. You are making a room assignment for a newly
arrived client whose laboratory testing indicates
pancytopenia. All of these clients are already on the
nursing unit. Which one will be the best roommate
for the new client?
a. The client with digoxin toxicity
b. The client with viral pneumonia

46. Answer: (C) Test for glucose

The CSF contains a large amount of glucose which can be detected by using glucostix. A positive
result with the drainage indicate CSF leakage.
47. Answer: (C) Apply a "shrinker" bandage with tighter arms around the proximal end of
the affected limb.
The shrinker bandage is applied to prevent swelling of the stump. It should be applied with the
distal end with the tighter arms. Applying the tighter arms at the proximal end will impair
circulation and cause swelling by reducing venous flow.
48. Answer: (D) Place items so that it is necessary to bend or stretch to reach them.
Patients with osteoarthritis have decreased mobility caused by joint pain. Over-reaching and
stretching to get an object are to be avoided as this can cause more pain and can even lead to
falls. The nurse should see to it therefore that objects are within easy reach of the patient.
49. Answer: (D) Ensure an intake of at least 3000 ml of fluid per day.
Gouty arthritis is a metabolic disease marked by urate deposits that cause painful arthritic joints.
The patient should be urged to increase his fluid intake to prevent the development of urinary uric
acid stones.
50. Answer: (B) Before log rolling, remove the pillow from under the clients head and
use no pillows between the clients legs.
Following a laminectomy and spinal fusion, it is important that the back of the patient be
maintained in straight alignment and to support the entire vertebral column to promote complete
healing.

c. The client with shingles

d. The client with cellulitis
7. A client admitted to the hospital with a sickle cell
crisis complains of severe abdominal, hip, and knee
pain. You observe an LPN accomplishing these client
care tasks. Which one requires that you, as charge
nurse, intervene immediately?
a. The LPN encourages the client to use the ordered
PCA.
b. The LPN positions cold packs on the clients
knees.
c. The LPN places a No Visitors sign on the clients
door.
d. The LPN checks the clients temperature every 2
hours.
8. A 67-year-old client who is receiving
chemotherapy for lung cancer is admitted to the
hospital with thrombocytopenia. While you are
taking the admission history, the client makes these
statements. Which statement is of most concern?
a. Ive noticed that I bruise more easily since the
chemotherapy started.
b. My bowel movements are soft and dark brown in
color.
c. I take one aspirin every morning because of my
history of angina.
d. My appetite has decreased since the
chemotherapy strated.
9. Following a car accident, a client with a MedicAlert bracelet indicating hemophilia A is admitted to
the emergency department (ED). Which physician
order should you implement first?
a. Transport to radiology for C-spine x-rays.
b. Transfuse Factor VII concentrate.
c. Type and cross-match for 4 units RBCs.
d. Infuse normal saline at 250 mL/hour.
10.As home health nurse, you are taking an
admission history for a client who has a deep vein
thrombosis and is taking warfarin (Coumadin) 2 mg
daily. Which statement by the client is the best
indicator that additional teaching about warfarin
may be needed?
a. I have started to eat more healthy foods like
green salads and fruit.
b. The doctor said that it is important to avoid
becoming constipated.
c. Coumadin makes me feel a little nauseated
unless I take it with food.
d. I will need to have some blood testing done once
or twice a week.
11.A client is admitted to the intensive car unit (ICU)
with disseminated intravascular coagulation (DIC)
associated with a gram-negative infection. Which
assessment information has the most immediate
implications for the clients care?
a. There is no palpable radial or pedal pulse.
b. The client complains of chest pain.
c. The clients oxygen saturation is 87%
d. There is mottling of the hands and feet.
12.A 22-year-old with stage I Hodgkins disease is
admitted to the oncology unit for radiation therapy.
During the initial assessment, the client tells you,

Sometimes I am afraid of dying. Which response is

most appropriate at this time?
a. Many individuals with this diagnosis have some
fears.
b. Perhaps you should ask the doctor about
medication.
c. Tell me a little bit more about your fear of
dying.
d. Most people with stage I Hodgkins disease
survive.
13.After receiving change-of-shift report about all of
these clients, which one will you assess first?
a. A 26-year-old with thalassemia major who has a
short-stay admission for a blood transfusion
b. A 44-year-old who was admitted 3 days previously
with a sickle cell crisis and has orders for a CT scan
c. A 50-year-old with newly diagnosed stage IV nonHodgskins lymphoma who is crying and stating Im
not ready to die.
d. A 69-year-old with chemotherapy-induced
neutropenia who has an elevated oral temperature
14.A long-term-care client with chronic lymphocytic
leukemia has a nursing diagnosis of Activity
Intolerance related to weakness and anemia. Which
of these nursing activities is most appropriate for
you, as the charge nurse, to delegate to a nursing
assistant?
a. Evaluate the clients response to normal activities
of daily living.
b. Check the clients blood pressure and pulse rate
after ambulation.
c. Determine which self-care activities the client can
do independently.
d. Assist the client in choosing a diet that will
improve strength.
15.A transfusion of PRBCs has been infusing for 5
minutes when the client becomes flushed and
tachypneic and says, I am having chills. Please get
me a blanket. Which action should you take first?
a. Obtain a warm blanket for the client.
b. Check the clients oral temperature.
c. Stop the medication.
d. Administer oxygen.
16.A group of clients is assigned to an RN-LPN/LVN
team. The LPN/LVN is most likely to be assigned to
provide client care and administer medications to
which of these clients?
a. A 36-year-old client with chronic renal failure who
will need a subcutaneous injection of epoetin
(Procrit)
b. A 39-year-old client with hemophilia B who has
been admitted for a blood transfusion
c. A 50-year-old client with newly diagnosed
polycythemia vera who is scheduled for
phlebotomy
d. A 55-year-old client with a history of stem cell
transplantation who will have a bone marrow
aspiration
17.You obtain the following data about a client
admitted with multiple myeloma. Which information
has the most immediate implications for the clients
care?
a. The client complains of chronic bone pain.
b. The blood uric acid level is very elevated.
c. The 240hour urine shows Bence-Jones protein.
d. The client is unable to plantarflex the feet.
18.The nurse in the outpatient clinic is assessing a
22-year-old with a history of a recent splenectomy
after a motor vehicle accident. Which information
obtained during the assessment will be of most
immediate concern to the nurse?
a. The client engages in unprotected sex.
b. The client has an oral temperature of 99.7o F
c. The client has abdominal pain with light
palpation.
d. The client admits to occasional marijuana use.
19.A client with graft-versus-host disease (GVHD)
after a bone marrow transplant is being cared for on
the medical unit. Which of these nursing activities is
best delegated to a newly graduated RN who has
had a 6-week orientation to the unit?

a. Administration of methotrexate and cyclosporine

to the client
b. Assessment of the client for signs of infection
caused by GVHD
c. Infusion of D5.45% normal saline at 125 mL/hour
to the client
d. Education of the client about ways to prevent
infection
20.You are the charge nurse in an oncology unit. A
client with an absolute neutrophil count (ANC) of
300/mm3 is placed in protective isolation. Which
staff member should you assign to provide care for
this client, under the supervision of an experienced
oncology RN?
a. An LPN who has floated from the same-daysurgery unit
b. An RN from the float pool who usually works on
the surgical unit
c. An LPN with 2 years of experience on the oncology
unit
d. An RN who transferred recently from the ED
21.You are transferring a client with newly diagnosed
chronic myeloid leukemia to a long-term-care (LTC)
facility. Which information is most important to the
LTC charge nurse prior to transferring the client?
a. The Philadelphia chromosome is present in the
blood smear
b. Glucose is elevated as a result of prednisone
therapy
c. There has been a 20-pound weight loss over the
past year
d. The clients chemotherapy has resulted in
neutropenia
22.A client with acute myelogenous leukemia is
receiving induction phase chemotherapy. Which
assessment information is of most concern?
a. Serum potassium level of 7.8 mEq/L
b. Urine output less than intake by 400 mL
c. Inflammation and redness of oral mucosa
d. Ecchymoses present on anterior trunk
23.A client who has been receiving cyclosporine
following an organ transplant is experiencing these
symptoms. Which one is of most concern?
a. Bleeding of the gums while brushing the teeth
b. Non-tender swelling in the right groin
c. Occasional nausea after taking the medication
d. Numbness and tingling of the feet
24.You have developed the nursing diagnosis Risk
for Impaired Tissue Integrity related to effects of
radiation for a client with Hodgkins lymphoma who
is receiving radiation to the groin area. Which
nursing activity is best delegated to a nursing
assistant caring for the client?
a. Check the skin for signs of redness or peeling.
b. Apply alcohol-free lotion to the area after
cleaning.
c. Explain good skin care to the client and family.
d. Clean the skin over daily with a mild soap.
25.After receiving the change-of-shift report, which
client will you assess first?
a. A 20-year-old with possible acute myelogenous
leukemia who has just arrived on the medical unit
b. A 38-year-old with aplastic anemia who needs
teaching about decreasing infection risk prior to
discharge
c. A 40-year-old with lymphedema who requests help
to put on compression stockings before getting out
of bed
d. A 60-year-old with non-Hodgkins lymphoma who
is refusing the ordered chemotherapy regimen
1. The nurse is preparing to teach a client with
microcytic hypochromic anemia about the diet
to follow after discharge. Which of the
following foods should be included in the diet?
a. Eggs
b. Lettuce
c. Citrus fruits
d. Cheese
2. The nurse would instruct the client to eat
which of the following foods to obtain the best
supply of vitamin B12?

a. Whole grains
b. Green leafy vegetables
c. Meats and dairy products
d. Broccoli and Brussels sprouts
3. The nurse has just admitted a 35-year-old
female client who has a serum B12
concentration of 800 pg/ml. Which of the
following laboratory findings would cue the
nurse to focus the client history on specific
drug or alcohol abuse?
a. Total bilirubin, 0.3 mg/dL
b. Serum creatinine, 0.5 mg/dL
c. Hemoglobin, 16 g/dL
d. Folate, 1.5 ng/mL
4. The nurse understands that the client with
pernicious anemia will have which
distinguishing laboratory findings?
a. Schillings test, elevated
b. Intrinsic factor, absent.
c. Sedimentation rate, 16 mm/hour
d. RBCs 5.0 million
5. The nurse devises a teaching plan for the
patient with aplastic anemia. Which of the
following is the most important concept to
teach for health maintenance?
a. Eat animal protein and dark leafy vegetables each day
b. Avoid exposure to others with acute infection
c. Practice yoga and meditation to decrease stress and
anxiety
d. Get 8 hours of sleep at night and take naps during the
day
6. A client comes into the health clinic 3 years
after undergoing a resection of the terminal
ileum complaining of weakness, shortness of
breath, and a sore tongue. Which client
statement indicates a need for intervention
and client teaching?
a. I have been drinking plenty of fluids.
b. I have been gargling with warm salt water for my sore
tongue.
c. I have 3 to 4 loose stools per day.
d. I take a vitamin B12 tablet every day.
7. A vegetarian client was referred to a
dietician for nutritional counseling for anemia.
Which client outcome indicates that the client
does not understand nutritional counseling?
The client:
a. Adds dried fruit to cereal and baked goods
b. Cooks tomato-based foods in iron pots
c. Drinks coffee or tea with meals
d. Adds vitamin C to all meals
8. A client was admitted with iron deficiency
anemia and blood-streaked emesis. Which
question is most appropriate for the nurse to
ask in determining the extent of the clients
activity intolerance?
a. What activities were you able to do 6 months ago
compared with the present?
b. How long have you had this problem?
c. Have you been able to keep up with all your usual
activities?
d. Are you more tired now than you used to be?
9. The primary purpose of the Schilling test is
to measure the clients ability to:
a. Store vitamin B12
b. Digest vitamin B12
c. Absorb vitamin B12
d. Produce vitamin B12
10. The nurse implements which of the
following for the client who is starting a
Schilling test?
a. Administering methylcellulose (Citrucel)
b. Starting a 24- to 48 hour urine specimen collection
c. Maintaining NPO status
d. Starting a 72 hour stool specimen collection
11. A client with pernicious anemia asks why
she must take vitamin B12 injections for the
rest of her life. What is the nurses best
response?
a. The reason for your vitamin deficiency is an inability to
absorb the vitamin because the stomach is not producing
sufficient acid.
b. The reason for your vitamin deficiency is an inability to
absorb the vitamin because the stomach is not producing
sufficient intrinsic factor.

c. The reason for your vitamin deficiency is an excessive

excretion of the vitamin because of kidney dysfunction.
d. The reason for your vitamin deficiency is an increased
requirement for the vitamin because of rapid red blood cell
production.
12. The nurse is assessing a clients activity
intolerance by having the client walk on a
treadmill for 5 minutes. Which of the following
indicates an abnormal response?
a. Pulse rate increased by 20 bpm immediately after the
activity
b. Respiratory rate decreased by 5 breaths/minute
c. Diastolic blood pressure increased by 7 mm Hg
d. Pulse rate within 6 bpm of resting phase after 3 minutes
of rest.
13. When comparing the hematocrit levels of a
post-op client, the nurse notes that the
hematocrit decreased from 36% to 34% on the
third day even though the RBC and
hemoglobin values remained stable at 4.5
million and 11.9 g/dL, respectively. Which
nursing intervention is most appropriate?
a. Check the dressing and drains for frank bleeding
b. Call the physician
c. Continue to monitor vital signs
d. Start oxygen at 2L/min per NC
14. A client is to receive epoetin (Epogen)
injections. What laboratory value should the
nurse assess before giving the injection?
a. Hematocrit
b. Partial thromboplastin time
c. Hemoglobin concentration
d. Prothrombin time
15. A client states that she is afraid of
receiving vitamin B12 injections because of
the potential toxic reactions. What is the
nurses best response to relieve these fears?
a. Vitamin B12 will cause ringing in the eats before a toxic
level is reached.
b. Vitamin B12 may cause a very mild skin rash initially.
c. Vitamin B12 may cause mild nausea but nothing toxic.
d. Vitamin B12 is generally free of toxicity because it is
water soluble.
16. A client with microcytic anemia is having
trouble selecting food items from the hospital
menu. Which food is best for the nurse to
suggest for satisfying the clients nutritional
needs and personal preferences?
a. Egg yolks
b. Brown rice
c. Vegetables
d. Tea
17. A client with macrocytic anemia has a burn
on her foot and states that she had been
watching television while lying on a heating
pad. What is the nurses first response?
a. Assess for potential abuse
b. Check for diminished sensations
c. Document the findings
d. Clean and dress the area
18. Which of the following nursing
assessments is a late symptom of
polycythemia vera?
a. Headache
b. Dizziness
c. Pruritus
d. Shortness of breath
19. The nurse is teaching a client with
polycythemia vera about potential
complications from this disease. Which
manifestations would the nurse include in the
clients teaching plan? Select all that apply.
a. Hearing loss
b. Visual disturbance
c. Headache
d. Orthopnea
e. Gout
f. Weight loss
20. When a client is diagnosed with aplastic
anemia, the nurse monitors for changes in
which of the following physiological functions?
a. Bleeding tendencies
b. Intake and output
c. Peripheral sensation
d. Bowel function

ANSWER KEY
1. ANSWER A An elevation in white blood cells may
indicate that the client has an infection, which would
likely require rescheduling of the surgical procedure. The
other values are slightly abnormal, but would not be likely
to cause post-operative problems for a knee arthroscopy.
Focus: Prioritization
2. ANSWER C Normal saline, an isotonic solution,
should be used when priming the IV line to avoid causing
hemolysis of RBCs. Ideally, blood products should be
infused as soon as possible after they are obtained;
however, a 20-minute delay would not be unsafe. Largegauge IV catheters are preferable for blood
administration; if a smaller catheter must be used, normal
saline may be used to dilute the RBCs. Although it is
appropriate to instruct clients to notify the nurse if
symptoms of a transfusion reaction such as shortness of
breath or chest pain occur, it will cause unnecessary
anxiety to indicate that a serious reaction is likely to
occur. Focus: Prioritization
3. ANSWER D Hypoxia and deoxygenation of the red
blood cells are the most common cause of sickling, so
administration of oxygen is the priority intervention here.
Pain control and hydration are also important
interventions for this client and should be accomplished
rapidly. Vaccination may help prevent future sickling
episodes by decreasing the risk of infection, but it will not
help with the current sickling crisis. Focus: Prioritization
4. ANSWER A An experienced nursing assistant would
have been taught how to obtain a stool specimen for the
Hematoccult slide test, because this is a common
screening test for hospitalized clients. Having the client
sign an informed consent should be done by the
physician who will be doing the colonoscopy.
Administration of medications and checking for allergies
are within the scope of practice for licensed nursing staff.
Focus: Delegation
5. ANSWER C A nurse who works in the PACU will be
familiar with the monitoring needed for a client who has
just returned from a procedure like a colonoscopy, which
requires conscious sedation. The other clients require
more experience with various types of hematologic
disorders and would be better to assign to nursing staff
who regularly work on the medical
surgical unit. Focus: Prioritization
6. ANSWER A Clients with pancytopenia are at higher
risk for infection. The client with digoxin toxicity presents
the least risk of infecting the new client. Viral pneumonia,
shingles, and cellulites are infectious processes. Focus:
Prioritization
7. ANSWER B The joint pain that occurs in sickle cell
crisis is caused by obstruction to blood flow by the
sickled red blood cells. The appropriate therapy for this
client would be application of moist heat to the joints to
cause vasodilation and improve circulation. Because
control of pain is a priority during sickle cell crisis, there is
no need to restrict all visitors or to check the temperature
every 2 hours. Focus: Prioritization
8. ANSWER C Because aspiring will decrease platelet
aggregation, clients with thrombocytopenia should not
use aspirin routinely. Client teaching about his should be
included in the care plan. Bruising is consistent with the
clients admission problem of thrombocytopenia. Soft,
dark brown stools indicate that there is no frank blood in
the bowel movements. A decrease in appetite is common
with chemotherapy, and more assessment is indicated.
Focus: Prioritization

Prioritization
11. ANSWER C Because the decrease in oxygen
saturation will have the greatest immediate effect on all
body systems, improvement in oxygenation should be
the priority goal of care. The other data also indicate the
need for rapid intervention, but improvement of
oxygenation is the most urgent need. Focus:
Prioritization
12. ANSWER C Most assessment about what the client
means is needed before any interventions can be
planned or implemented. All of the other statements
indicate a conclusion that the client is afraid of dying of
Hodgkins disease. Focus: Prioritization
13. ANSWER D Any temperature elevation in a
neutropenic client may indicate the presence of a lifethreatening infection, so actions such as blood cultures
and antibiotic administration should be initiated quickly.
The other clients need to e assessed as soon as
possible, but are not critically ill. Focus: Prioritization
14. ANSWER B Nursing assistant education include
routine nursing skills such as assessment of vital signs.
Evaluation, baseline assessment of client abilities, and
nutrition planning are roles appropriate to RN practice.
15. ANSWER C The clients symptoms indicate that a
transfusion reaction may be occurring so the first action
should be to stop the transfusion. Chills are an indication
of a febrile reaction, so warming the client is not
appropriate. Checking the clients temperature and
administration of oxygen are also appropriate actions if a
transfusion reaction is suspected; however, stopping the
transfusion is the priority. Focus: Prioritization
16. ANSWER A Subcutaneous administration of
epoetin is within the LPN/LVN scope of practice. The
other clients require skills (blood transfusion and client
teaching about phlebotomy and bone marrow aspiration)
that are more appropriate to RN-level practice. Focus:
Assignment
17. ANSWER D The lack of plantar flexion may indicate
spinal cord compression, which should be evaluated and
treated immediately by the physician to prevent further
loss of function. While chronic bone pain, hyperuricemia,
and the presence of Bence-Jones protein in the urine all
are typical Focus: Prioritization
18. ANSWER B Because the spleen has an important
role in the phagocytosis of microorganisms, the client is
at higher risk for severe infection after a splenectomy.
Medical therapy, such as antibiotic administration, is
usually indicated for any symptoms of infection. The
other information also indicates the need for more
assessment and intervention, but prevention and
treatment of infection are the highest priorities for this
client. Focus: Prioritization
19. ANSWER C Infusion of IV fluids is indicated in RN
education, and the new RN would also have had
experience with this as part of an orientation to the
medical unit. Administration of potent
immunosuppressive medications, assessment for subtle
indications of infection, and client teaching are more
complex tasks that should be delegated to more
experienced RN staff members. Focus:Delegation

9. ANSWER B When a hemophiliac client is at high risk

for bleeding, for example, after a motor vehicle accident,
the priority intervention is to maximize the availability of
clotting factors. The other orders also should be
implemented rapidly, but do not have as high a priority.
Focus: Prioritization

20. ANSWER C Because many aspects of nursing care

need to be modified to prevent infection when a client
has a low ANC, care should be provided by the staff
member with the most experience with neutropenic
clients. The other staff members have the education
required to care for this client, but are not as clinically
experienced. When making acute care client
assignments for LPN staff members, they must work
under the supervision of an RN. The LPN in this case
would report to the RN assigned to the client. Focus:
Assignment

10. ANSWER A Clients taking warfarin are advised to

avoid making sudden diet changes, because changing
the oral intake of foods high in vitamin K (such as green
leafy vegetables and some fruits) will have an impact on
the effectiveness of the medication. The other statements
suggest that further teaching may be indicated, but more
assessment for teaching needs is indicated first. Focus:

21. ANSWER D The neutropenic client is at increased

risk for infection, so the LTC charge nurse needs to know
this in order to make decisions about the client room
assignment and to plan care. The other information also
will impact on planning for client care, but the charge
nurse needs the information about neutropenia before
the client is transferred. Focus: Prioritization

22. ANSWER A Fatal hyperkalemia may be caused by

tumor lysis syndrome, a potentially serious consequence
of chemotherapy in acute leukemia. The other symptoms
also indicate a need for further assessment or
intervention, but are not as critical as the elevated
potassium level. Focus: Prioritization
23. ANSWER B A non-tender swelling in this area (or
near any lymph node) may indicate that he client has
developed lymphoma, a possible adverse effect of
immunosuppressive therapy. The client should receive
further evaluation immediately. The other symptoms may
also indicate side effects of cyclosporine (gingival
hyperplasia, nausea, paresthesia) but do not indicate the
need for immediate action. Focus: Prioritization
24. ANSWER D Skin care is included in nursing
assistant education and job description. Assessment and
client teaching are more complex tasks that should be
delegated to registered nurses. Use of lotions to the
irradiated area is usually avoided during radiation
therapy. Focus: Delegation
25. ANSWER A The newly admitted client should be
assessed first, because the baseline assessment and
plan of care need to be completed. The other clients also
need assessments or interventions, but do not need
immediate nursing care. Focus: Prioritization
1. ANSWER A. One of the microcytic, hypochromic
anemias is iron-deficiency amenia. A rich source of iron is
needed in the diet, and eggs are high in iron. Other foods
high in iron include organ and muscle (dark) meats;
shellfish, shrimp, and tuna; enriched, whole-grain, and
fortified cereals and breads; legumes, nuts, dried fruits,
and beans; oatmeal; and sweet potatoes. Dark green
leafy vegetables and citrus fruits are good sources of
vitamin C. Cheese is a good source of calcium.
2. ANSWER C. Good sources of vitamin B12 include
meats and dairy products. Whole grains are a good
source of thiamine. Green leafy vegetables are good
sources of niacin, folate, and carotenoids (precursors of
vitamin A). Broccoli and Brussels sprouts are good
sources of ascorbic acid (vitamin C).
3. ANSWER D. The normal range of folic acid is 1.8 to 9
ng/mL, and the normal range of vitamin B12 is 200 to
900 pg/mL. A low folic acid level in the presence of a
normal vitamin B12 level is indicative of a primary folic
acid-deficiency anemia. Factors that affect the absorption
of folic acid are drugs such as methotrexate, oral
contraceptives, antiseizure drugs, and alcohol. The total
bilirubin, serum creatinine, and hemoglobin values are
within normal limits.
4. ANSWER B. The defining characteristic of pernicious
anemia, a megaloblastic anemia, is lack of the intrinsic
factor, which results from atrophy of the stomach wall.
Without the intrinsic factor, vitamin B12 cannot be
absorbed in the small intestines, and folic acid needs
vitamin B12 for DNA synthesis of RBCs. The gastric
analysis was done to determine the primary cause of the
anemia. An elevated excretion of the injected radioactive
vitamin B12, which is protocol for the first and second
stage of the Schilling test, indicates that the client has the
intrinsic factor and can absorb vitamin B12 into the
intestinal tract. A sedimentation rate of 16 mm/hour is
normal for both men and women and is a nonspecific test
to detect the presence of inflammation. It is not specific
to anemias. An RBC value of 5.0 million is a normal value
for both men and women and does not indicate anemia.
5. ANSWER B. Clients with aplastic anemia are severely
immunocompromised and at risk for infection and
possible death related to bone marrow suppression and
pancytopenia. Strict aseptic technique and reverse
isolation are important measures to prevent infection.
Although diet, reduced stress, and rest are valued in
supporting health, the potentially fatal consequence of an
acute infection places it as a priority for teaching the
client about health maintenance. Animal meat and dark
green leafy vegetables, good sources of vitamin B12
andfolic acid, should be included in the daily diet. Yoga
and meditation are good complimentary therapies to
reduce stress. Eight hours of rest and naps are good for
spacing and pacing activity and rest.
6. ANSWER D. Vitamin B12 combines with intrinsic
factor in the stomach and is then carried to the ileum,
where it is absorbed in the bloodstream. In this situation,
vitamin B12 cannot be absorbed regardless of the
amount of oral intake of sources of vitamin B12 such as
animal protein or vitamin B12 tablets. Vitamin B12 needw

to be injected every month, because the ileum has been

surgically removed. Replacement of fluids and
electrolytes is important when the client has continuous
multiple loose stools on a daily basis. Warm salt water is
used to soothe sore mucous membranes. Crohns
disease and small bowel resection may cause several
loose stools a day.
7. ANSWER C. Coffee and tea increase gastrointestinal
mobility and inhibit the absorption of nonheme iron.
Clients are instructed to add dried fruits to dishes at
every meal because dried fruits are a nonheme or
nonanimal iron source. Cooking in iron cookware,
especially acid-based foods such as tomatoes, adds iron
to the diet. Clients are instructed to add a rich supply of
vitamin C to every meal because the absorption of iron is
increased when food with vitamin C or ascorbic acid is
consumed.
8. ANSWER A. It is difficult to determine activity
intolerance without objectively comparing activities from
one time frame to another. Because iron deficiency
anemia can occur gradually and individual endurance
varies, the nurse can best assess the clients activity
tolerance by asking the client to compare activities 6
months ago and at the present. Asking a client how long
a problem has existed is a very open-ended question that
allows for too much subjectivity for any definition of the
clients activity tolerance. Also, the client may not even
identify that a problem exists. Asking the client whether
he is staying abreast of usual activities addresses
whether the tasks were completed, not the tolerance of
the client while the tasks were beingcompleted or the
resulting condition of the client after the tasks
were completed. Asking the client if he is more tired now
than usual does not address his activity tolerance.
Tiredness is a subjective evaluation and again can be
distorted by factors such as the gradual onset of the
anemia or the endurance of the individual.
9. ANSWER C. Pernicious anemia is caused by the
bodys inability to absorb vitamin B12. This results in a
lack of intrinsic factor in the gastric juices. Schillings test
helps diagnose pernicious anemia by determining the
clients ability to absorb vitamin B12.
10. ANSWER B. Urinary vitamin B12 levels are
measured after the ingestion of radioactive vitamin B12.
A 24-to 48- hour urine specimen is collected after
administration of an oral dose of radioactively tagged
vitamin B12 and an injection of nonradioactive vitamin
B12. In a healthy state of absorption, excess vitamin B12
is excreted in the urine; in a malabsorption state or when
the intrinsic factor is missing, vitamin B12 is excreted in
the feces. Citrucel is a bulk-forming agent. Laxatives
interfere with the absorption of vitamin B12. The client is
NPO 8 to 12 hours before the test but is not NPO during
the test. A stool collection is not part of the Schilling test.
If stool contaminates the urine collection, the results will
be altered.
11. ANSWER B. Most clients with pernicious anemia
have deficient production of intrinsic factor in the
stomach. Intrinsic factor attaches to the vitamin in the
stomach and forms a complex that allows the vitamin to
be absorbed in the small intestine. The stomach is
producing enough acid, there is not an excessive
excretion of the vitamin, and there is not a rapid
production of RBCs in this condition.
12. ANSWER B. The normal physiologic response to
activity is an increased metabolic rate over the resting
basal rate. The decrease in respiratory rate indicates that
the client is not strong enough to complete the
mechanical cycle of respiration needed for gas
exchange. The postactivity pulse is expected to increase
immediately after activity but by no more than 50 bpm if it
is strenuous activity. The diastolic blood pressure is
expected to rise but by no more than 15 mm Hg. The
pulse returns to within 6 bpm of the resting pulse after 3
minutes of rest.
13. ANSWER C. The nurse should continue to monitor
the client, because this value reflects a normal
physiologic response. The physician does not need to be
called, and oxygen does not need to be started based on
these laboratory findings. Immediately after surgery, the
clients hematocrit reflects a falsely high value related to
the bodys compensatory response to the stress of
sudden loss of fluids and blood. Activation of the intrinsic
pathway and the renin-angiotensin cycle via antidiuretic
hormone produces vasoconstriction and retention of fluid
for the first 1 to 2 day post-op. By the second to third day,
this response decreases and the clients hematocrit level
is more reflective of the amount of RBCs in the plasma.
Fresh bleeding is a less likely occurrence on the third
post-op day but is not impossible; however, the nurse

would have expected to see a decrease in the RBC and

hemoglobin values accompanying the hematocrit.
14. ANSWER A. Epogen is a recombinant DNA form of
erythropoietin, which stimulates the production of RBCs
and therefore causes the hematocrit to rise. The
elevation in hematocrit causes an elevation in blood
pressure; therefore, the blood pressure is a vital sign that
should be checked. The PTT, hemoglobin level, and PT
are not monitored for this drug.
15. ANSWER D. Vitamin B12 is a water-soluble vitamin.
When water-soluble vitamins are taken in excess of the
bodys needs, they are filtered through the kidneys and
excreted. Vitamin B12 is considered to be nontoxic.
Adverse reactions that have occurred are believed to be
related to impurities or to the preservative in B12
preparations. Ringing in the ears, skin rash, and nausea
are not considered to be related to vitamin B12
administration.
16. ANSWER B. Brown rice is a source of iron from plant
sources (nonheme iron). Other sources of nonheme iron
are whole-grain cereals and breads, dark green
vegetables, legumes, nuts, dried fruits (apricots, raisins,
dates), oatmeal, and sweet potatoes. Egg yolks have iron
but it is not as well absorbed as iron from other sources.
Vegetables are a good source of vitamins that may
facilitate iron absorption. Tea contains tannin, which
combines with nonheme iron, preventing its absorption.
17. ANSWER B. Macrocytic anemias can result from
deficiencies in vitamin B12 or ascorbic acid. Only vitamin
B12 deficiency causes diminished sensations of
peripheral nerve endings. The nurse should assess for
peripheral neuropathy and instruct the client in self-care
activities for her diminished sensation to heat and pain.

The burn could be related to abuse, but this conclusion

would require more supporting data. The findings should
be documented, but the nurse would want to address the
clients sensations first. The decision of how to treat the
burn should be determined by the physician.
18. ANSWER C. Pruritus is a late symptom that results
from abnormal histamine metabolism. Headache and
dizziness are early symptoms from engorged veins.
Shortness of breath is an early symptom from congested
mucous membrane and ineffective gas exchange.
19. ANSWERS B, C, D and E. Polycythemia vera, a
condition in which too many RBCs are produced in the
blood serum, can lead to an increase in the hematocrit
and hypervolemia, hyperviscosity, and hypertension.
Subsequently, the client can experience dizziness,
tinnitus, visual disturbances, headaches, or a feeling of
fullness in the head. The client may also experience
cardiovascular symptoms such as heart failure
(shortness of breath and orthopnea) and increased
clotting time or symptoms of an increased uric acid level
such as painful swollen joints (usually the big toe).
Hearing loss and weight loss are not manifestations
associated with polycythemia vera.
20. ANSWER A. Aplastic anemia decreases the bone
marrow production of RBCs, WBCs, and platelets. The
client is at risk for bruising and bleeding tendencies. A
change in the intake and output is important, but
assessment for the potential for bleeding takes priority.
Change in the peripheral nervous system is a priority
problem specific to clients with vitamin B12 deficiency.
Change in bowel function is not associated with aplastic
anemia.