Ramon Carlo T. Almiranez, RN, RM, USRN
Encourage coughing and deep breathing
Respiratory System Disorders
1. Miriam, a college student with acute rhinitis sees the
campus nurse because of excessive nasal drainage. The
nurse asks the patient about the color of the drainage.
In acute rhinitis, nasal drainage normally is:
a. Yellow
b. Green
c. Clear
d. Gray
Answer C. Normally, nasal drainage in acute rhinitis is
clear. Yellow or green drainage indicates spread of the
infection to the sinuses. Gray drainage may indicate a
secondary infection.
2. On auscultation, which finding suggests a right
pneumothorax?
a. Bilateral inspiratory and expiratory crackles
b. Absence of breaths sound in the right thorax
c. Inspiratory wheezes in the right thorax
d. Bilateral pleural friction rub.
Answer B. In pneumothorax, the alveoli are deflated and
no air exchange occurs in the lungs. Therefore, breath
sounds in the affected lung field are absent. None of the
other options are associated with pneumothorax.
Bilateral crackles may result from pulmonary
congestion, inspiratory wheezes may signal asthma, and
a pleural friction rub may indicate pleural inflammation.
3. A male patient is admitted to the health care facility
for treatment of chronic obstructive pulmonary disease.
Which nursing diagnosis is most important for this
patient?
a. Activity intolerance related to fatigue
b. Anxiety related to actual threat to health status
c. Risk for infection related to retained secretions
d. Impaired gas exchange related to airflow obstruction
Answer D. A patient airway and an adequate breathing
pattern are the top priority for any patient, making
“impaired gas exchange related to airflow obstruction”
the most important nursing diagnosis. The other options
also may apply to this patient but less important.
4. Nurse Ruth assessing a patient for tracheal
displacement should know that the trachea will deviate
toward the:
a. Contralateral side in a simple pneumothorax
b. Affected side in a hemothorax
c. Affected side in a tension pneumothorax
d. Contralateral side in hemothorax
Answer D. The trachea will shift according to the
pressure gradients within the thoracic cavity. In tension
pneumothorax and hemothorax, accumulation of air or
fluid causes a shift away from the injured side. If there is
no significant air or fluid accumulation, the trachea will
not shift. Tracheal deviation toward the contralateral
side in simple pneumothorax is seen when the thoracic
contents shift in response to the release of normal
thoracic pressure gradients on the injured side.
5. After undergoing a left pneumonectomy, a female
patient has a chest tube in place for drainage. When
caring for this patient, the nurse must:
a. Monitor fluctuations in the water-seal chamber
b. Clamp the chest tube once every shift
c.
d. Milk the chest tube every 2 hours
Answer C. When caring for a patient who is recovering
from a pneumonectomy, the nurse should encourage
coughing and deep breathing to prevent pneumonia in
the unaffected lung. Because the lung has been
removed, the water-seal chamber should display no
fluctuations. Reinflation is not the purpose of chest
tube. Chest tube milking is controversial and should be
done only to remove blood clots that obstruct the flow
of drainage.
6. A male patient has a sucking stab wound to the chest.
Which action should the nurse take first?
a. Drawing blood for a hematocrit and hemoglobin level
b. Applying a dressing over the wound and taping it on
three sides
c. Preparing a chest tube insertion tray
d. Preparing to start an I.V. line
Answer B. The nurse immediately should apply a
dressing over the stab wound and tape it on three sides
to allow air to escape and to prevent tension
pneumothorax (which is more life-threatening than an
open chest wound). Only after covering and taping the
wound should the nurse draw blood for laboratory tests,
assist with chest tube insertion, and start an I.V. line.
7. For a female patient with chronic obstructive
pulmonary disease, which nursing intervention would
help maintain a patent airway?
a. Restricting fluid intake to 1,000 ml per day
b. Enforcing absolute bed rest
c. Teaching the patient how to perform controlled
coughing
d. Administering prescribe sedatives regularly and in
large amounts
Answer C. Controlled coughing helps maintain a patent
airway by helping to mobilize and remove secretions. A
moderate fluid intake (usually 2 L or more daily) and
moderate activity help liquefy and mobilize secretions.
Bed rest and sedatives may limit the patient’s ability to
maintain a patent airway, causing a high risk for
infection from pooled secretions.
8. Nurse Lei caring for a client with a pneumothorax and
who has had a chest tube inserted notes continues
gentle bubbling in the suction control chamber. What
action is appropriate?
a. Do nothing, because this is an expected finding
b. Immediately clamp the chest tube and notify the
physician
c. Check for an air leak because the bubbling should be
intermittent
d. Increase the suction pressure so that the bubbling
becomes vigorous
Answer A. Continuous gentle bubbling should be noted
in the suction control chamber. Option b is incorrect.
Chest tubes should only be clamped to check for an air
leak or when changing drainage devices (according to
agency policy). Option c is incorrect. Bubbling should be
continuous and not intermittent. Option d is incorrect
because bubbling should be gentle. Increasing the
suction pressure only increases the rate of evaporation
of water in the drainage system.
9. An emergency room nurse is assessing a male client
who has sustained a blunt injury to the chest wall.
Which of these signs would indicate the presence of a
pneumothorax in this client?
a. A low respiratory rate
b. Diminished breath sounds
c. The presence of a barrel chest
d. A sucking sound at the site of injury
Answer B. This client has sustained a blunt or a closed
chest injury. Basic symptoms of a closed pneumothorax
are shortness of breath and chest pain. A larger
pneumothorax may cause tachypnea, cyanosis,
diminished breath sounds, and subcutaneous
emphysema. Hyperresonance also may occur on the
affected side. A sucking sound at the site of injury would
be noted with an open chest injury.
10. Blessy, a community health nurse is conducting an
educational session with community members regarding
tuberculosis. The nurse tells the group that one of the
first symptoms associated with tuberculosis is:
a. Dyspnea
b. Chest pain
c. A bloody, productive cough
d. A cough with the expectoration of mucoid sputum
Answer D. One of the first pulmonary symptoms is a
slight cough with the expectoration of mucoid sputum.
Options A, B, and C are late symptoms and signify
cavitation and extensive lung involvement.
11. A 79-year-old female client is admitted to the hos-
pital with a diagnosis of bacterial pneumonia.
While obtaining the client's health history, the nurse
learns that the client has osteoarthritis, follows a
vegetarian diet, and is very concerned with cleanliness.
Which of the following would most likely be a
predisposing factor for the diagnosis of pneumonia?
a. Age.
b. Osteoarthritis.
c. Vegetarian diet.
d. Daily bathing.
Answer: A. The client's age is a predisposing factor for
pneumonia; pneumonia is more common in elderly or
debilitated clients. Other predisposing factors include
smoking, upper respiratory tract infections, malnutri-
tion, immunosuppression, and the presence of a chronic
illness. Osteoarthritis, a nutritionally sound vegetarian
diet, and frequent bathing are not predisposing factors
for pneumonia.
12. A client with bacterial pneumonia is to be started on
intravenous antibiotics. Which of the
following diagnostic tests must be completed before
antibiotic therapy begins?
a. Urinalysis.
b. Sputum culture.
c. Chest radiograph.
d. Red blood cell count.
Answer: B. A sputum specimen is obtained for culture to
determine the causative organism. After the organism is
identified, an appropriate antibiotic can be prescribed.
Beginning antibiotic therapy before obtaining the
sputum specimen may alter the results of the test.
Neither a urinalysis, a chest radiograph, nor a red blood
cell count needs to be obtained before initiation of an-
tibiotic therapy for pneumonia.
13. The cyanosis that accompanies bacterial pneu-
monia is primarily caused by which of the
following?
a. Decreased cardiac output.
b. Pleural effusion. '
c. Inadequate peripheral circulation.
d. Decreased oxygenation of the blood.
Answer: D. A client with pneumonia has less lung surface
available for the diffusion of gases because of the in-
flammatory pulmonary response that creates lung exu-
date and results in reduced oxygenation of the blood.
The client becomes cyanotic because blood is not ade-
quately oxygenated in the lungs before it enters the pe-
ripheral circulation. Decreased cardiac output may be a
comorbid condition in some clients with pneumonia;
however, it is not the cause of cyanosis. Pleural effusions
are a potential complication of pneumonia but are not
the primary cause of decreased oxygenation. Inadequate
peripheral circulation is also not the cause of the
cyanosis that develops with bacterial pneumonia.
14. A client with pneumonia is experiencing pleuritic
chest pain. Which of the following describes pleuritic
chest pain?
a. A mild but constant aching in the chest.
b. Severe midsternal pain.
c. Moderate pain that worsens on inspiration.
d. Muscle spasm pain that accompanies coughing.
Answer: C. Chest pain in pneumonia is generally caused
by friction between the pleural layers. It is more severe
on inspiration than on expiration, secondary to chest
wall movement. Pleuritic chest pain is usually described
as sharp, not mild or aching. Pleuritic chest pain is not
localized to the sternum, and it is not the result of a
muscle spasm.
15. A client with pneumonia has a temperature ranging
between 101° and 102°F (38.3° and 38.8°C) and periods
of diaphoresis. Based on this information, which of the
following nursing interventions would be a priority?
a. Maintain complete bed rest.
b. Administer oxygen therapy.
c. Provide frequent linen changes.
d. Provide fluid intake of 3 L/day.
Answer: D. A fluid intake of at least 3 L/day should be
provided to replace any fluid loss occurring as a result of
the fever and diaphoresis; this is a high-priority inter-
vention. Although clients with pneumonia may be pre-
scribed bed rest, complete bed rest is not necessary
solely because of the elevated temperature. Administra-
tion of oxygen therapy also is not indicated for the pur-
poses of treating the fever. Frequent linen changes is an
appropriate intervention, but it is not of the highest
priority among the options given.
16. Which of the following mental status changes may
occur when a client with pneumonia is first
experiencing hypoxia?
a. Coma.
b. Apathy.
c. Irritability.
d. Depression.
Answer: C. Clients who are experiencing hypoxia charac-
teristically exhibit irritability, restlessness, or anxiety as
initial mental status changes. As the hypoxia becomes
more pronounced, the client may become confused and
combative. Coma is a late clinical manifestation of
hypoxia. Apathy and depression are not symptoms of
hypoxia.
17. Which of the following symptoms is common in
clients with active tuberculosis?
a. Weight loss.
b. Increased appetite.
c. Dyspnea on exertion.
d. Mental status changes.
Answer: A. Tuberculosis typically produces anorexia and
weight loss. Other signs and symptoms may include fa-
tigue, low-grade fever, and night sweats. Increased ap-
petite is not a symptom of tuberculosis; dyspnea on
exertion and change in mental status are not common
symptoms of tuberculosis.
18. The nurse obtains a sputum specimen from a client
with suspected tuberculosis for laboratory
study. Which of the following laboratory techniques is
most commonly used to identify tubercle bacilli in
sputum?
a. Acid-fast staining.
b. Sensitivity testing.
c. Agglutination testing.
d. Dark-field illumination.
Answer: A. The most commonly used technique to
identify tubercle bacilli is acid-fast staining. The bacilli
have a waxy surface, which makes them difficult to stain
in the laboratory. However, once they are stained, the
stain is resistant to removal, even with acids. Therefore,
tubercle bacilli are often called acid-fast bacilli.
Sensitivity testing, agglutination testing, arid dark-field
illumination are not used to identify tubercle bacilli.
19. Which of the following antituberculosis drugs can
cause damage to the eighth cranial nerve?
a. Streptomycin.
b. Isoniazid (INH).
c. Para-aminosalicylic acid (PAS).
d. [Ethambutol hydrochloride (Myambutol).
Answer: A. Streptomycin is an aminoglycoside, and
eighth cranial nerve damage (ototoxicity) is a common
side effect of aminoglycosides. A common side effect of
INH is peripheral neuritis. A common side effect of PAS is
gastrointestinal disturbance. A common side effect of
ethambutol hydrochloride (Myambutol) is optic neuritis.
20. The client who experiences eighth cranial nerve
damage will most likely report which of the following
symptoms?
a. Vertigo.
b. Facial paralysis.
c. Impaired vision.
d. Difficulty swallowing.
Answer: A. The eighth cranial nerve is the vestibulo-
cochlear nerve, which is responsible for hearing and
equilibrium. Streptomycin can damage this nerve (oto-
toxicity). Symptoms of ototoxicity include vertigo, tin-
nitus, hearing loss, and ataxia. Facial paralysis would
result from damage to the facial nerve (VII). Impaired
vision would result from damage to the optic (II), ocu-
lomotor (III), or the trochlear (IV) nerves. Difficulty
swallowing would result from damage to the glos-
sopharyngeal (IX) or the vagus (X) nerve.
21. INH treatment is associated with the development
of peripheral neuropathies. Which of the following
interventions would the nurse teach the client to help
prevent this complication?
a. Adhere to a low-cholesterol diet.
b. Supplement the diet with
pyridoxine (vitamin B).
c. Get extra rest.
d. Avoid excessive sun exposure.
Answer: B. INH competes for the available vitamin B 6 in
the body and leaves the client at risk for development of
neuropathies related to vitamin deficiency. Supple-
mental vitamin B6 is routinely prescribed. Following a
low-cholesterol diet, getting extra rest, and avoiding ex-
cessive sun exposure will not prevent the development
of peripheral neuropathies.
22. The nurse should include which of the following
instructions when developing a teaching plan for clients
who are receiving INH and rifampin for treatment of
tuberculosis?
a. Take the medications with antacids.
b. Double the dosage if a drug dose is forgotten.
c. Increase intake of dairy products.
d. Limit alcohol intake.
Answer: D. INH and rifampin are hepatotoxic drugs.
Clients should be warned to limit intake of alcohol
during drug therapy. Both drugs should be taken on an
empty stomach. If antacids are needed for gastroin-
testinal distress, they should be taken 1 hour before or 2
hours after these drug are administered. Clients should
not double the dosage of these drugs because of their
potential toxicity. Clients taking INH should avoid foods
that are rich in tyramine, such as cheese and dairy
products, or they may develop hypertension.
23. Which of the following physical assessment find-
ings would the nurse expect to find in a client with ad-
vanced COPD?
a. Increased anteroposterior chest diameter.
b. Underdeveloped neck muscles.
c. Collapsed neck veins.
d. Increased chest excursions with respiration.
Answer: A. Increased anteroposterior chest diameter is
characteristic of advanced COPD. Air is trapped in the
overextended alveoli, and the ribs are fixed in an inspi-
ratory position. The result is the typical barrel-chested
appearance. Overly developed, not underdeveloped,
neck muscles are associated with COPD because of their
increased use in the work of breathing. Distended, not
collapsed, neck veins are associated with COPD as a
symptom of the heart failure that the client may expe-
rience secondary to the increased workload on the
heart to pump blood into the pulmonary vasculature.
Diminished, not increased, chest excursion is associated
with COPD.
24. When instructing clients on how to decrease the risk
of COPD, the nurse should emphasize which of the
following behaviors?
a. Participate regularly in aerobic exercises.
b. Maintain a high-protein diet.
c. Avoid exposure to people with known,
respiratory infections.
d. Abstain from cigarette smoking.
Answer: D. Cigarette smoking is the primary cause of
COPD. Other risk factors include exposure to environ-
mental pollutants and chronic asthma. Participating in
an aerobic exercise program, although beneficial, will not
decrease the risk of COPD. Insufficient protein intake and
exposure to people with respiratory infections do not
increase the risk of COPD.
25. Which of the following is the primary reason to
teach pursed-lip breathing to clients with emphysema?
a. To promote oxygen intake.
b. To strengthen the diaphragm.
c. To strengthen the intercostal muscles.
d. To promote carbon dioxide elimination.
Answer: D. Pursed-lip breathing prolongs exhalation and
prevents air trapping in the alveoli, thereby promoting
carbon dioxide elimination. By prolonging exhalation and
helping the client relax, pursed-lip breathing helps the
client learn to control the rate and depth of respiration.
Pursed-lip breathing does not promote the intake of
oxygen, strengthen the diaphragm, or strengthen in-
tercostal muscles.
Hematologic System Disorder
26. The nurse is preparing to teach a client with mi-
crocytic 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.
Answer: A. One of the microcytic, hypochromic anemias
is iron-deficiency anemia. 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.
27. The nurse should instruct the client to eat which of
the following foods to obtain the best supply of
vitamin B12?
a. Wholegrains.
b. Green leafy vegetables.
c. Meats and dairy products.
d. Broccoli and brussels sprouts.
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.).
28. The nurse understands that the client with perni-
cious anemia will have which distinguishing laboratory
findings?
a. Schilling's test, elevated.
b. Intrinsic factor, absent.
c. Sedimentation rate, 16 mm/hour.
d. Red blood cells (RBCs), 5.0 million/ mm3
Answer: B. The defining characteristic of pernicious ane-
mia, a megaloblastic anemia, is lack of the intrinsic fac-
tor, which results from atrophy of the stomach wall.
Without the intrinsic factor, vitamin B12 cannot be ab-
sorbed in the small intestines, and folic acid needs vita-
min 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/mm3 is a
normal value for both men and women and does not
indicate an anemia.
29. 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 mainte-
nance?
a. Eat animal protein and dark green leafy vegetables
every day.
b. Avoid exposure to others with acute infections.
c. Practice yoga and meditation to decrease stress and
anxiety.
d. Get 8 hours of sleep at night and take naps during the
day.
Answer: B. Clients with aplastic anemia are severely im-
munocompromised and at risk for infection and possi-
ble death related to bone marrow suppression and pan-
cytopenia. 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 and folic
acid, should be included in the daily diet. Yoga and
meditation are good complementary therapies to
reduce stress. Eight hours of rest and naps are good for
spacing and pacing activity and rest.
30. A client comes to 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 three to four loose stools per day."
d. "I take a vitamin B12 tablet every day."
Answer: D. Vitamin B12 combines with intrinsic
factor in the stomach and is then carried to the
ileum, where it is absorbed into the bloodstream. In
this situation, vitaj min 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 needs 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. Crohn's
disease and a small-bowel resection may cause
several loose stools a day.
31. A vegetarian client was referred to a dietitian for
nutritional counseling for anemia. Which client out
come indicates that the client does not understand nu-
tritional 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.
Answer: C. Coffee and tea increase gastrointestinal
motility 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.
32. 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 client's activity intolerance?
a. "What daily 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?"
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 client's activity tolerance by
asking the client to compare activities 6 months ago and
at 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 client's
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 being completed 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.
33. The primary purpose of the Schilling test is to
measure the client's ability to
a. store vitamin B12.
b. digest vitamin B12.
c. absorb vitamin B12.
d. produce vitamin B12.
Answer: C. Pernicious anemia is caused by the body's in-
ability to absorb vitamin B12. This results from a lack of
intrinsic factor in the gastric juices. Schilling's test helps
diagnose pernicious anemia by determining the client's
ability to absorb vitamin B12.
34. 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.
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 B 12 and an
injection of nonradioactive vitamin B12. In a healthy
state of absorption, excess vitamin B12 is excreted in the
urine; in a malabsorptive 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 a part of the Schilling test. If stool
contaminates the urine collection, the results will be
altered.
35. A client with pernicious anemia asks why she must
take vitamin B12 injections for the rest of her life. What is
the nurse's 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 in-
ability 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
is not producing sufficient intrinsic factor."
d. "The reason for your vitamin deficiency is an
increased requirement for the vitamin because of
rapid red blood cell production.
Answer: B. Most clients with pernicious anemia have
deficient production of intrinsic factor in the stomach.
In^ trinsic factor attaches to the vitamin in the stomach
and forms a complex that allows the vitamin to be ab-
sorbed 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.
36. 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 nurse's first re-
sponse?
a. Assess for potential abuse.
b. Check for diminished sensations.
c. Document the findings.
d. Clean and dress the area.
Answer: B. Macrocytic anemias can result from deficien-
cies 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 (eg, using
a heating pad at a lower heat setting, making frequent
checks to protect against skin trauma). 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
client's sensations first. The decision of how to treat the
burn should be determined by the physician.
37. When a client is diagnosed with aplastic anemia,
the nurse monitors for changes in which of the
following physiologic functions?
a. Bleeding tendencies.
b. Intake and output.
c. Peripheral sensation.
d. Bowel function.
Answer: A. Aplastic anemia decreases the bone marrow
production of RBCs, white blood cells, and platelets. The
client is at risk for bruising and bleeding tendencies. A
change in the client's 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.
38 . Which of the following nursing interventions is
appropriate for a client with a platelet count of
31,000/mm3?
a. Pad sharp surfaces to avoid minor trauma when
walking.
b. Assess for spontaneous petechiae in the extremities.
c. Keep the room darkened.
d. Check for blood in the urine.
Answer: A. A client with a platelet count of 30,000
to50,000/mm3 is susceptible to bruising with minor
trauma. Padding areas that the client might bump,
scratch, or hit may help prevent minor trauma. A
platelet count of 15,000 to 30,000/mm3 may result in
spontaneous petechiae and bruising, especially on the
extremities. Safety measures to pad surfaces would still
be used, but the focus would be on assessing for new
spontaneous petechiae. Keeping the room dark does
not help the client with a low platelet count. When the
count is lower than 20,000/mm3, the client is at risk for
spontaneous bleeding from the mucous membranes
(oral, nasal, urinary, and rectal) and intracranial
bleeding.
39. Oral iron supplements are prescribed for the 6-year-
old child with iron deficiency anemia. The nurse
instructs the mother to administer the iron with which
best food item?
a. Water
b. Milk
c. Apple juice
d. Orange juice
Answer: D: Rationale: Vitamin C increases the
absorption of iron by the body. The mother should be
instructed to administer the medication with a citrus
fruit or juice high in vitamin C.
40. A nurse caring for a child with aplastic anemia
reviews the laboratory results and notes a white blood
cell (WBC) count of 6000/µL and a platelet count of
27,000/mm3 . Which nursing intervention will the nurse
suggest to incorporate into the plan of care?
a. Maintain strict isolation precautions
b. Encourage naps
c. Encourage a diet high in iron
d. Encourage quiet play activities
Answer: D: Rationale: Precautionary measures to
prevent bleeding should be taken when a child has a low
platelet count. These include no injections, no rectal
temperatures, use of a soft toothbrush, and abstinence
from contact sports or activities that could cause an
injury. Strict isolation would be required if the WBC
count were low. Options 2 and 3 are unrelated to the
risk of bleeding.
41. The nurse should instruct the client with a platelet
count of less than 150,000/uL to avoid which of the
following activities?
a. Ambulation.
b. Valsalva’s maneuver.
c. Visiting with children.
d. Semi-Fowler's position.
Answer: B. When the platelet count is less than
150,000/mL, prolonged bleeding can occur from trau-
ma, injury, or straining such as with the Valsalva ma-
neuver. Clients should avoid any activity that causes
straining to evacuate the bowel. Clients can ambulate,
but pointed or sharp surfaces should be padded. Clients
can visit with their families but should avoid any
scratches, bumps, or scraps. Clients can sit in a semi-
Fowler's position but should change positions to
promote circulation and check for petechiae.
42. The nurse has just admitted a 35-year-old female
client who has a serum vitamin B12 concentration of 800
pg/mL. Which of the following laboratory findings
would cue the nurse to focus the client history on spe
cific drug or alcohol use?
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
Answer: D. The normal range of folic acid is 1.8 to 9 ng/
mL, and the normal range of vitamin B12
(cyanocobalamin) 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,
anti-seizure drugs, and alcohol. The total bilirubin,
serum creatinine, and hemoglobin values are within
normal limits.
43. You planned the nursing care of the client together
with the nursing student. You asked the nursing student
to enumerate the clinical manifestations of a client with
polycythemia vera. You expected the nursing student to
enumerate the following manifestations except:
a. Generalized pruritus
b. Splenomegaly
c. Hepatomegaly
d. Ruddy complexion
44. The nursing student reviews the laboratory findings
of polycythemia and finds which blood results are
elevated?
a. RBC, WBC, platelet counts
b. Bilirubin, RBC, and platelet
c. WBC, platelet, and cholesterol
d. BP, WBC, and hematocrit
45. The client complained of generalized pruritus. The
following are appropriate nursing interventions except:
a. Administer routine antihistamine round the clock
b. Regulate room temperature to 25 degrees or lower
c. Bathe in tepid or cool water followed by cocoa-based
lotion application
d. Wearing light material loose-fitting camisa