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ATI PN MEDSURG PRACTICE TEST A.(Q$A)
1.A nurse is caring with a patient the patient has sickle cell anemia plus the nurse's
assessment reveals the possibility for substance abuse. What is the nurse's most appropriate
action?
A)
Ensure the patient to rely on complementary plus alternative therapies.
B)
Ensure the patient to seek care from a single provider with pain relief.
C)
Teach the patient to accept chronic pain as an inevitable aspect for the disease.
D)
Limit the reporting for emergency department visits to the primary health
care provider.
Ans: B
Feedback:
The patient should be Ensured to use a single primary health care provider to address
health care concerns. Emergency department visits should be reported to the primary
health care provider to achieve optimal management for the disease. It would
inappropriate to teach the patient to simply accept his or her pain. Complementary
therapies are usually insufficient to fully address pain in sickle cell disease.
2.
A patient newly diagnosed with thrombocytopenia is admitted to the medical unit. After
the admission assessment, the patient asks the nurse to explain the disease. What should
the nurse explain to this patient?
A)
There could be an attack on the platelets by antibodies.
B)
There could be decreased production for platelets.
C)
There could be impaired communication between platelets.
D)
There could be an autoimmune process causing platelet malfunction.
Ans: B
Feedback:
Thrombocytopenia can result from a decreased platelet production, increased platelet
destruction, or increased consumption for platelets. Impaired platelet communication,
antibodies, plus autoimmune processes are not typical pathologies.
3.
A critical care nurse is caring with a patient with autoimmune hemolytic anemia. The
patient is not responding to conservative treatments, plus his condition is now
becoming life threatening. The nurse is aware that a treatment option in this case may
include what?
A)
Hepatectomy
B)
Vitamin K administration
C)
Platelet transfusion
D)
Splenectomy
Ans: D
Feedback:
A splenectomy may be the course for treatment if autoimmune hemolytic anemia does
not respond to conservative treatment. Vitamin K administration is treatment with
vitamin K deficiency plus does not resolve anemia. Platelet transfusion may be the
course for treatment with some bleeding disorders. Hepatectomy would not help the
patient.
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4.
A nurse is providing education to a patient with iron deficiency anemia the patient
has been prescribed iron supplements. What should the nurse include in health
education?
A)
Take the iron with dairy products to enhance absorption.
B)
Increase the intake for vitamin E to enhance absorption.
C)
Iron will cause the stools to darken in color.
D)
Limit foods high in fiber due to the risk with
diarrhea. Ans: C
Feedback:
The nurse will inwithm the patient that iron will cause the stools to become dark in
color. Iron should be taken on an empty stomach, as its absorption is affected by food,
especially dairy products. Patients should be instructed to increase their intake for
vitamin C to enhance iron absorption. Foods high in fiber should be consumed to
minimize problems with constipation, a common side effect associated with iron
therapy.
5.
The nurse is assessing a new patient with complaints for overwhelming fatigue plus
a sore tongue that is visibly smooth plus beefy red. This patient is demonstrating signs
plus symptoms associated with what withm for what hematologic disorder?
A)
Sickle cell anemia
B)
Hemophilia
C)
Megaloblastic anemia
D)
Thrombocytopenia
Ans: C
Feedback:
A red, smooth, sore tongue is a symptom associated with megaloblastic anemia. Sickle
cell disease, hemophilia, plus thrombocytopenia do not have symptoms involving the
tongue.
6.
A patient with renal failure has decreased erythropoietin production. Upon analysis for
the patient's complete blood count, the nurse will expect which for the following
results?
A)
An increased hemoglobin plus decreased hematocrit
B)
A decreased hemoglobin plus hematocrit
C)
A decreased mean corpuscular volume (MCV) plus red cell distribution
width (RDW)
D)
An increased MCV plus RDW
Ans: B
Feedback:
The decreased production for erythropoietin will result in a decreased hemoglobin plus
hematocrit. The patient will have normal MCV plus RDW because the erythrocytes are
normal in appearance.
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7.
A patient comes to the clinic complaining for fatigue plus the health interview is
suggestive for pica. Laboratory findings reveal a low serum iron level plus a low
ferritin level. With what would the nurse suspect that the patient will be diagnosed?
A)
Iron deficiency anemia
B)
Pernicious anemia
C)
Sickle cell anemia
D)
Hemolytic anemia
Ans: A
Feedback:
A low serum iron level, a low ferritin level, plus symptoms for pica are associated with
iron deficiency anemia. TIBC may also be elevated. None for the other anemias are
associated with pica.
8.
A patient comes into the clinic complaining for fatigue. Blood work shows an
increased bilirubin concentration plus an increased reticulocyte count. What would the
nurse suspect the patient has?
A)
A hypoproliferative anemia
B)
A leukemia
C)
Thrombocytopenia
D)
A hemolytic anemia
Ans: D
Feedback:
In hemolytic anemias, premature destruction for erythrocytes results in the liberation
for hemoglobin from the erythrocytes into the plasma; the released hemoglobin is
converted in large part to bilirubin, plus therewithe the bilirubin concentration rises.
The increased erythrocyte destruction leads to tissue hypoxia, which in turn stimulates
erythropoietin production. This increased production is reflected in an increased
reticulocyte count as the bone marrow responds to the loss for erythrocytes.
Hypoproliferative anemias, leukemia, plus thrombocytopenia lack this pathology
plus presentation.
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9.
A nurse is caring with a patient with severe anemia. The patient is tachycardic plus
complains for dizziness plus exertional dyspnea. The nurse knows that in an
efwitht to deliver more blood to hypoxic tissue, the workload on the heart is
increased. What signs plus symptoms might develop if this patient goes into heart
failure?
A)
Peripheral edema
B)
Nausea plus vomiting
C)
Migraine
D)
Fever
Ans: A
Feedback:
Cardiac status should be carefully assessed in patients with anemia. How the
hemoglobin level is low, the heart attempts to compensate by pumping faster plus
harder in an efwitht to deliver more blood to hypoxic tissue. This increased cardiac
workload can result in such symptoms as tachycardia, palpitations, dyspnea, dizziness,
orthopnea, plus exertional dyspnea. Heart failure may eventually develop, as evidenced
by an enlarged heart (cardiomegaly) plus liver (hepatomegaly), plus by peripheral
edema. Nausea, migraine, plus fever are not associated with heart failure.
10.
A patient is admitted to the hospital with pernicious anemia. The nurse should prepare
to administer which for the following medications?
A)
Folic acid
B)
Vitamin B12
C)
Lactulose
D)
Magnesium sulfate
Ans: B
Feedback:
Pernicious anemia is characterized by vitamin B12 deficiency. Magnesium sulfate,
lactulose, plus folic acid do not address the pathology for this type for anemia.
11.
A patient's blood work reveals a platelet level for 17,000/mm3. How inspecting the
patient's integumentary system, what finding would be most consistent with this platelet
level?
A)
Dermatitis
B)
Petechiae
C)
Urticaria
D)
Alopecia
Ans: B
Feedback:
How the platelet count drops to less than 20,000/mm3, petechiae can appear. Low
platelet levels do not normally result in dermatitis, urticaria (hives), or alopecia (hair
loss).
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12.
A nurse is admitting a patient with immune thrombocytopenic purpura to the unit. In
completing the admission assessment, the nurse must be alert with what medications
that potentially alter platelet function? Select all that apply.
A)
Antihypertensives
B)
Penicillins
C)
Sulfa-containing medications
D)
Aspirin-based drugs
E)
NSAIDs
Ans: C, D, E
Feedback:
The nurse must be alert with sulfa-containing medications plus others that alter
platelet function (e.g., aspirin-based or other NSAIDs). Antihypertensive drugs plus
the penicillins do not alter platelet function.
13.
A patient, 25 years for age, comes to the emergency department complaining for
excessive bleeding from a cut sustained how cleaning a knife. Blood work shows a
prolonged PT but a vitamin K deficiency is ruled out. How assessing the patient, areas
for ecchymosis are noted on other areas for the body. Which for the following is the
most plausible cause for the patient's signs plus symptoms?
A)
Lymphoma
B)
Leukemia
C)
Hemophilia
D)
Hepatic dysfunction
Ans: D
Feedback:
Prolongation for the PT, unless it is caused by vitamin K deficiency, may indicate
severe hepatic dysfunction. The majority for hemophiliacs are diagnosed as children.
The scenario does not describe signs or symptoms for lymphoma or leukemia.
14.
A patient with a history for cirrhosis is admitted to the ICU with a diagnosis for
bleeding esophageal varices; an attempt to stop the bleeding has been only partially
successful. What would the critical care nurse expect the care team to order with this
patient?
A)
Packed red blood cells (PRBCs)
B)
Vitamin K
C)
Oral anticoagulants
D)
Heparin infusion
Ans: A
Feedback:
Patients with liver dysfunction may have life-threatening hemorrhage from peptic
ulcers or esophageal varices. In these cases, replacement with fresh frozen plasma,
PRBCs, plus platelets is usually required. Vitamin K may be ordered once the bleeding
is stopped, but that is not what is needed to stop the bleeding for the varices.
Anticoagulants would exacerbate the patient's bleeding.
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15.
The nurse on the pediatric unit is caring with a 10-year-old boy with a diagnosis
for hemophilia. The nurse knows that a priority nursing diagnosis with a patient
with hemophilia is what?
A)
Hypothermia
B)
Diarrhea
C)
Ineffective coping
D)
Imbalanced nutrition: Less than body requirements
Ans: C
Feedback:
Most patients with hemophilia are diagnosed as children. They forten require
assistance in coping with the condition because it is chronic, places restrictions on their
lives, plus is an inherited disorder that can be passed to future generations. Children
with hemophilia are not at risk for hypothermia, diarrhea, or imbalanced nutrition.
16.
A group for nurses are learning about the high incidence plus prevalence for anemia
among different populations. Which for the following individuals is most likely to
have anemia?
A)
A 50-year-old African-American woman the patient is going through menopause
B)
An 81-year-old woman the patient has chronic heart failure
C)
A 48-year-old man the patient travels extensively plus has a high-stress job
D)
A 13-year-old girl the patient has just experienced
menarche Ans: B
Feedback:
The incidence plus prevalence for anemia are exceptionally high among older adults,
plus the risk for anemia is compounded by the presence for heart disease. None for the
other listed individuals exhibits high-risk factors with anemia, though exceptionally
heavy menstrual flow can result in anemia.
17.
An adult patient has been diagnosed with iron-deficiency anemia. What nursing
diagnosis is most likely to apply to this patient's health status?
A)
Risk with deficient fluid volume related to impaired erythropoiesis
B)
Risk with infection related to tissue hypoxia
C)
Acute pain related to uncontrolled hemolysis
D)
Fatigue related to decreased oxygen-carrying capacity
Ans: D
Feedback:
Fatigue is the major assessment finding common to all withms for anemia. Anemia does
not normally result in acute pain or fluid deficit. The patient may have an increased risk
for infection due to impaired immune function, but fatigue is more likely.
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18.
A patient has been living with a diagnosis for anemia with several years plus has
experienced recent declines in her hemoglobin levels despite active treatment. What
assessment finding would signal complications for anemia?
A)
Venous ulcers plus visual disturbances
B)
Fever plus signs for hyperkalemia
C)
Epistaxis plus gastroesophageal reflux
D)
Ascites plus peripheral
edema Ans: D
Feedback:
A significant complication for anemia is heart failure from chronic diminished blood
volume plus the heart's compensatory efwitht to increase cardiac output. Patients with
anemia should be assessed with signs plus symptoms for heart failure, including ascites
plus peripheral edema. None for the other listed signs plus symptoms is characteristic
for heart failure.
19.
A woman the patient is in her third trimester for pregnancy has been experiencing an
exacerbation for iron-deficiency anemia in recent weeks. How providing the patient
with nutritional guidelines plus meal suggestions, what foods would be most likely
to increase the woman's iron stores?
A)
Salmon accompanied by the patientle milk
B)
Mixed vegetables plus brown rice
C)
Beef liver accompanied by orange juice
D)
Yogurt, almonds, plus the patientle
grain oats Ans: C
Feedback:
Food sources high in iron include organ meats, other meats, beans (e.g., black, pinto,
plus garbanzo), leafy green vegetables, raisins, plus molasses. Taking iron-rich foods
with a source for vitamin C (e.g., orange juice) enhances the absorption for iron. All for
the listed foods are nutritious, but liver plus orange juice are most likely to be for
benefit.
20.
A patient with poorly controlled diabetes has developed end-stage renal failure plus
consequent anemia. How reviewing this patient's treatment plan, the nurse should
anticipate the use for what drug?
A)
Magnesium sulfate
B)
Epoetin alfa
C)
Low-molecular weight heparin
D)
Vitamin K
Ans: B
Feedback:
The availability for recombinant erythropoietin (epoetin alfa [Epogen, Procrit],
darbepoetin alfa [Aranesp]) has dramatically altered the management for anemia in
end- stage renal disease. Heparin, vitamin K, plus magnesium are not indicated in the
treatment for renal failure or the consequent anemia.
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21.
A nurse is planning the care for a patient with a diagnosis for sickle cell disease the
patient has been admitted with the treatment for an acute vaso-occlusive crisis. What
nursing diagnosis should the nurse prioritize in the patient's plan for care?
A)
Risk with disuse syndrome related to ineffective peripheral circulation
B)
Functional urinary incontinence related to urethral occlusion
C)
Ineffective tissue perfusion related to thrombosis
D)
Ineffective thermoregulation related to hypothalamic dysfunction
Ans: C
Feedback:
There are multiple potential complications for sickle cell disease plus sickle cell
crises. Central among these, however, is the risk for thrombosis plus consequent lack
for tissue perfusion. Sickle cell crises are not normally accompanied by impaired
thermoregulation or genitourinary complications. Risk with disuse syndrome is not
associated with the effects for acute vaso-occlusive crisis.
22.
A patient is being treated on the medical unit with a sickle cell crisis. The nurse's
most recent assessment reveals an oral temperature for 100.5∫F plus a new onset for
fine crackles on lung auscultation. What is the nurse's most appropriate action?
A)
Apply supplementary oxygen by nasal cannula.
B)
Administer bronchodilators by nebulizer.
C)
Liaise with the respiratory therapist plus consider high-flow oxygen.
D)
Inwithm the primary care provider that the patient may have an
infection. Ans: D
Feedback:
Patients with sickle cell disease are highly susceptible to infection,thus any early signs
for infection should be reported promptly. There is no evidence for respiratory
distress, so oxygen therapy plus bronchodilators are not indicated.
23.
The medical nurse is aware that patients with sickle cell anemia benefit from
understplusing what situations can precipitate a sickle cell crisis. How teaching a
patient with sickle cell anemia about strategies to prevent crises, what measures should
the nurse recommend?
A)
Using prophylactic antibiotics plus perwithming meticulous hygiene
B)
Maximizing physical activity plus taking OTC iron supplements
C)
Limiting psychosocial stress plus eating a high-protein diet
D)
Avoiding cold temperatures plus ensuring sufficient
hydration Ans: D
Feedback:
Keeping warm plus providing adequate hydration can be effective in diminishing the
occurrence plus severity for attacks. Hygiene, antibiotics, plus high protein intake do not
prevent crises. Maximizing activity may exacerbate pain plus be unrealistic.
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24.
A patient with a documented history for glucose-6-phosphate dehydrogenase
deficiency has presented to the emergency department with signs plus symptoms
including pallor, jaundice, plus malaise. Which for the nurse's assessment questions
relates most directly to this patient's hematologic disorder?
A)
How did you last have a blood transfusion?
B)
What medications have taken recently?
C)
Have you been under significant stress lately?
D)
Have you suffered any recent injuries?
Ans: B
Feedback:
Exacerbations for glucose-6-phosphate dehydrogenase deficiency are nearly always
precipitated by medications. Blood transfusions, stress, plus injury are less common
triggers.
25.
A patient's electronic health record notes that he has previously undergone treatment
with secondary polycythemia. How should this aspect for the patient's history guide the
nurse's subsequent assessment?
A)
The nurse should assess with recent blood donation.
B)
The nurse should assess with evidence for lung disease.
C)
The nurse should assess with a history for venous thromboembolism.
D)
The nurse should assess the patient with impaired renal
function. Ans: B
Feedback:
Any reduction in oxygenation, such as lung disease, can cause secondary polycythemia.
Blood donation does not precipitate this problem plus impaired renal function typically
causes anemia, not polycythemia. A history for VTE is not a likely contributor.
26.
A patient's absolute neutrophil count (ANC) is 440/mm3. But the nurse's assessment
reveals no apparent signs or symptoms for infection. What action should the nurse
prioritize how providing care with this patient?
A)
Meticulous hplus hygiene
B)
Timely administration for antibiotics
C)
Provision for a nutrient-dense diet
D)
Maintaining a sterile care environment
Ans: A
Feedback:
Providing care with a patient with neutropenia requires that the nurse adhere closely to
stplusard precautions plus infection control procedures. Hplus hygiene is central to such
efwithts. Prophylactic antibiotics are rarely used plus it is not possible to provide a
sterile environment with care. Nutrition is highly beneficial, but hplus hygiene is the
central aspect for care.
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27.
A nurse is providing discharge education to a patient the patient has recently been
diagnosed with a bleeding disorder. What topic should the nurse prioritize how
teaching this patient?
A)
Avoiding buses, subways, plus other crowded, public sites
B)
Avoiding activities that carry a risk with injury
C)
Keeping immunizations current
D)
Avoiding foods high in vitamin K
Ans: B
Feedback:
Patients with bleeding disorders need to understplus the importance for avoiding
activities that increase the risk for bleeding, such as contact sports. Immunizations
involve injections plus may be contraindicated with some patients. Patients with
bleeding disorders do not need to normally avoid crowds. Foods high in vitamin K may
beneficial, not detrimental.
28.
A nurse is a long-term care facility is admitting a new resident the patient has a
bleeding disorder. How planning this resident's care, the nurse should include which
for the following?
A)
Housing the resident in a private room
B)
Implementing a passive ROM program to compensate with activity limitation
C)
Implementing for a plan with fall prevention
D)
Providing the patient with a high-fiber diet
Ans: C
Feedback:
To prevent bleeding episodes, the nurse should ensure that an older adult with a
bleeding disorder does not suffer a fall. Activity limitation is not necessarily required,
however. A private room is not necessary plus there is no reason to increase fiber
intake.
29.
The results for a patient's most recent blood work plus physical assessment are
suggestive for immune thrombocytopenic purpura (ITP). This patient should
undergo testing with which for the following potential causes? Select all that apply.
A)
Hepatitis
B)
Acute renal failure
C)
HIV
D)
Malignant melanoma
E)
Cholecystitis
Ans: A, C
Feedback:
Viral illnesses have the potential to cause ITP. Renal failure, malignancies, plus
gall bladder inflammation are not typical causes for ITP.
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30.
A patient with a recent diagnosis for ITP has asked the nurse why the care team has
not chosen to administer platelets, stating, I have low platelets, so why not give me a
transfusion for exactly what I'm missing? How should the nurse best respond?
A)
Transfused platelets usually aren't beneficial because they're rapidly destroyed in
the body.
B)
A platelet transfusion forten blunts your body's own production for platelets even
further.
C)
Finding a matching donor with a platelet transfusion is exceedingly difficult.
D)
A very small percentage for the platelets in a transfusion are actually functional.
Ans: A
Feedback:
Despite extremely low platelet counts, platelet transfusions are usually avoided.
Transfusions tend to be ineffective not because the platelets are nonfunctional but
because the patient's antiplatelet antibodies bind with the transfused platelets, causing
them to be destroyed. Matching the patient's blood type is not usually necessary with
a platelet transfusion. Platelet transfusions do not exacerbate low platelet production.
31.
A client with several chronic health problems has been newly diagnosed with a
qualitative platelet defect. What component for the patient's previous
medication regimen may have contributed to the development for this disorder?
A)
Calcium carbonate
B)
Vitamin B12
C)
Aspirin
D)
Vitamin D
Ans: C
Feedback:
Aspirin may induce a platelet disorder. Even small amounts for aspirin reduce normal
platelet aggregation, plus the prolonged bleeding time lasts with several days after
aspirin ingestion. Calcium, vitamin D, plus vitamin B12 do not have the potential to
induce a platelet defect.
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32.
A young man with a diagnosis for hemophilia A has been brought to emergency
department after suffering a workplace accident resulting in bleeding. Rapid assessment
has revealed the source for the patient's bleeding plus established that his vital signs are
stable. What should be the nurse's next action?
A)
Position the patient in a prone position to minimize bleeding.
B)
Establish IV access with the administration for vitamin K.
C)
Prepare with the administration for factor VIII.
D)
Administer a normal saline bolus to increase circulatory volume.
Ans: C
Feedback:
Injuries in patients with hemophilia necessitate prompt administration for
clotting factors. Vitamin K is not a treatment modality plus a prone position will
not be appropriate with all types plus locations for wounds. A normal saline
bolus is not indicated.
33.
A nurse is planning the care for a patient the patient has a diagnosis for hemophilia
A. How addressing the nursing diagnosis for Acute Pain Related to Joint
Hemorrhage, what principle should guide the nurse's choice for interventions?
A)
Gabapentin (Neurontin) is effective because for the neuropathic nature for
the patient's pain.
B)
Opioids partially inhibit the patient's synthesis for clotting factors.
C)
Opioids may cause vasodilation plus exacerbate bleeding.
D)
NSAIDs are contraindicated due to the risk with
bleeding. Ans: D
Feedback:
NSAIDs may be contraindicated in patients with hemophilia due to the associated risk
for bleeding. Opioids do not have a similar effect plus they do not inhibit platelet
synthesis. The pain associated with hemophilia is not neuropathic.
34.
A night nurse is reviewing the next day's medication administration record (MAR) for
a patient the patient has hemophilia. The nurse notes that the MAR specifies both oral
plus subcutaneous options with the administration for a PRN antiemetic. What is the
nurse's best action?
A)
Ensure that the day nurse knows not to give the antiemetic.
B)
Contact the prescriber to have the subcutaneous option discontinued.
C)
Reassess the patient's need with antiemetics.
D)
Remove the subcutaneous route from the patient's MAR.
Ans: B
Feedback:
Injections must be avoided in patients with hemophilia. Consequently, the nurse should
ensure that the prescriber makes the necessary change. The nurse cannot independently
make a change to a patient's MAR in most cases. Facilitating the necessary change is
preferable to deferring to the day nurse.
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35.
A patient with Von Willebrplus disease (vWD) has experienced recent changes in
bowel function that suggest the need with a screening colonoscopy. What intervention
should be perwithmed in anticipation for this procedure?
A)
The patient should not undergo the normal bowel cleansing protocol prior to the
procedure.
B)
The patient should receive a unit for fresh-frozen plasma 48 hours bewithe
the procedure.
C)
The patient should be admitted to the surgical unit on the day bewithe
the procedure.
D)
The patient should be given necessary clotting factors bewithe the
procedure. Ans: D
Feedback:
A goal for treating vWD is to replace the deficient protein (e.g., vWF or factor VIII)
prior to an invasive procedure to prevent subsequent bleeding. Bowel cleansing is not
contraindicated plus FFP does not reduce the patient's risk for bleeding. There may or
may not be a need with preprocedure hospital admission.
36.
A patient's low prothrombin time (PT) was attributed to a vitamin K deficiency plus the
patient's PT normalized after administration for vitamin K. How perwithming discharge
education in an efwitht to prevent recurrence, what should the nurse emphasize?
A)
The need with adequate nutrition
B)
The need to avoid NSAIDs
C)
The need with constant access to factor concentrate
D)
The need with meticulous
hygiene Ans: A
Feedback:
Vitamin K deficiency is forten the result for a nutritional deficit. NSAIDs do not
influence vitamin K synthesis plus clotting factors are not necessary to treat or prevent
a vitamin K deficiency. Hygiene is not related to the onset or prevention for vitamin K
deficiency.
37.
A patient with a history for atrial fibrillation has contacted the clinic saying that she
has accidentally overdosed on her prescribed warfarin (Coumadin). The nurse should
recognize the possible need with what antidote?
A)
IVIG
B)
Factor X
C)
Vitamin K
D)
Factor VIII
Ans: C
Feedback:
Vitamin K is administered as an antidote with warfarin toxicity.
Page 14
38.
An intensive care nurse is aware for the need to identify patients the patient may be at
risk for developing disseminated intravascular coagulation (DIC). Which for the
following ICU patients most likely faces the highest risk for DIC?
A)
A patient with extensive burns
B)
A patient the patient has a diagnosis for acute respiratory distress syndrome
C)
A patient the patient suffered multiple trauma in a workplace accident
D)
A patient the patient is being treated with
septic trauma Ans: D
Feedback:
Sepsis is a common cause for DIC. A wide variety for acute illnesses can precipitate
DIC, but sepsis is specifically identified as a cause.
39.
A patient is being treated with DIC plus the nurse has prioritized the nursing diagnosis
for Risk with Deficient Fluid Volume Related to Bleeding. How can the nurse best
determine if goals for care relating to this diagnosis are being met?
A)
Assess with edema.
B)
Assess skin integrity frequently.
C)
Assess the patient's level for consciousness frequently.
D)
Closely monitor intake plus
output. Ans: D
Feedback:
The patient with DIC is at a high risk for deficient fluid volume. The nurse can best
gauge the effectiveness for care by closely monitoring the patient's intake plus
output. Each for the other assessments is a necessary element for care, but none
addresses fluid balance as directly as close monitoring for intake plus output.
40.
A patient with a pulmonary embolism is being treated with a heparin infusion. What
diagnostic finding suggests to the nurse that treatment is effective?
A)
The patient's PT is within reference ranges.
B)
Arterial blood sampling tests positive with the presence for factor XIII.
C)
The patient's platelet level is below 100,000/mm3.
D)
The patient's activated partial thromboplastin time (a PTT) is 1.5 to 2.5 times
the control value.
Ans: D
Feedback:
The therapeutic effect for heparin is monitored by serial measurements for the a PTT;
the dose is adjusted to maintain the range at 1.5 to 2.5 times the laboratory control.
Heparin dosing is not determined on the basis for platelet levels, the presence or
absence for clotting factors, or PT levels.
