Some NCLEX RN Practice Questions present ethical dilemmas, requiring students to analyze moral principles and make ethically responsible choices.
NCLEX Hematology/Immunology Questions - NCLEX Questions on Hematology/Immunology
Hematology/Immunology NCLEX Practice Questions
Question 1.
The nurse in the clinic is assessing a 72-year-Old patient for signs and symptoms of infection. What response by the nurse is best when the patient’s temperature is found to be 97.5°F (36.3°C)?
(a) Assess more specific signs
(b) Reasure the patient the temperature indicates no infection is present
(c) Document the temperature and tell the patient to return to the clinic if the temperature rises above 1oo°F (37.7°C)
(d) Request blood cultures
Answer:
(a) Assess more specific signs
Explanation:
Due to natural weakening of the immune system function with age, and decreased thermoregulation ability, a fever may not be present in an elderly patient with an infection. The nurse should assess the patient for further, more specific signs of infection.
Rationale:
(b) is incorrect because immune system function is decreased, so specific signs of infection should be assessed.
(c) is incorrect because documentation should not be completed until a more thorough assessment has been made.
(d) is incorrect because a more thorough assessment should be made prior to obtaining blood cultures.
Question 2.
A patient who underwent a liver transp’ant is beginning treatment with prednisone. Which instruction provided by the nurse is the most important regarding the medication?
(a) “Avoid crowds and sick people.”
(b) “If you take over-the-counter medications, check the label for acetaminophen.”
(c) “Take the medication exactly as ordered, even if you have a fever.”
(d) “There is an increased risk of cancer when taking this medication.”
Answer:
(a) “Avoid crowds and sick people.”
Explanation:
Prednisone is a steroid medication taken to prevent transplant organ rejection. It works by depressing cell-mediated immune reactors. The patient should avoid crowds and sick people because the body will have decreased ability to fight off infection while taking prednisone.
Rationale:
(b) is incorrect because prednisone does not contain acetaminophen, and acetaminophen is not contraindicated when taking prednisone.
(c) is incorrect because although the medication should be taken exactly as ordered, a fever can be a sign of infection and the healthcare should be notified. The patient should also be taught that abrupt withdrawal of prednisone can cause headache, nausea, vomiting, and papilledema. The medication should be taken at evenly-spaced intei’als throughout the day.
(d) is incorrect because prednisone does not carry an increased risk of cancer. Rare adverse effects of prednisone include peptic ulcer, gastric hemorrhage, and psychosis.
Question 3.
A patient in the intensive care unit (ICU) is recovering from kidney transplant. When the patient experiences hvperacute rejection and the blood pressure is 105/72, the nurse facilitates which treatment?
(a) Dialysis
(b) Administration of high dose steroids
(c) Monoclonal antibody therapy
(d) Plasmapheresis
Answer:
(a) Dialysis
Explanation:
Nothing stops the process of hyperacute rejection, which can begin minutes to several days after transplantation occurs. The transplanted kidney becomes grossly mottled and cyanotic, and the capsule bulges out due to marked edema. The kidney will not function and will have to be removed. The patient will have to undergo dialysis again.
Rationale:
(a) B is incorrect because steroids are ineffective in hyperacute rejection. Cyclosporine and tacrolirnus are often used initially.
(c) is incorrect because monoclonal antibody therapy is ineffective in hyperacute rejection.
(d) is incorrect because plasmapheresis can only be used in hyperacute rejection if the patient is hemodynamically stable; this patient is hypotensive.
Question 4.
The community health nurse in the clinic is teaching older patients about infection prevention. The nurse knows which of the following is crucial for infection prevention in this population?
(a) Reviewing vaccination records
(b) Encouraging a healthy diet
(c) Proper care of minor wounds
(d) Hand hygiene
Answer:
(a) Reviewing vaccination records
Explanation:
As people age, the efficiency of the immune system decreases, along with antibodies produced due to past exposure. Older adults will need booster shots for previously administered vaccinations, so the nurse should review vaccination records for this. Diseases that can be prevented in the elderly by administering boosters include shingles, diphtheria, tetanus, pertussis, and pneumonia. Elderly patients should also be encouraged to receive their annual influenza vaccine.
Rationale:
(b) is incorrect because healthy diet is necessary for all ages and is not as specific to infection prevention as vaccinations.
(c) is incorrect because the risk for infection in the elderly related to wound infection is not as great as the risk for infection from non-vaccination.
(d) is incorrect because poor hand hygiene is the leading cause of hospital-acquired infection but not specific to infection prevention in older adults in the community setting.
Question 5.
A 65-year-old patient is in the clinic complaining of night sweats and a productive cough. The nurse notes a low fever. The tuberculin skin test is negative. What is the best action for the nurse to do?
(a) Recommend pneumonia vaccination
(b) Teach about viral infections
(c) Recommend rest and fluids
(d) Obtain a chest X-ray
Answer:
(d) Obtain a chest X-ray
Explanation:
T lymphocytes decrease in number with age. This can cause a tuberculin skin test to come back falsely negative. Because the patient has signs and symptoms consistent with tuberculosis (TB), the patient should undergo a chest X-ray for further diagnosis.
Rationale:
(a) is incorrect because the pneumonia vaccination is not appropriate for anyone who is moderately to severely ill. The pneumococcal pneumonia (PPSV) vaccine should be administered after the patient’s current illness has been treated.
(b) is incorrect because this patient is showing signs of TB, which is a bacterial infection, not a virus.
(c) is incorrect because although rest and fluids are components of TB treatment, further assessment is more important at this time.
Question 6.
The nurse is caring for patients on the medical-surgical unit and using specific practices for prevention of acquisition of human immune deficiency virus (H ¡V). Which practice by the nurse is the most effective?
(a)Standard precautions used consistently
(b) Double gloves with potential body fluid exposure
(c) Label patient charts and armbands with HIV+
(d) Wear a mask when near the patient
Answer:
(a)Standard precautions used consistently
Explanation:
Standard precautions are the primary strategy for infection control in all settings and should be used for all patients. This is the best way to prevent transmission of infectious organisms. Standard precautions apply to contact with blood, body fluids, non-intact skin, and mucous membranes from all patients. The Joint Commission has stated HIV exposure prevention is most effective with Standard Precautions used consistently. HIV does not require the use of droplet, airborne, or contact precautions.
Rationale:
(b) is incorrect because double gloves are not necessary for bedside patient care. Double gloving is practiced during surgical procedures due to the increased risk of glove penetration with surgical instruments.
(c) is incorrect because labeling the patient’s chart and armband vith HW+ violates the Health Information Portability and Accountability Act (HIPAA).
(d) is incorrect because a mask is only necessary with airborne precautions. HIV is not spread via the airborne route.
Question 7.
The nurse in the clinic is speaking with a patient who just received a negative result for the enzyme-linked immunosorbent assay (ELISA) for HIV. The patient tells the nurse they were worried about getting the results. What is the most important action b’ the nurse?
(a) Assess sexual activity and patterns
(b) Reassure the patient
(c) Educate the patient regarding safe sex practices
(d) Schedule the patient for another ELISA test in three months
Answer:
(a) Assess sexual activity and patterns
Explanation:
The ELISA tests for antibodies for human immune deficiency virus (HIV). Falsely negative ELISA tests can occur after exposure but before antibodies are produced by the immune system. It can take up to 36 months for the antibodies to be produced to get a positive test result. The patient’s sexual behavior and patterns need to be assessed in relation to the negative test result and risk for exposure. If the patient knows they have been sexually active with another HIV positive individual, further testing may be warranted at this time.
Rationale:
(b) is incorrect because the nurse should be cautious to not provide false reassurance. This patient could be infected with HIV even though the preliminary ELISA test is negative.
(c) is incorrect because education regarding safe sex practices is appropriate, but if the patient has been exposed, further testing is more important that patient education.
(d) is incorrect because a follow-up ELISA test may be appropriate, but it is more important to focus on the here and now. A Western blot test may be done sooner than three months from now to determine the presence of HIV. The Western blot test has a higher sensitivity to the presence of HIV in the blood.
Question 8.
A patient in the clinic is distraught over a recent diagnosis of human immune deficiency virus (H IV). When the patient tells the nurse they don’t know what to do, what is the best intervention by the nurse?
(a) Assess for support systems
(b) Offer clergy assistance
(c) Explain requirements by law to inform sex partners
(d) Offer to inform the patient’s family
Answer:
(a) Assess for support systems
Explanation:
The patient is in great need of support systems for assistance. The nurse can help identify the patient’s support systems and how they can help.
Rationale:
(b) is incorrect because the patient may not welcome a clergy member. The nurse should remain focused on nurse-specific activities that can help the patient, and clergy can be called secondarily.
(c) is incorrect because laws regarding HIV are different in each state and addressing the patient’s distress is more important at this time.
(d) is incorrect because informing the family for the patient is enabling behavior. The nurse should remain focused on the patient and determine coping abilities and support systems before addressing the need to tell the family. It is the patient’s choice if and when to inform he family of the diagnosis.
Question 9.
A patient with a history of HIV is admitted to the medical unit for pneumonia. The healthcare provider has ordered the addition of several medications to the patient’s current regimen. What is the most important action by the nurse?
(a) Consult with the pharmacy regarding drug interactions
(b) Ensure patient understanding of new medications
(c) Administer new medications as well as current medications
(d) Schedule administrations at normal times
Answer:
(a) Consult with the pharmacy regarding drug interactions
Explanation:
Medications for HW/AIDS are complex and are given at specific times throughout the day. This could lead to drug interactions with the new medications ordered by the healthcare provider, so the pharmacy should be consulted about interactions. This is the safest answer choice.
Rationale:
(b) is incorrect because patient understanding of medications is appropriate hut does not provide for patient safety.
(c) is incorrect because administration of medications without awareness of interactions could he dangerous for the patient.
(d) is incorrect because HIV/AIDS medications must be administered at specific times. Zidovudine, for example, requires strict adherence to dosage schedule, and didanosine must be taken on an empty stomach.
Question 10.
A patient is admitted to the emergency room in sickle cell crisis. Which of the following lab results should be reported to the healthcare provider by the nurse?
(a) Creatinine 2.8 mg/dL
(b) Hematocrit 31%
(c) Sodium 148 mECIJL
(d) White blood cells 11,500/mm3
Answer:
(a) Creatinine 2.8 mg/dL
Explanation:
Sickle cell disease is abnormal formation of red blood cells into a sickle shape, which makes it difficult for them to absorb and transport oxygen through the bloodstream. This leads to fatigue, difficulty breathing, severe pain, joint swelling, jaundice, tachycardia, and low hemoglobin. Organ damage may result, too. Kidney damage is indicated by elevated creatinine levels, which can occur in patients with sickle cell disease. Normal adult creatinine for is 0.7-1.4 mg/dl. Normal child creatinine is 0.4-1.2 mg/dl.
Rationale:
(b) is incorrect because decreased hematocrit is expected with sickle cell disease. Hematocrit measures the percentage of red blood cells per fluid volume of blood. Normal hematocrit is 42-52% for men, 35-47% for women, and 35-45% for children.
(c) is incorrect because the sodium is slightly elevated, which can indicate dehydration, but this is not the main concern. Normal sodium is 135-145 mEq/L.
(d) is incorrect because the white blood cell count is slightly elevated, which could indicate infection, hut the creatinine is extremely high, so the patient needs to be evaluated for organ failure ahead of potential infection. Normal adult WBC is 4,500-11,000/mm3. Normal child WBC is 5,000-13,000/mm3.
Question 11.
The nurse on the medical-surgical unit is assigned to four patients with immune disorders. Once the hand-off report is received, which of the following patients should be seen by the nurse first?
(a) Patient with AIDS and CD+4 count 200/mm3, temperature 102.1°F (38.8°C)
(b) Patient admitted for Bruton’s agammaglonulinemia awaiting discharge teaching
(c) Patient with hypogammaglobulinemia who received immune serum globulin infusion an hour ago
(d) Patient admitted for pneumonia with selective immunoglobulin A deficiency receiving IV antibiotics
Answer:
(a) Patient with AIDS and CD+4 count 200/mm3, temperature 102.1°F (38.8°C)
Explanation:
Patients who are immunosuppressed with high fevers need to be assessed by the nurse first. The patient’s immune system is not able to fight infection as well due to decreased CD+4 count, and the high fever can lead to vascular collapse as well as possibly sepsis, which could be fatal. AIDS patients are at risk for opportunistic infections such as P. jiroveci (P. carinii) pneumonia, C. albicans esophagitis or stomatitis, C. neoformans meningitis, cytomegalovirus, and Kaposi’s sarcoma.
Rationale:
(b) is incorrect because discharge teaching could be delegated to another nurse so the critical patient can be seen.
(c) is incorrect because the patient should have ita1 signs taken after completion of the immune serum globulin infusion, but there is no current indication of a complication and taking itals can be delegated to another member of the nursing team.
(d) is incorrect because the patient with selective immunoglobulin A deficiency is stable and can be seen later.
Question 12.
A patient is admitted to the emergency room for sickle cell crisis. The patient is dehydrated, and the nurse is planning for IV fluid therapy. Which of the following fluids is the best choice for this patient?
(a) D5W
(b) 3% sodium
(c) Dextrose 50% (D5O)
(d) Lactated Ringer’s soLution
Answer:
(a) D5W
Explanation:
Sickle cell disease is abnormal formation of red blood cells into a sickle shape. The red blood cells have difficulty transporting oxygen through the bloodstream, causing fatigue, difficulty breathing, severe pain, joint swelling, jaundice, tachycardia, and low hemoglobin. Dehydration is often present when a patient is in sickle cell crisis. Oral hydration must be promoted in sickling crisis, however, sometimes IV hydration is necessary to treat the dehydration and prevent further sickling of cells. The choice fluid for this situation is D5W or D5 in 0.25% NS. Supplemental oxygen may also be needed.
Rationale:
(b) is incorrect because 3% sodium is a hypertonic solution used to treat patients who are hyponatre mie. The sickle cell crisis patent needs D5W to replace fluid loss from dehydration and provide additional glucose to cells.
(c) is incorrect because D5O is very hypertonic and is used to treat a patient who is hypoglycemic, not dehydrated.
(d) is incorrect because Lactated Ringer’s is an isotonic solution which is safe to use during sickle cell crisis but doesn’t provide the needed glucose as does D5W.
Question 13.
A patient who is allergic to bee stings receives a new prescription for an epinephrine auto injector. After educating the patient regarding the EpiPen, which statement demonstrates more teaching is necessary?
(a) “If symptoms subside, after using my EpiPen, I don’t have to come to the emergency room".
(b) “I will have two EpiPens in my purse all the time.”
(c) “The expiration date should be written on the calendar.”
(d) “I can inject the EpiPen through my clothing.”
Answer:
(a) “If symptoms subside, after using my EpiPen, I don’t have to come to the emergency room".
Explanation:
EpiPen is used in severe allergic reactions or anaphylaxis to counteract the massive vasodilation and subsequent hypotension that occurs. Epinephrine causes bronchodilation and reduces mucosal edema to relieve bronchoconstriction and improve respiratory effort. After use of an EpiPen, patients should call 911 or go to the emergency room to be monitored.
Rationale:
(b) is incorrect because having two EpiPens at all times is good practice and indicates understanding. In the event that one pen is ineffective, faulty, or another dose is needed, it is beneficial to have another pen available.
(c) is incorrect because the statement indicates understanding. EpiPens have an expiration date, which is important to note on the calendar. Even if the EpiPen hasn’t been used, if it becomes expired, it should be disposed of appropriately and a new pen should be obtained.
(d) is incorrect because it indicates understanding. The EpiPen can be injected through clothing. It is safer to inject through clothing than to postpone the medication’s beneficial effects by waiting for clothing removal.
Question 14.
The preoperative nurse assesses a patient prior to a spinal laminectomy surgical procedure. The nurse notes the patient is allergic to strawberries and avocados. What is the best action by the nurse?
(a) Assess that the patient has been NPO prior to surgery
(b) Communicate this information with dietary staff
(c) Document the information in the patient’s chart
(d) Ensure the information is passed on to the surgical team
Answer:
(d) Ensure the information is passed on to the surgical team
Explanation:
Patients who are allergic to strawberries and avocados are at high risk for latex allergy, which the surgical team should be informed of. The surgical area can he made latex-free as a precaution to prevent an allergic reaction. Patients with allergies to bananas, kiwis, chestnuts, and passionfruit are also at higher risk for latex allergies.
Rationale:
(a) is incorrect because NPO status is important for a pre-operative patient but unrelated to allergy history or potential latex allergy.
(b) is incorrect because dietary staff can be notified at a later time. This is not a priOrity at this time, because the patient will be NPO prior to surgery.
(c) is incorrect because preventative care is a higher priority than documentation. It is the nurse’s responsibility to be sure the pertinent information is passed on to the surgical team before the procedure is initiated to reduce the likelihood of a latex allergic reaction.
Question 15.
The nurse working in the allergy clinic is caring for clients. Which task below takes priority?
(a) Checking emergency equipment every morning
(b) Ensuring consent is obtained when needed
(c) Providing educational materials in several languages
(d) Teaching clients about managing their allergies
Answer:
(a) Checking emergency equipment every morning
Explanation:
Safety is always priority in patient care. Emergency equipment should be checked every morning and medications availaNe, so this is the priority action.
Rationale:
(b) is incorrect because informed consent is ultimately the healthcare provider’s responsibility. The nurse acts as a witness, but obtaining consent is not the nurse’s greatest priority.
(c) is incorrect because educational materials are important, but not the greatest priority. This addressed the patient’s psychosocial needs, but safety is the biggest concern.
(d) is incorrect because teaching regarding allergies is important for the general patient population but not as much as a safety priority as answer choice.
Question 16.
The clinic nurse receives a call trom a patient who has been exposed to poison ivy. The patient reports an itchy rash that has not been relieved by over-the-counter antihistamines. What is the best response by the nurse?
(a) “Antihistamines will not relieve poison ivy.”
(b) “There are several antihistamines to try.”
(c) “You need to come to the clinic right away.”
(d) “You may need IV steroid treatment.”
Answer:
(a) “Antihistamines will not relieve poison ivy.”
Explanation:
Poison ivy rash is caused by an allergic reaction to an oily resin found in the leaves, stems, and roots of poison iy, poison oak, and poison sumac. The rash can be very itchy and last for weeks but generally goes away on its own. Antihistamines do not relieve poison ivy because this is a type IV reaction, and histamine is not a mediator of this type of reaction. The patient will need to be educated regarding this.
Rationale:
(b) is incorrect because antihistamines do not provide relief from poison ivy.
(c) is incorrect because the patient does not need to go to the clinic right away. The patient should be taught about the use of soothing lotions and cool baths to relieve the itching associated with poison ivy rash. Only if blisters or signs of a bacterial skin infection appear should the patient come see the healthcare provider.
(d) is incorrect because steroids may not be needed unless blisters appear or the rash persists for longer than 2-3 weeks. If steroids are indicated (commonly prednisone), the PO or topical route would be used ahead of IV steroids.
Question 17.
Plasmapheresis is ordered by the healthcare provider for a client with Goodpasture’s syndrome. As the nurse is planning his care, which potential problem is the nurse’s greatest priority?
(a) Reduced physical activity due to disease effects on the lungs
(b) Inadequate family coping related to patient’s hospitalization
(c) Inadequate knowledge related to plasmapheresis process
(d) Potential for infection related to plasmapheresis
Answer:
(d) Potential for infection related to plasmapheresis
Explanation:
Goodpasture’s syndrome is an uncommon autoimmune disease that affects both the kidneys and the lungs. Symptoms include fatigue, weakness, and loss of appetite caused by the body’s antibodies attacking the lining of the lungs and the kidneys. This can lead to blood in the sputum or glomerulonephritis. Plasmapheresis may be performed to filter the blood and remove harmful antibodies. This treatment requires close hemodynamic monitoring and increases the patient’s risk for infection.
Rationale:
(a) is incorrect because reduced activity will only be indicated if the vital signs and oxygenation status reflect the need. Risk for infection is a greater priority.
(b) is incorrect because family coping is not priority.
(c) is incorrect because inadequate knowledge is a definite potential but not as much of a priority as risk for infection.
Question 18.
The nurse has administered four doses of IV antihistamines to a patient experiencing severe allergy symptoms. What is the most important action by the nurse?
(a) Assess the patient’s bedside glucose
(b) Instruct patient not to get up without help
(c) Monitor frequently for tachycardia
(d) Monitor frequently for tachycardia
Answer:
(b) Instruct patient not to get up without help
Explanation:
Drowsiness frequently occurs with the use of antihistamines, so the patient should call for help before getting up to prevent injuìy. Common side effects of antihistamines include drowsiness and dry mouth. More serious adverse reactions that the nurse should monitor for include sedation, bronchospasm, depression, and nightmares.
Rationale:
(a) is incorrect because blood glucose changes are not related to antihistamine administration.
(c) is incorrect because tachvcardia is not a common adverse reaction to antihistamine treatment.
(d) is incorrect because intake, output, and weight are generally required for all patients but not directly related to antihistamine administration.
Question 19.
A patient on the medical floor has been receiving IV antibiotics for septicemia. When the nurse responds to their call light, the patient appears to have a swollen face and lips. What is the first action the nurse should take?
(a) Administer epinephrine 1:1000, 0.3 mg IV push immediately
(b) Apply a pulse oximeter and ioo% oxygen by facemask
(c) Ensure a patent airway while calling the rapid response ream
(d) Reassure the patient that she will receive the best care
Answer:
(c) Ensure a patent airway while calling the rapid response ream
Explanation:
Anaphylaxis is a severe, multi-system response to an antigen-antibody reaction upon subsequent exposure to a substance for which the patient has developed a sensitivity. Large amounts of histamine are rapidly dispersed throughout the circulatory system causing extensive vasodilation and severe edema of bronchial tissues. This can lead to pulmonary obstruction.
Especially when the face and lips become swollen, airway assessment is priority in the patient who has an allergic reaction to a medication. The nurse must assess patency of the airway and the rapid response ream should be notified for immediate assistance at the bedside. Other assessments the nurse might find include hypotension, tachycardia, dilated pupils, diaphoresis, dyspnea, and flushing.
Rationale:
(a) is incorrect because epinephrine may be needed, but the nurse must first determine if the airway is affected by the allergic reaction. Checking the airway is the first action the nurse should take.
(b) is incorrect because oxygen may be needed, but assessing the airway is priority. If the airway is swollen shut and the patient is not effectively breathing, applying high flow oxygen by mask will not help.
(d) is incorrect because reassurance is appropriate, but this meets the patient’s psychosocial need. Airway is the physical priority.
Question 20.
A patient who is receiving treatment for a snake bite is suspected by the nurse of having serum sickness. Which lab result would be most concerning to the nurse?
(a) Blood urea nitrogen: 13 mg/dL
(b) Creatinine: 3.3 mg/dL
(c) Hemoglobin: 8.3 mg/dL
(d) White blood cell count: 13,000/mm3
Answer:
(b) Creatinine: 3.3 mg/dL
Explanation:
Serum sickness is a type III hypersensitivity delayed immune response to either a medication (most commonly penicillin) or an anti-serum (such as is given for a snake bite). Symptoms include redness and itching at the injection site, hives, joint pain, fever, malaise, swollen lymph nodes, wheezing, and flushing. Antihistamines, NSAIDs, and corticosteroids are used to treat serum sickness. If untreated, serum sickness nephritis can occur, which manifests with elevated creatinine level. (Normal creatinine for an adult is 0.7-1.4 mg/dl normal for a child is 0.4-1.2 mg/dl.)
Rationale:
(a) is incorrect because this blood urea nitrogen is normal (10-20 mg/dl). The nurse would expect to see elevated BUN if serum sickness nephntis is present.
(c) is incorrect because low hemoglobin is unrelated to serum sickness. (Normal for a male is 13-18 g/dl; normal for a female is 12-16 g/dl; normal for a child aged 3-12 is 11-12.5 g/dl.)
(d) is incorrect because the white blood cell count is slightly elevated but is not a sign of a complication with serum sickness.
Question 21.
A nurse working on the medical floor is assessing patients. Which action will prevent a type II hypersensitivity reaction in the clients?
(a) Steroid administration for severe serum sickness
(b) Correctly identifying patients prior to blood transfusions
(c) Keeping the patient free of offending agents
(d) Providing a latex-free environment for patients
Answer:
(b) Correctly identifying patients prior to blood transfusions
Explanation:
A Nood transfusion reaction is a type II hypersensitivity reaction. Correct identification of patients and cross-matching blood to be administered can prevent this type of reaction.
Rationale:
(a) is incorrect because serum sickness is a type III reaction.
(c) is incorrect because avoidance therapy is important for type I and 1V hypersensitivities. Examples include allergic contact dermatitis (from poison ivy) and inflammatory bowel disease.
(d) is incorrect because latex allergy is a type I hypersensitivity: an allergic reaction provoked by exposure to a specific type of antigen called an “allergen.” Other examples include allergic asthma, allergic rhinitis (hay fever), food allergies, and antibiotic allergies.
Question 22.
The nurse administers rivaroxaban to a patient. When the patient asks how the medication works, what is the best response by the nurse?
(a) “It inhibits thrombin.”
(b) “It inhibits fibrinogen.”
(c) “It keeps your blood from becoming too thin.”
(d) “It works against vitamin K.”
Answer:
(a) “It inhibits thrombin.”
Explanation:
Direct thrombin inhibitors, like rivaroxaban, work by inhibiting the enzyme thrombin, which is instrumental in the formation of blood clots. Rivaroxaban interrupts the intrinsic and extrinsic blood clotting cascade, decreasing the likelihood of blood clot formation. The most serious adverse effect is bleeding.
Rationale:
(b) is incorrect because rivaroxaban does not affect fibrinogen. Heparin is an example of a drug that helps to prevent conversion of fibrinogen to fibrin. Another drug, pentoxifvlline, is a hemorrheologic agent that reduces blood viscosity (used to treat peripheral arterial disease) and can decrease fibrinogen concentration in the blood.
(c) is incorrect because rivaroxaban causes the blood to become thinner and helps prevent clot formation.
(d) is incorrect because rivaroxaban does not work against vitamin K. Vitamin K is important in the blood clotting process, and it is used is the antidote to warfarin.
Question 23.
A patient on the medical-surgical unit is confused and mumbling, and upon reviewing the lab results, the nurse finds the platelet count is 8,000/mm3. Which action by the nurse takes priority?
(a) Calling the rapid response team
(b) Obtaining a set of vital signs
(c) Instituting bleeding precautions
(d) Placing the patient on bedrest
Answer:
(a) Calling the rapid response team
Explanation:
Normal platelet (thrombocyte) count is 150,000-450,000/mm3. The patient with severe thrombocytopenia is at risk for spontaneous bleeding. Since the patient has a neurologic change as well, the rapid response team should be notified for immediate bedside assistance.
Rationale:
(b) is incorrect because vital signs are important but not priority.
(c) is incorrect because instituting bleeding precautions is important, but the greatest priority is to address the confusion and mumbled speech. These signs of neurological decline can indicate cerebral hemorrhage.
(d) is incorrect because placing the patient on bedrest is important for general safety but does not address the potential bleeding.
Question 24.
The nurse is preparing a blood transfusion to hang on a patient in the surgical unit. The patient is recovering from a lower laminectomy spinal surgery. Current vital signs are HR 88, BP 118/72, temperature 98.9°F (37.2°C), and RR i8. Which of the following actions by the nurse is most important?
(a) Documenting of the vital signs before beginning the blood infusion
(b) Placing the patient on NPO status
(c) Placing the patient in protective isolation
(d) Putting on gloves
Answer:
(d) Putting on gloves
Explanation:
Standard Precautions are important when handling blood products to prevent bloodborne illness. Clean gloves should be worn before preparing the blood product for administration.
Rationale:
(a) is incorrect because documentation is not more important than safety.
(b) is incorrect because NPO status is unnecessary for a patient receiving a blood transfusion.
(c) is incorrect because protective isolation is unnecessary for a patient receiving a blood transfusion. Protective isolation is only required if the patient has been determined to be immunocompromised and thus highly susceptible to become infected.
Question 25.
The nurse on the oncology unit has just received the hand-off report on four patients admitted with leukemia. Which patient shou’d be seen b the nurse first?
(a) Patient who passed two bloody diarrhea stools in the past four hours
(b) Patient who received promethazine before chemotherapy, complains of dry mouth
(c) Patient whose respiratory rate increased from i6 to 22 bpm
(d) Patient who has a lesion on the lower left lateral malleolus
Answer:
(a) Patient who passed two bloody diarrhea stools in the past four hours
Explanation:
Bloody stools indicate this patient may he suffering from acute gastrointestinal tract bleeding. This can be caused by the intense chemotherapy, which is used to treat leukemia. This is a potential circulatory emergency, which must be addressed first.
Rationale:
(b) is incorrect because promethazine is an anti-emetic which commonly causes dry mouth, so this is not most concerning to the nurse. Other side effects include drowsiness, dizziness, constipation, and urinary retention.
(c) is incorrect because the increase in respiratory rate may indicate infection or anemia. This patient should be seen next by the nurse.
(d) is incorrect because the patient with integumentary issues, such as a skin lesion, is not higher priority than potential bleeding.
Question 26.
A patient admitted to the medical unit for deep vein thrombus has developed petechiae after treatment. The platelet count is 43,000/mm3. The nurse will review the medication administration record for which medication?
(a) Enoxaparin
(b) Salicylates
(c) Unfractionated heparin
(d) Warfarin
Answer:
(c) Unfractionated heparin
Explanation:
Normal platelet (thrombocyte) count is 150,000-450,000/mm3. The patient with severe thrombocytopenia is at risk for spontaneous bleeding. Petechiae are indicative of heparin induced thrombocytopenia. This is a condition in which the platelets are destroyed by use of heparin, leading to decreased platelet count. Petechiae can also develop after administration of antineoplastic medications and glucocorticoids.
Rationale:
(a) is incorrect because enoxaparin is low molecular weight heparin, which is less likely to cause heparin-induced thrombocytopenia than unfractioned heparin.
(b) is incorrect because salicylates are not associated with heparin-induced thrombocytopenia. Salicylates, such as aspirin, can cause GI bleeding, heartburn, and
nausea.
(d) is incorrect because warfarin is not associated with heparin-induced thrombocytopenia. Warfarin can cause hemorrhage, diarrhea, rash, and fever.
Question 27.
A patient admitted to the emergency room for sickle cell crisis is complaining of right lower extremity pain of io out of w. Which of the following comfort measures should the nurse delegate to the unlicensed assistive personnel (UAP) for this patient?
(a) Apply ice packs to the legs
(b) Elevate the lower extremities on pillows
(c) Keep lower extremities warm with a blanket
(d) Place compression wraps on the lower extremities
Answer:
(c) Keep lower extremities warm with a blanket
Explanation:
Sickle cell crisis causes decreased peripheral blood flow to the extremities due to occlusion of small blood vessels with sickled red blood cells. This causes extreme pain due to tissue ischemia. The patient needs to have the lower extremities kept warm, which promotes vasodilation and increases perfusion. This task can be delegated to the UAP.
Rationale:
(a) is incorrect because cold temperatures cause vasoconstriction, which will further decrease the tissue perfusion.
(b) is incorrect because elevating the extremities decreases blood flow to the area and will not help improve circulation and perfusion to the affected extremity. Elevation is used to decrease edema.
(d) is incorrect because compression wraps are contraindicated in sickle cell crisis.
Question 28.
A patient on the medical unit is receiving a blood transfusion. The patient calls the nurse to report anxiety and lower back pain. After stopping the blood transfusion, changing the IV tubing, and hanging normal saline, which of the following nursing actions is the most important?
(a)Documenting the reaction in the patient’s chart
(b) Double checking patient and blood product for identification
(c) Placing patient on strict bed rest
(d) Reviewing the chart for known allergies
Answer:
(b) Double checking patient and blood product for identification
Explanation:
This patient has signs and symptoms characteristic of a hemolytic transfusion reaction. This type of reaction can be caused by ABO or Rh blood type incompatibility. The nurse must double check patient identification and blood product identification for blood typing. Other symptoms to be alert for include nausea, chills, vomiting, hypotension, tachvcardia, hematuria, and decreased urine output. Normal saline should be infused IV immediately after stopping the blood.
Rationale:
(a) is incorrect because direct patient care is more important than documentation. The nurse must first address the potential hemolytic reaction ahead of documenting.
(c) is incorrect because bed rest is not necessary for a hemolytic reaction. Supportive care for a hemolytic reaction includes oxygen, diphenhvdramine, and airway management.
(d) is incorrect because history of allergies is unrelated to hemolytic transfusion reaction.
Question 29.
A patient on the oncology ward is placed on neutropenic precautions. The family calls the nurse to report the patient “is not acting like himself.” What is the priority action by the nurse?
(a) Inquire about pain
(b) Assess for infection
(c) Delegate vital signs
(d) Review lab results from this morning
Answer:
(b) Assess for infection
Explanation:
Neutropenic patients are at increased risk of infection and may not display the normal signs and symptoms related to infection. Neutropenic precautions are instituted to prevent infection. The nurse needs to assess the patient for any type of infection which may be manifesting as change in level of consciousness or mentation.
Rationale:
(a) is incorrect because pain assessment is not a component of neutropenic precautions and this action will not provide information related to potential infection.
(c) is incorrect because this patient is not exhibiting expected behavior. The family’s report suggests a change in level of consciousness, which can indicate infection. Vitals need to be taken, but they should not be delegated for this patient.
(d) is incorrect because Lab results may not provide necessary information. A neutropenic patient may have an infection without elevated WBCs.
Question 30.
A 22-year-old male patient on the oncology unit is beginning treatment for lymphoma. Which of the following topics is priority for the nurse to teach the patient?
(a) Genetic testing
(b) Infection prevention
(c) Sperm banking
(d) Treatment options
Answer:
(c) Sperm banking
Explanation:
Lymphoma (cancer of lymphoid tissue) is treated with radiation, which can destroy sperm and sperm-producing abilities, especially if the irradiated areas are near the pelvis or lower abdomen. Because it is difficult to predict the exact impact of cancer treatment on fertility, sperm preservation prior to cancer treatment is important for fertility preservation.
Sperm banking should be discussed with this patient for future planning. In some cases, inca alkaloid antineoplastic medications may be used in the treatment of lymphoma; these medications are less gonadotoxic than radiation.
Rationale:
(a) is incorrect because genetic testing is important but not priority.
(b) is incorrect because infection prevention is generally important for a lymphoma patient but not specifically a priority at the beginning of lymphoma treatment. It is important that the patient be offered information about sperm banking before radiation therapy begins.
(d) is incorrect because discussion of treatment options is important but not the responsibility of the nurse. The oncologist is responsible for reviewing treatment options with the lymphoma patient.
Question 31.
The nursing student on the medical unit is caring for a patient with HIV infection. The student knows which of the following traits regarding HW are correct? (Select all that apply.)
(a) CD4+ cells create new HIV virus cells
(b) Antibody production is strengthened in the early stages
(c) Macrophages do not work properly
(d) Leading causes of death include opportunistic infection and cancer
(e) Stage 1 HIV is not infectious to others
Answer:
(a) CD4+ cells create new HIV virus cells
(c) Macrophages do not work properly
(d) Leading causes of death include opportunistic infection and cancer
Explanation:
Once in the body, the HIV virus attaches to CD4 cells (a type of WBC) and then muhiplies,making more copies of HIV. Macrophages are phagocytic WBCs whose action is severely limited in HIV patients. Opportunistic infections (such as P. jiroveci pneumonia, C. albicans stomatitis, C. neoformans meningitis, and cytomegalovirus) and a form of cancer called Kaposi’s sarcoma can take advantage of the body’s weakened immune system.
Rationale:
(b) is incorrect because HIV is characterized by a weakened immune system which continues to weaken over time as the disease progresses.
(e) is incorrect because HTV is infectious, regardless of stage.
Question 32.
The nurse is caring for a patient with AIDS on the medical-surgical unit. Which of the following are characteristic of AIDS? (Select all that apply.)What is the most appropriate action by the nurse?
(a) CD+4 count less than 200/mm3 or 14%
(b) Pneumocystisjiroveci pneumonia infection
(c) Positive ELISA test for HIV
(d) HIV wasting syndrome
(e) Antiretroviral medications prescribed
Answer:
(a) CD+4 count less than 200/mm3 or 14%
(b) Pneumocystisjiroveci pneumonia infection
(d) HIV wasting syndrome
Explanation:
The AIDS diagnosis is confirmed with positive HIV and CD4+ less than 200/mm3 or 14% or opportunistic infection including Pneumocystisjiroveci plus HIV wasting syndrome. (HIV wasting syndrome isnt a disease specifically but refers to an HIV patient who has lost 10% of their muscle mass.)
Rationale:
(c) is incorrect because a positive ELISA test is not a characteristic of AIDS. The ELISA test confirms HIV.
(e) is incorrect because prescribed antiretroviral medication is not necessarily a characteristic of AIDS. Two other retroviruses that are capable of causing human infection include human T-lymphotropic virus type 1 and 2 (HTLV-I and HTLV-Il). Both these retroviruses are also treated with antiretroviral medications.
Question 33.
The nurse is on a mission trip in an under-developed country to care for those infected with HIV. The nurse recognizes which of the following as barriers to preventing transmission of HIV perinatally? (Select all that apply.)
(a) Clean drinking water
(b) Cultural concerns about bottle-feeding
(c) Lack of antiretroviral medication availability
(d) Social stigma
(e) Knowledge deficit related to HIV transmission routes
Answer:
(b) Cultural concerns about bottle-feeding
(c) Lack of antiretroviral medication availability
(d) Social stigma
(e) Knowledge deficit related to HIV transmission routes
Explanation:
HIV treatment is complex, and there are numerous barriers in third world countries. Breastfeeding is cheaper and more convenient than bottle-feeding. Especially in low- income populations, some women are reluctant to accept treatment for HIV because they know they will be encouraged to bottle-feed instead of breastfeeding. These cultural and financial concerns about bottle-feeding can impact a woman’s willingness to be tested or accept HW treatment.
Lack of medication availability is another barrier. Social stigma is a barrier too. Some women are reluctant to be tested for HIV while pregnant because they live in areas where they are prone to be beaten if their diagnosis is revealed within their community. Lack of education about perinatal transmission is a barrier as well. Transmission can occur across the placenta during birth, by exposure to body fluids during birth, and through breastfeeding with HIV-contaminated breastmilk.
Rationale:
(a) is incorrect because although lack of access to clean drinking water poses a serious health threat in third world countries, this is not specifically a barrier to preventing transmission of HIV from infected mother to baby. HIV is not transmitted via contaminated water.
Question 34.
A patient with AIDS is in the clinic seeing the nurse about difficulty in eating due to oral thrush. Which actions can be delegated by the nurse to the unlicensed assistive personnel (UAP)? (Select all that apply.)
(a) Applying oral anesthetic before eating
(b) Assisting with oral care every two hours
(c) Offering cool drink sips frequently
(d) Providing alcohol-based mouthwash
(e) Providing a soft toothbrush
Answer:
(b) Assisting with oral care every two hours
(c) Offering cool drink sips frequently
(e) Providing a soft toothbrush
Explanation:
Oral thrush is a yeast infection of the mouth characterized by white exudate and inflammation in the mouth and back of the throat. This is most commonly caused by Candida albicans and is very uncomfortable. Inflammation and irritation of the oral cavity make it difficult to eat and drink without pain. It is within the scope of practice of the UAP to assist with oral care, offer fluids to drink, and remind the patient of activities and interventions previously taught by the nurse.
Rationale:
(a) is incorrect because it is not within the UAP’s scope of practice to administer any medications.
(d) is incorrect because an alcohol-based mouthwash will be ineffective in treating oral thrush and will cause further irritation and discomfort inside the patient’s mouth. Nystatin swish-and-swallow or clotrimazole oral solution can be administered by the nurse to treat thrush.
Question 35.
The student nurse is caring for a patient on the medical-surgical unit for splenectomy. The student learns the functions of the spleen include which of the following? (Select all that apply.)
(a) Breakdown of hemoglobin
(b) Destruction of red blood cells that are old or defective
(c) Production of vitamin K
(d) Storage of iron
(e) Storage of platelets
Answer:
(a) Breakdown of hemoglobin
(b) Destruction of red blood cells that are old or defective
(e) Storage of platelets
Explanation:
The spleen resembles a large lymph node and is located in the upper left portion of the abdominal cavity (behind stomach). Its main functions are the destruction of worn-out blood cells, breakdown of hemoglobin, removal of foreign bacteria, platelet storage, and storage and release of blood during hemorrhage. The spleen also functions in immunity as a site of B cell proliferation into plasma cells.
Rationale:
(c) is incorrect because vitamin K production occurs in the liver. Vitamin K is a necessary component in the production of four coagulation factors.
(d) is incorrect because iron is recycled in the spleen but stored in the liver.
Question 36.
The nurse in the clinic knows there are many medications that impact the immune system. Which of the following medications are included that have this effect? (Select all that apply.)
(a) Acetam i nophen
(b) Amphotericin B
(c) Sertraline
(d) Metformin
(e) Atorvastatin
Answer:
(b) Amphotericin B
(c) Sertraline
(e) Atorvastatin
Explanation:
The hematologic or immune system is disrupted by numerous medications. Amphotericin B is a powerful antifungal medication which is generally reserved only for progressive, potential life-threatening fungal infections. This medication can cause hernatological abnormalities affecting the immune system such as leukopenia and eosinophilia.
Sertraline is a SSRI antidepressant that increases serum serotonin levels and also boosts the immune system, sometimes even to the point of auto-immune disease. Atorvastatin is a drug used to lower cholesterol and has also been shown to reduce organ transplant rejection, indicating
that it suppresses the immune system.
Rationale:
(a) is incorrect because acetaminophen is an antipyretic and analgesic that can cause liver damage but does not directly affect the immune system. In fact, acetaminophen is a safe drug of choice prescribed to treat the pain associated with many autoimmune disorders.
(d) is incorrect because metformin is an oral hypoglycemic agent used to treat type II diabetes, which does not affect the immune system.
Question 37.
A 65-year-old patient asks the clinic nurse why the immune system in people his age is weaker than in youth. What are the best responses by the nurse? (Select all that apply.)
(a) ‘Your bone marrow produces less blood cells than when you were younger.”
(b) “You have decreased levels of platelets circulating in the bloodstream.”
(c) “You have decreased levels of proteins and plasma in the bloodstream.”
(d) “Lymphocytes are more reactive to foreign antigens.”
(e) “The function of the spleen decreases after age 60.”
Answer:
(a) ‘Your bone marrow produces less blood cells than when you were younger.”
(c) “You have decreased levels of proteins and plasma in the bloodstream.”
Explanation:
As adults age, the bone marrow starts to produce fewer blood cells and blood volume is decreased with less plasma proteins. With age, the body’s ability to determine self from non-self-diminishes, and macrophage activity slows.
Rationale:
(b) is incorrect because platelet count is only affected minimally by age, and platelets do not play a large role in immune function. Platelets are functional in blood clotting, and the normal platelet count is 150,000-450,000/mm3.
(d) is incorrect because lymphocytes are less reactive with age, making the body more susceptible to infection.
(e) is incorrect because spleen function is not directly affected by age. Decreased spleen function in the elderly is commonly linked so other underlying medical disorders or disease processes.
Question 38.
A patient tells the nurse they are always tired upon waking, despite getting eight hours of sleep. What is the first action the nurse should take?
(a) “Avoid dehydration.”
(b) “Minimize exercise and stay within your home as much as possible to prevent infection.”
(c) “Avoid extremely stressful situations.”
(d) “Take your antimetabolite medication daily.”
(e) “Avoid opioids for pain control, as they can cause central nervous system depression.”
Answer:
(a) “Avoid dehydration.”
(c) “Avoid extremely stressful situations.”
(d) “Take your antimetabolite medication daily.”
Explanation:
Sickle cell disease is abnormal formation of red blood cells into a sickle shape, which makes it difficult to absorb and transport oxygen through the bloodstream. This leads to difficulty breathing, pain, and end organ damage. Sickle cell crisis can be precipitated by several factors including dehydration, high levels of stress, exposure to high altitudes, and pregnancy. Antimetaboiites, analgesics, antibiotics, and vaccines are routine component of treatment for sickle cell anemia.
Rationale:
(b) is incorrect because sickle cell anemia is a chronic disease and the patient should be taught to stay as active as possible. Extreme vigorous exercise should be avoided, but exacerbation of sickle cell disease is unlikely to occur with a moderate exercise regimen. Although sickle cell patients are at greater risk for infection, they do not need to remain homebound. The nurse should teach the patient to avoid large crowds, where infection is most likely to be transmitted, but to remain active and independent within their community.
(e) is incorrect because sickle cell disease is often managed with oral acetaminophen and hydrococlone, or morphine as a part of the patient’s daily analgesic medication regime at home. Ineffective pain control for sickle cell patients has been shown to contribute to social isolation, depression, inactivity, and decreased adherence to the medication regimen.
Question 39.
The student nurse on the oncology floor is learning about risk factors related to leukemia. Which of the following are risk factors for leukemia? (Select all that apply.)
(a) Chemica exposure
(b) Genetically modified foods
(c) Ionizing radiation exposure
(d) Vaccinations
(e) Viral infections
Answer:
(a) Chemica exposure
(c) Ionizing radiation exposure
(e) Viral infections
Explanation:
Leukemia is neoplastic disease that affects the blood-forming tissues of the body, including the lymphatic system, spleen, bone marrow, and blood cells. The effect is uncontrolled destruction of leukocytes. Risk factors for development of leukemia include ionizing radiation exposure, certain iral infections, and chemical exposure. People can be exposed to chemicals such as benzene, pvridine, and aniline at work (plastic, lubricant, rubber, and dye manufacturing), in the general environment (gasoline fumes), and through the use of some consumer products.
Rationale:
(b) is incorrect because consumption of genetically modified organisms (GMOs) is not a known risk factor for leukemia. GMOs have, however, been linked to allergies, pesticide exposure, and antibiotic resistance.
(d) is incorrect because vaccinations are not a known risk factor for leukemia.
Question 40.
A patient is admitted to the oncology unit for Ann Arbor stage Ib Hodgkin’s lymphoma. Which manifestations does the nurse assess the patient for? (Select all that apply.)
(a) E-Ieadaches
(b) Night sweats
(c) Persistent fever
(d) Urinary frequency
(e) Neight loss
Answer:
(b) Night sweats
(c) Persistent fever
(e) Neight loss
Explanation:
“Ann Arbor staging” is the staging system for both Hodgkin’s and Non-Hodgkin’s lymphomas. The stage depends on the location of malignant tissue and the severity of the symptoms. Ann Arbor stage Ib Hodgkin’s lymphoma is characterized by single lymph node or single lymph region location of the disease with constitutional symptoms present, such as night sweats, persistent fever, and weight loss.
Rationale:
(a) is incorrect because headaches are not related to Hodgkin’s lymphoma.
(d) is incorrect because urinary frequency is not related to Hodgkin’s lymphoma.
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