MED SURG FINAL EXAM QUESTION BANK (From Exams 1-3 & ATI’s)

Exam 1
1. A patient has received atropine before surgery and complains of dry mouth. Which
action by the nurse is best? Answer: Tell the patient dry mouth is an expected side effect.
2. A patient arrives at the ambulatory surgery center for a scheduled laparoscopy
procedure in outpatient surgery. Which information is of most concern to the nurse?
Answer: The patient is planning to drive home after surgery.
3. As the nurse prepares a patient the morning of surgery, the patient refuses to remove a
wedding ring, saying, "I have never taken it off since the day I was married." Which
response by the nurse is best? Answer: Suggest that the patient give the ring to a family
member to keep.
4. The outpatient surgery nurse reviews the complete blood cell (CBC) count results for a
patient who is scheduled for surgery in a few days. The results are white blood cell
(WBC) count 10.2 × 103/µL; hemoglobin 15 g/dL; hematocrit 45%; platelets 150 ×
103/µL. Which action should the nurse take? Answer: Continue to prepare the patient for
the surgical procedure.
5. A 36-year-old female is admitted for an elective surgical procedure. Which information
obtained by the nurse during the preoperative assessment is most important to report to
the anesthesiologist before surgery? Answer: The patient's statement that her last
menstrual period was 8 weeks ago
6. Which information in the preoperative patient's medication history is most important to
communicate to the health care provider? Answer: The patient takes garlic capsules
daily.
7. A patient who takes a diuretic and a β-blocker to control blood pressure is scheduled for
breast reconstruction surgery. Which patient information is most important to
communicate to the health care provider before surgery? Answer: Serum potassium 3.2
mEq/L
8. Monitored anesthesia care (MAC) is going to be used for a closed, manual reduction of a
dislocated shoulder. What does the nurse anticipate? Answer: Starting an IV in the
patient’s unaffected arm.
9. While in the holding area, a patient reveals to the nurse that his father had a high fever
after surgery. What action by the nurse is a priority? Answer: Alert the anesthesia care
provider of the family member’s reaction to surgery
10. The nurse facilitates student clinical experiences in the surgical suite. Which action, if
performed by a student, would require the nurse to intervene? Answer: The student
wears street clothed in the semi-restricted area.
11. The operating room nurse is providing orientation to a student nurse. Which action would
the nurse list as a major responsibility of a scrub nurse? Answer: Keep both hands
above the operating table level
12. A patient in surgery receives a neuromuscular blocking agent as an adjunct to general
anesthesia. While in the PACU, what assessment finding is most important for the nurse
to report? Answer: Weak chest movement
13. Which action in the perioperative patient plan of care can the charge nurse delegate to a
surgical technologist? Answer: Pass sterile instruments and supplies to the surgeon and
scrub technician
14. When caring for a patient who has received general anesthetic, the circulating nurse
notes red, raised wheals on the patient’s arms. Which action should the nurse take?
Answer: Notify the ACP

15. The NG tube is removed 2nd day postop, pt is placed on a clear, liquid diet. 4 hrs later the
pt complains of sharp, cramping gas pains. What action by the RN is most appropriate?
Answer: assist the patient to ambulate

16. On admission of a patient to the postanesthesia care unit (PACU), the blood pressure
(BP) is 122/72. Thirty minutes after admission, the BP falls to 114/62, with a pulse of 74
and warm, dry skin. Which action by the nurse is most appropriate? Answer: Continue to
take vital signs every 15 minutes.
17. A postop patient has not voided for 8 hrs after surgery…. what action should the nurse
take first? Answer: Bladder scan
18. A patient is transferred from the postanesthesia care unit (PACU) to the clinical unit.
Which action by the nurse on the clinical unit should be performed first? Answer: Take
the patient's vital signs.
19. A postop pt has a nursing dx of ineffective airway clearance. The nurse determines that
interventions for this nursing diagnosis have been successful if which is observed?
Answer: Patients breath sounds are clear to auscultation
20. In the postanesthesia care unit (PACU), a patient's vital signs are blood pressure 116/72,
pulse 74, respirations 12, and SpO2 91%. The patient is sleepy but awakens easily.
Which action should the nurse take first? Answer: Encourage the patient to take deep
breaths.
21. Which action could the PACU nurse delegate to an UAP? Answer: Help with transfer
onto a stretcher
22. An older pt is being dc from the ambulatory surgical unit following L eye surgery. The pt
tells the nurse, “I don’t know if I can take care of myself once I’m home”. Which action by
the nurse is most appropriate? Answer: discuss specific concerns regarding self-care
23. A patient is admitted with possible botulism poisoning after eating home-canned green
beans. Which intervention ordered would the nurse question? Answer: Encourage oral
fluids to 3L/day
24. A 22-year-old patient who sustained a T2 spinal cord injury 10 days ago tells the nurse "i
want to be transferred to a hospital where the nurses know what they are doing"…
Answer: Request patient to take part in their care
25. The nurse will explain to the patient who has a T2 spinal cord transection injury that…
Answer: function of both arms should be retained

26. A 27-year-old patient is hospitalized with new onset of Guillain-Barré syndrome. The
most essential assessment for the nurse to carry out is? Answer: observing respiratory
rate and effort.

27. A construction worker arrives at an urgent care center with a deep puncture wound after
an old nail penetrated his boot.. The patient reports having had a tetanus booster 6
years ago. The nurse will anticipate? Answer: administration of the tetanus-diphtheria
(Td) booster.

28. Which assessment data for a patient who has GBS will require the nurses most
immediate action? Answer: The patient is continuously drooling saliva

29. A 35 yr old pt who has had a spinal cord injury returned home following rehab. The home
care RN notes the spouse is performing many of the activities the pt has been managing
unassisted in rehab… Answer: develop a plan to increase pt independence in consult
with pt and spouse

30. Which nursing action will the home health nurse include in the plan of care for a patient
with paraplegia at the T4 level in order to prevent autonomic dysreflexia? Answer: Assist
in planning a prescribed bowel program.

31. When giving home care instructions to a patient who has comminuted L forearm
fractures ana long-arm cast, which info should the nurse include? Answer: Call the
health care provider for numbness of the hand

32. Which statement by the pt indicates a good understanding of the nurse’s teaching about
a new short-arm synthetic cast? Answer: “I will apply an ice pack to the cast over the
fracture site off and on for 24 hrs”

33. Which dc instruction will the ED nurse include for a pt w/ a sprained ankle? Answer: use
pillows to elevate the ankle above the heart

34. A pt w/ a complex pelvic fracture from a MVC is on bed rest. Which nursing assessment
finding indicates a potential complication? Answer: Abdomen is distended and bowel
sounds are absent

35. How often should pin site care be performed? Daily with sterile cotton tipped applicator.
Books says to use chlorhexidine not hydrogen peroxide.

36. A pt who is to have NWB on the R leg is learning to walk w/ crutches. Which observation
by the nurse indicates the pt can ambulate independently? Answer: The pt advances the
right leg and both crutches together and then advances the left leg

37. A pt is being dc in 3 days after hip arthroplasty using the posterior approach. Which
action requires intervention? Answer: The pt leans over to pull on shoes and socks

38. Which info will the nurse teach seniors at a community recreation center about ways to
prevent fractures? Answer: Buy shoes that provide good support and are comfortable
39. When caring for a preoperative patient on the day of surgery, which actions included in
the plan of care can the nurse delegate to unlicensed assistive personnel (UAP)? (Select
all that apply.)
Answers: Obtain and document baseline vital signs, remove nail polish and apply pulse
oximeter, Transport the patient by stretcher to the operating room.
40. Which actions will the nurse include in the surgical time-out procedure before surgery?
Answer: Verify pt ID band number, ask pt to state procedure, pt state name and DOB

Exam 2
1. A pts cap BG level is 120 mg/dL 6 hrs after the nurse initiated a parenteral nutrition
infusion. The appropriate action by the nurse is to
a. Recheck BG 4-6 hrs later
2. After abdominal surgery, a pt w/ protein calorie malnutrition that is receiving PN; what is
the best indicator of adequate nutrition?
a. Surgical incision is healing normally
3. When caring for a pt with a soft, silicone NG tube in place for tube feeding the nurse will
a. Flush the tubing after checking for residual volume
4. A 76 yr old woman w/ a BMI of 17 kg/m2 and a low serum albumin level is being
admitted by the nurse. Which assessment finding will the nurse expect to find?
a. Pitting edema
5. A healthy adult woman who weighs 145 lb asks the clinic nurse about the minimum daily
requirement for protein. How many grams of protein will the nurse recommend?
a. 53
6. Which menu choice best indicates that the pt is implementing the nurses suggestion to
choose high-calorie, high-protein food?
a. Fried chicken with potatoes and gravy
7. The nurse will be teaching self-management to pts after gastric bypass surgery. Which
info will the nurse plan to include?
a. Drink fluids between meals but not with meals
8. A pt is being admitted for bariatric surgery. Which nursing action can the nurse delegate
to UAP?
a. Assist with IV insertion by holding adipose tissue out of the way
9. After the nurse teaches a pt about the recommended amounts of foods from animal and
plant sources, which menu selections indicate that the initial instructions about diet have
been understood?
a. 3 oz of roasted pork, a cup of corn, and a cup of carrot sticks
10. Which item should the nurse offer to the pt who is to restart oral intake after being NPO
due to nausea and vomiting?
a. Dish of lemon gelatin
11. Which info will the nurse include when teaching adults to decrease the risk of cancers of
the tongue and buccal mucosa?
a. Avoid use of cigarettes and smokeless tobacco
12. Which info will the nurse include when teaching a pt with peptic ulcer disease about the
effect of zantac?
a. Ranitidine decreases gastric acid secretion
13. A pt vomiting blood-streaked fluid is admitted to the hospital with acute gastritis. To
determine possible risk factors for gastritis, the nurse will ask the pt about
a. Use of NSAIDs
14. The nurse explaining esomeprazole (Nexium) to a patient with recurring heartburn
describes that the medication
a. Treats GERD by decreasing stomach acid production
15. A pt who has GERD is experiencing increasing discomfort. Which pt statement to the
nurse indicates that additional teaching about GERD is needed?
a. “I eat small meals during the day and have a bedtime snack”
16. The health care provider prescribes antacids and sucralfate (Carafate) for treatment of a
pts peptic ulcer. The nurse will teach the patient to take
a. Antacids after meals and sucralfate 30 minutes before meals
17. Which info will the nurse include for a pt that is newly diagnosed with GERD?
a. “Keep the HOB elevated on blocks”
18. A pt has peptic ulcer disease that has been associated with Helicobacter pylori. About
which meds will the nurse plan to teach the patient?
a. Amoxicillin (Amoxil), clarithromycin (Biaxin), and omeprazole (Prilosec)
19. The nurse evaluates that admin of Hep B vaccine to a healthy pt has been effective
when the pts blood specimen reveals
a. Anti-HBs
20. Which action should the nurse take to evaluate treatment effectiveness for a pt who has
hepatic encephalopathy?
a. Ask the pt to extend both arms forward
21. Which info given by a 70 yr old pt during a health history indicates to the nurse that the
pt should be screened for hep C?
a. The pt used IV drugs about 20 yrs ago
22. Which finding indicates to the nurse that lactulose is effective for an older adult who has
advanced cirrhosis?
a. The pt is alert and oriented
23. A pt is transferred from the recovery room to a surgical unit after a transverse colostomy.
The nurse observes the stoma to be deep pink with edema and a small amount of
sanguineous drainage. The nurse should
a. Document stoma assessment findings
24. The nurse preparing for the annual physical exam of a 50 yr old man will plan to teach
the patient about
a. Colonoscopy
25. A pt with a new ileostomy asks how much drainage to expect. The nurse explains that
after the bowel adjusts to the ileostomy, the usual drainage will be about ____ cups daily
a. 2
26. A pt with diverticulosis has a large bowel obstruction. The nurse will monitor for
a. Abdominal distention
27. A pt being admitted with an acute exacerbation of ulcerative colitis reports crampy
abdominal pain and passing 15 or more bloody stools a day. The nurse will plan to
a. Discontinue the pts oral food intake
28. A pt has a new diagnosis of Crohn’s disease after having frequent diarrhea and a weight
loss of 10 lb over 2 months. The nurse will plan to teach about
a. Medication use
 29. Which assessment should the nurse perform first for a pt who just vomited bright red
blood?
a. Taking the BP and the pulse
30. After bariatric surgery, a pt who is being discharged tells the nurse “I prefer to be
independent. I am not interested in any support groups” which reponse by the nurse is
best?
a. “Tell me what types of resources you think you might use after surgery”
31. 0.25 mL dilaudid
32. 85 mL/hr RBC
33. In what quadrant is the liver located?
a. Left upper and right upper
34. Picture
a.

35. 0.8 mL enoxaparin

36. 2 tablets digoxin
37. 20 mcg sodium
38. 2 tablets aspirin
Exam 3
A patient with a family history of cystic fibrosis (CF) asks for information about genetic testing.
Which response by the nurse is most appropriate?
a. Refer the patient to a qualified genetic counselor.

When caring for a young adult patient who has abnormalities in the cytochrome P450 (CYP
450) gene, which action will the nurse include in the patient’s plan of care?
a. Teach that some medications may not work effectively.

A patient tells the nurse, “I would like to use a home genetic test to see if I will develop breast
cancer.” Which is the nurse’s best initial response?
c. “Are you concerned about developing breast cancer?”
 The nurse in the outpatient clinic has obtained health histories for these new patients. Which
patient may need referral for genetic testing?
c. A 30-yr-old patient who has a sibling with newly diagnosed polycystic kidney
disease

The nurse provides discharge instructions to a patient who has an immune deficiency involving
the T lymphocytes. Which health screening should the nurse include in the teaching plan for this
patient?
b. Screening for malignancies

Which example should the nurse use to explain an infant’s “passive immunity” to a new mother?
b. Breastfeeding

A patient is being evaluated for possible atopic dermatitis. The nurse expects elevation of which
laboratory value?
a. IgE

An older adult patient who is having an annual check-up tells the nurse, “I feel fine, and I don’t
want to pay for all these unnecessary cancer screening tests!” Which information should the
nurse plan to teach this patient?
a. Consequences of aging on cell-mediated immunity

The nurse taking a health history learns that the patient, who has worked in rubber tire
manufacturing, has allergic rhinitis and multiple food allergies. Which action by the nurse is
correct?
b. Document the patient’s history and teach about clinical manifestations of a type I
latex allergy.

Which statement by a patient would alert the nurse to a risk for decreased immune function?
b. “I had my spleen removed after a car accident.”

Ten days after receiving a bone marrow transplant, a patient develops a skin rash. What would
the nurse suspect is the cause of the rash?
a. The donor T cells are attacking the patient’s skin cells.

A patient seeks care in the emergency department after sharing needles for heroin injection with
a friend who has hepatitis B. To provide immediate protection from infection, what medication
will the nurse expect to administer?
b. Gamma globulin

The nurse is advising a clinic patient who was exposed a week ago to human immunodeficiency
virus (HIV) through unprotected sexual intercourse. The patient’s antigen and antibody test has
just been reported as negative for HIV. What instructions should the nurse give to this patient?
a. “You will need to be retested in 2 weeks.”

A patient informed of a positive rapid antibody test result for human immunodeficiency virus
(HIV) is anxious and does not appear to hear what the nurse is saying. What action by the nurse
is most important at this time?
c. Remind the patient about the need to return for retesting to verify the results.
A patient who is diagnosed with acquired immunodeficiency syndrome (AIDS) tells the nurse, “I
feel obsessed with morbid thoughts about dying.” Which response by the nurse is appropriate?
c. “Can you tell me more about the thoughts that you are having?”

Which patient exposure by the nurse is most likely to require postexposure prophylaxis when
the patient’s human immunodeficiency virus (HIV) status is unknown?
c. Needle stick with a needle and syringe used for a venipuncture

A patient who uses injectable illegal drugs asks the nurse about preventing acquired
immunodeficiency syndrome (AIDS). Which response by the nurse is best?
c. “Consider participating in a needle-exchange program.”

The nurse prepares to administer the following medications to a hospitalized patient with human
immunodeficiency (HIV). Which medication is most important to administer at the scheduled
time?
c. Oral saquinavir (Invirase)

To evaluate the effectiveness of antiretroviral therapy (ART), which laboratory test result will the
nurse review?
a. Viral load testing

The registered nurse (RN) caring for an HIV-positive patient admitted with tuberculosis can
delegate which action to unlicensed assistive personnel (UAP)?
b. Stock the patient’s room with the necessary personal protective equipment.

A patient who is scheduled for a breast biopsy asks the nurse the difference between a benign
tumor and a malignant tumor. Which answer by the nurse is correct?
c. “Malignant tumors may spread to other tissues or organs.”

The nurse is caring for a patient who smokes two packs/day. Which action by the nurse could
help reduce the patient’s risk of lung cancer?
d. Discuss risks associated with cigarette smoking during each patient encounter.

The nurse teaches a patient who is scheduled for a prostate needle biopsy about the procedure.
Which statement, if made by the patient, indicates that teaching was effective?
c. “The biopsy will help decide the treatment for my enlarged prostate.”

The nurse is caring for a patient with colon cancer who is scheduled for external radiation
therapy to the abdomen. Which information obtained by the nurse would indicate a need for
patient teaching?
b. The patient swims several days each week.

A patient with metastatic cancer of the colon experiences severe vomiting after each
administration of chemotherapy. Which action, if taken by the nurse, is appropriate?
c. Administer prescribed antiemetics 1 hour before the treatments.

The nurse administers an IV vesicant chemotherapeutic agent to a patient. Which action is

most important for the nurse to take?
b. Stop the infusion if swelling is observed at the site.
A chemotherapy drug that causes alopecia is prescribed for a patient. Which action should the
nurse take to support the patient’s self-esteem?
a. Encourage the patient to purchase a wig or hat to wear when hair loss begins.

A patient who has a small cell carcinoma of the lung develops syndrome of inappropriate
antidiuretic hormone (SIADH). The nurse should notify the health care provider about which
assessment finding?
b. Serum sodium level of 120 mg/dL

IV potassium chloride (KCl) 60 mEq is prescribed for treatment of a patient with severe
hypokalemia. Which action should the nurse take?
b. Infuse the KCl at a rate of 10 mEq/hour.

A patient who was involved in a motor vehicle crash has had a tracheostomy placed to allow for
continued mechanical ventilation. How should the nurse interpret the following arterial blood gas
results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mEq/L?
d. Respiratory alkalosis

White on Right, Snow over trees, smoke over fire, chocolate warms the heart
Chapter 29: Assessment of Hematologic System

1. The nurse is caring for a patient who is being discharged after an emergency splenectomy
following a motor vehicle crash. Which instructions should the nurse include in the discharge
teaching?
d. Wash hands and avoid persons who are ill.

2. The nurse assesses a patient who has numerous petechiae on both arms. Which question should
the nurse ask the patient?
c. “Do you take medication containing salicylates?”

3. A nurse reviews the laboratory data for an older patient. The nurse would be most concerned
about which finding?
d. White blood cell (WBC) count of 2800/µL

4. A patient with pancytopenia has a bone marrow aspiration from the left posterior iliac crest.
Which action would be important for the nurse to take after the procedure?
b. Have the patient lie on the left side for 1 hour.

5. The nurse assesses a patient with pernicious anemia. Which assessment finding would the nurse
expect?
c. Numbness of the extremities

6. A patient’s complete blood count (CBC) shows a hemoglobin of 19 g/dL and a hematocrit of
54%. Which question should the nurse ask to determine possible causes of this finding?
b. “Do you have any history of lung disease?”

7. The nurse is reviewing laboratory results and notes a patient’s activated partial thromboplastin
time (aPTT) level of 28 seconds. The nurse should notify the health care provider in anticipation
of adjusting which medication?
b. Heparin

8. The nurse notes pallor of the skin and nail beds in a newly admitted patient. The nurse should
ensure that which laboratory test has been ordered?
c. Hemoglobin level

9. The nurse examines the lymph nodes of a patient during a physical assessment. Which
assessment finding would be of most concern to the nurse?
a. A 2-cm nontender supraclavicular node

10. A patient who had a total hip replacement had an intraoperative hemorrhage 14 hours ago. Which
laboratory test result would the nurse expect?
c. Elevated reticulocyte count
 11. The complete blood count (CBC) indicates that a patient is thrombocytopenic. Which action
should the nurse include in the plan of care?
a. Avoid intramuscular injections.

12. The health care provider’s progress note for a patient states that the complete blood count (CBC)
shows a “shift to the left.” Which assessment finding will the nurse expect?
c. Elevated temperature

13. The health care provider orders a liver and spleen scan for a patient who has been in a motor
vehicle crash. Which action should the nurse take before this procedure?
d. Assist the patient to a flat position.

14. A patient with pancytopenia of unknown origin is scheduled for the following diagnostic tests.
The nurse will provide a consent form to sign for which test?
a. Bone marrow biopsy

15. The nurse reviews the laboratory test results of a patient admitted with abdominal pain. Which
information will be most important for the nurse to communicate to the health care provider?
d. White blood cell (WBC) count 15,500/µL

16. Which information shown in the table below about a patient who has just arrived in the
emergency department is most urgent for the nurse to communicate to the health care provider?

Assessment Complete Blood Count Patient History

· BP 110/68 · Hgb 10.6 g/dL · Occasional aspirin
· Pulse 98 beats/min · Hct 30% use
· Brisk capillary refill · WBC 5100/µL · Abdominal pain x 1
· Multiple ecchymoses · Platelets 19,500/µL week
on arms · Large, dark stool this
morning

b. Platelet count

Chapter 30: Hematologic Problems

1. A 62-year old man with chronic anemia is experiencing increased fatigue and occasional
palpitations at rest. The nurse would expect the patient’s laboratory test findings to include
d. a hemoglobin (Hgb) of 8.6 g/dL (86 g/L).

2. Which menu choice indicates that the patient understands the nurse’s teaching about
recommended dietary choices for iron-deficiency anemia?
a. Omelet and whole wheat toast

3. A patient who is receiving methotrexate for severe rheumatoid arthritis develops a megaloblastic
anemia. The nurse will anticipate teaching the patient about increasing oral intake of
 b. folic acid.

4. A 52-yr-old patient has a new diagnosis of pernicious anemia. The nurse determines that the
patient understands the teaching about the disorder when the patient states,
c. “I could choose nasal spray rather than injections of vitamin B12.”

5. An appropriate nursing intervention for a hospitalized patient with severe hemolytic anemia is to
b. alternate periods of rest and activity.

6. Which patient statement to the nurse indicates a need for additional instruction about taking oral
ferrous sulfate?
a. “I will call my health care provider if my stools turn black.”

7. Which collaborative problem will the nurse include in a care plan for a patient admitted to the
hospital with idiopathic aplastic anemia?
b. Potential complication: infection

8. It is important for the nurse providing care for a patient with sickle cell crisis to
b. evaluate the effectiveness of opioid analgesics.

9. Which statement by a patient indicates good understanding of the nurse’s teaching about
prevention of sickle cell crisis?
d. “Risk for a crisis is decreased by having an annual influenza vaccination.”

10. Which instruction will the nurse plan to include in discharge teaching for a patient admitted with
a sickle cell crisis?
c. Avoid exposure to crowds when possible.

11. The nurse notes scleral jaundice in a patient being admitted with hemolytic anemia. The nurse
will plan to check the laboratory results for the
b. bilirubin level.

12. A patient who has been receiving IV heparin infusion and oral warfarin (Coumadin) for a deep
vein thrombosis (DVT) is diagnosed with heparin-induced thrombocytopenia (HIT) when the
platelet level drops to 110,000/µL. Which action will the nurse include in the plan of care?
b. Discontinue the heparin infusion.

13. An expected action by the nurse caring for a patient who has an acute exacerbation of
polycythemia vera is to
d. monitor fluid intake and output.

14. Which intervention will be included in the nursing care plan for a patient with immune
thrombocytopenic purpura?
b. Avoid intramuscular (IM) injections.

15. Which laboratory result will the nurse expect to show a decreased value if a patient develops
heparin-induced thrombocytopenia (HIT)?
 d. Activated partial thromboplastin time

16. The nurse is caring for a patient with type A hemophilia being admitted to the hospital with
severe pain and swelling in the right knee. The nurse should
b. immobilize the knee joint.

17. A young adult who has von Willebrand disease is admitted to the hospital for minor knee surgery.
The nurse will review the coagulation survey to check the
b. bleeding time.

18. A routine complete blood count for an active older man indicates possible myelodysplastic
syndrome. The nurse will plan to teach the patient about
b. bone marrow biopsy.

19. Which action will the admitting nurse include in the care plan for a patient who has neutropenia?
b. Check temperature every 4 hours.

20. Which laboratory test will the nurse use to determine whether filgrastim (Neupogen) is effective
for a patient with acute lymphocytic leukemia who is receiving chemotherapy?
d. Absolute neutrophil count

21. A patient who has acute myelogenous leukemia (AML) asks the nurse whether the planned
chemotherapy will be worth undergoing. Which response by the nurse is appropriate?
b. “The side effects of chemotherapy are difficult, but AML frequently goes into
remission with chemotherapy.”

22. A patient who has a history of a transfusion-related acute lung injury (TRALI) is to receive a
transfusion of packed red blood cells (PRBCs). Which action by the nurse will decrease the risk
for TRALI for this patient?
b. Transfuse only leukocyte-reduced PRBCs.

23. A patient who has acute myelogenous leukemia (AML) is considering treatment with a
hematopoietic stem cell transplant (HSCT). The best approach for the nurse to assist the patient
with a treatment decision is to
b. ask whether there are questions or concerns about HSCT.

24. Which action will the nurse include in the plan of care for a patient admitted with multiple
myeloma?
a. Monitor fluid intake and output.

25. An appropriate nursing intervention for a patient with non-Hodgkin’s lymphoma whose platelet
count drops to 18,000/µL during chemotherapy is to
a. check all stools for occult blood.

26. A patient who has acute myelogenous leukemia develops an absolute neutrophil count of 850/µL
while receiving outpatient chemotherapy. Which action by the outpatient clinic nurse is most
appropriate?
 b. Teach the patient to administer filgrastim (Neupogen) injections.

27. Which assessment finding should the nurse caring for a patient with thrombocytopenia
communicate immediately to the health care provider?
b. The patient is difficult to arouse.

28. The nurse is planning to administer a transfusion of packed red blood cells (PRBCs) to a patient
with blood loss from gastrointestinal hemorrhage. Which action can the nurse delegate to
unlicensed assistive personnel (UAP)?
b. Obtain the temperature, blood pressure, and pulse before the transfusion.

29. A postoperative patient receiving a transfusion of packed red blood cells develops chills, fever,
headache, and anxiety 35 minutes after the transfusion is started. After stopping the transfusion,
what action should the nurse take?
c. Administer PRN acetaminophen (Tylenol).

30. A patient in the emergency department complains of back pain and difficulty breathing 15
minutes after a transfusion of packed red blood cells is started. The nurse’s first action should be
to
d. disconnect the transfusion and infuse normal saline.

31. Which patient should the nurse assign as the roommate for a patient who has aplastic anemia?
a. A patient with chronic heart failure

32. Which patient requires the most rapid assessment and care by the emergency department nurse?
b. The patient with neutropenia who has a temperature of 101.8° F

33. A patient with immune thrombocytopenic purpura (ITP) has an order for a platelet transfusion.
Which information indicates that the nurse should consult with the health care provider before
obtaining and administering platelets?
a. Platelet count is 42,000/mL.

34. Which problem reported by a patient with hemophilia is most important for the nurse to
communicate to the health care provider?
b. Tarry stools

35. A patient with septicemia develops prolonged bleeding from venipuncture sites and blood in the
stools. Which action is most important for the nurse to take?
c. Notify the health care provider.

36. A patient with possible disseminated intravascular coagulation arrives in the emergency
department with a blood pressure of 82/40, temperature of 102° F (38.9° C), and severe back
pain. Which prescribed action will the nurse implement first?
c. Infuse normal saline 500 mL over 30 minutes.

37. Which action for a patient with neutropenia is appropriate for the registered nurse (RN) to
delegate to a licensed practical/vocational nurse (LPN/LVN)?
 c. Administering subcutaneous filgrastim (Neupogen) injection

38. Several patients call the outpatient clinic and ask to make an appointment as soon as possible.
Which patient should the nurse schedule to be seen first?
b. A 23-yr-old with no previous health problems who has a nontender lump in the
axilla

39. After receiving change-of-shift report for several patients with neutropenia, which patient should
the nurse assess first?
b. A 33-yr-old with a fever of 100.8° F (38.2° C)

40. Which action will the nurse include in the plan of care for a patient who has thalassemia major?
c. Administer iron chelation therapy as needed.

41. Which patient information is most important for the nurse to monitor when evaluating the
effectiveness of deferoxamine (Desferal) for a patient with hemochromatosis?
d. Serum iron level

42. Which finding about a patient with polycythemia vera is most important for the nurse to report to
the health care provider?
c. Calf swelling and pain

43. Following successful treatment of Hodgkin’s lymphoma for a 55-yr-old woman, which topic will
the nurse include in patient teaching?
d. Need for follow-up appointments to screen for malignancy

44. A patient who has non-Hodgkin’s lymphoma is receiving combination treatment with rituximab
(Rituxan) and chemotherapy. Which patient assessment finding requires the most rapid action by
the nurse?
d. Lip swelling

45. Which information obtained by the nurse assessing a patient admitted with multiple myeloma is
most important to report to the health care provider?
a. Serum calcium level is 15 mg/dL.

46. When a patient with splenomegaly is scheduled for splenectomy, which action will the nurse
include in the preoperative plan of care?
c. Schedule immunization with the pneumococcal vaccine (e.g., Pneumovax).

47. The nurse has obtained the health history, physical assessment data, and laboratory results shown
in the accompanying figure for a patient admitted with aplastic anemia. Which information is
most important to communicate to the health care provider?

History Physical Assessment Laboratory Results

· Fatigue, which has · Conjunctiva pale · Hct 33%

 increased over last pink, moist · WBC 1500/µL
month · Multiple bruises · Platelets 70,000/µL
· Frequent · Clear lung sounds
constipation

a. Neutropenia

SHORT ANSWER

1. A patient is to receive an infusion of 250 mL of platelets over 2 hours through tubing that is
labeled: 1 mL equals 10 drops. How many drops per minute will the nurse infuse?
ANS: 21