nclex 2

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nclex 2
2012-04-13 03:26:30

nclex 2
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  1. 46. A client has been diagnosed with Disseminated Intravascular Coagulation (DIC) and transferred to the medicalintensive care unit (ICU) subsequent to an acute bleeding episode. In the ICU, continuous heparin drip therapyis initiated. Which of the following assessment findings would indicate a positive response to heparin therapy?1. increased platelet count2. increased fibrinogen3. decreased fibrin split products4. decreased bleeding
    (2) Effective heparin therapy should stop the process of intravascular coagulation, which should result in increased fibrinogen;Heparin administration, which interferes with thrombin-induced of fibrinogen to fibrin; bleeding should ceasedue to the increased availability of platelets and coagulation factors; DIC always occurs secondary to an underlying diseaseor condition, including: septicemia, obstetrical complications, disseminated malignancies, massive tissue injury(burns and trauma), hemolytic transfusion reaction, shock, and anaphylaxis.
  2. 47. The client, aged 28, was recently diagnosed with Hodgkin’s disease. After staging, therapy is planned to includecombination radiation therapy and systemic chemotherapy with MOPP (nitrogen mustard, vincristine {Onconvin},prednisone, and procarbazine). In planning care for the client, the nurse should anticipate which of the followingeffects to contribute to a sense of altered body image?1. cushingoid appearance2. alopecia3. temporary or permanent sterility4. pathologic fractures
    (4) Pathologic fractures are not common to the disease process or its treatment, although osteoporosis may be potentialcomplication of steroid use; Hodgkin’s disease most commonly affects young adults (males) and is spread through lymphaticchannels to contiguous nodes. It also may spread via hematogenous route to extradal sites (GI, bone marrow,skin, and other organs); a working “staging” classification is done for clinical use and care.
  3. 48. Which of the following would be an inappropriate item to include in planning care for a severely neutropenicpatient?1. Transfuse netrophils (granulocytes) to prevent infection.2. Exclude raw vegetables from the diet.3. Avoid administering rectal suppositories.4. Prohibit vases of fresh flowers and plants in the patient’s room.
    (1) Granulocyte transfusion is not indicated to prevent infection; produced in the bone marrow, granulocytes normallycompromise 70 percent of all WBCs. They are subdivided into three types based on staining properties: neutrophils,eosinophils, and basophils. They may be beneficial in selected population of infected, severely granulocytopenic patients(less than 500/mm3) not responding to antibiotic therapy and who are expected to experience prolonged suppressed granulocyteproduction.
  4. 49. Patients who take iron preparations should be warned of the possible side effects, which may include:1. dizziness and orthostatic hypotension.2. nausea, vomiting, diarrhea, and stomach cramps.3. drowsiness, lethargy, and fatigue.4. neuropathy and tingling in the extremities.
    (2) Oral iron preparations are often used to help those patients who have iron deficiency anemia to regain a positiveiron balance; these preparations need to be supplemented with adequate dietary intake of iron. It can take 2–3 weeksto see improvement and up to 6–10 months to return to a stable iron level once a deficiency exists; the most commonadverse effects associated with oral iron are related to direct GI upset, anorexia, nausea, vomiting, diarrhea, dark stools,and constipation.
  5. 50. What happens if folic acid is given to treat anemias without determining the underlying cause of the anemia?1. Erythropoiesis is inhibited.2. Excessive levels of folic acid may accumulate, causing toxicity.3. The symptoms of pernicious anemia may be masked, delaying treatment.4. Intrinsic factor is destroyed.
    (3) Folate deficiencies usually occur secondary to increased as a result of absorption problems in the small intestine;usually given with vitamin B12; they are both essential for cell growth and division and for the production of a strongstroma in the RBCs. Folic acid is used as a rescue drug for cells exposed to some toxic chemotherapeutic agents; confirmthe nature of the anemia to ensure that the proper drug regimen is being used.
  6. 51. Which of the following would not be included in the teaching for a patient who take oral iron preparations?1. Mix the liquid iron preparation with antacids to reduce GI distress.2. Take the iron with meals if GI distress occurs.3. Liquid forms should be taken with a straw to avoid discoloration of tooth enamel.4. Oral forms should be taken with juice not milk.
    (1) Iron is a toxic substance if too much is taken; iron can be taken with food, orange juice, and never with eggs, milk,coffee, and tea.
  7. 52. The test used to differentiate sickle cell anemia/sickle cell trait is:1. sickle cell preparation.2. peripheral smear.3. sickledex.4. hemoglobin electrophoresis.
    (4) Hemoglobin electrophoresis is used for the confirmation and discrimination between anemia/trait (sickle celltrait—HbS and HbA; sickle cell anemia—HbS); a test to identify various abnormal hemoglobins in the blood, includingcertain genetic disorders, as sickle cell anemias.
  8. 53. The anemias most often associated with pregnancy are:1. folic acid and iron deficiency.2. folic acid deficiency and Thalassemia.3. iron deficiency and Thalassemia.4. Thalassemia and B12 deficiency.
    1) Folic acid and iron deficiency anemia is one of the most common anemias, prevalent in women of childbearing agewith 50 percent of pregnant women having this type of anemia. Iron deficiency anemia during pregnancy is a result(usually) of the increase in the plasma level during pregnancy but not in the constituent level. Also, if a woman has thistype of anemia prepregnancy, it will get worse during pregnancy.
  9. 54. Neural tube defects in the fetus have been primarily associated with which deficiency in the mother?1. iron2. folic Acid3. vitamin B124. vitamin E
    (2) Neural Tube Defect—any of a group of congenital malformations involving defects in the skull and spinal columnthat are caused primarily by the failure of the neural tube to close during embryonic development. Folic acid is essentialfor the development of the neural tube and prevent the defect or failure of the tube to close (congenital anomalies).
  10. 55. Elderly persons with pernicious anemia should:1. be instructed to increase their dietary intake of foods high in B12.2. be told they will not need to return for follow-up for at least a month after initiation of treatment.3. be told that oral B12 is safer and less expensive than parenteral replacement.4. be told that diarrhea can be a transient side effect of B12 injections.
    (4) Pernicious anemia—a megaloblastic, macrocytic, normochronic anemia caused by a deficiency of the intrinsic factorproduced by the stomach, which results in malabsorption of vitamin B12 necessary for DNA synthesis and maturation ofRBC. Education should include side effects of vitamin B12: pain and burning at injection site, peripheral vascular thrombosis,and transient diarrhea; comfort/safety measures.
  11. 56. Which of the following would be included in a diet rich in iron?1. peaches, eggs, beef2. cereals, kale, cheese3. red beans, enriched breads, squash4. legumes, green beans, eggs
    (1) Home sources of iron include meat, poultry, and fish that can be absorbed in the body; in addition these sourcescontain a factor that helps to enhance iron absorption of nonheme sources as well as the diet. Eating vitamin C at thesame time with iron sources in the diet also helps to promote iron absorption; high calcium intake in the diet promotesthe absorption of iron, because it helps to bind to phytates and thereby limits their effect; and the use of iron-containingcookware can increase the iron content in the diet.
  12. 50. Which of the following conditions may cause an increase in the white blood cell (WBC) count?1. glaucoma2. dementia3. pneumonia4. atrial fibrillation
    (3) WBC count is elevated with infectious processes, such as pneumonia. The other conditions do not have anincreased WBC.
  13. 51. Which of the following describes a shift to the left in the white blood cell (WBC) count?1. an increase in granulocytes2. an increase in bands3. an increase in monocytes4. an increase in eosinophils
    (2) An increase in immature neutrophils, such as bands, is a shift to the left. The other options are mature types of WBCs.
  14. 52. For the client with a white blood cell count (WBC) less than 1,000, which sign should the nurse be vigilant inassessing?1. hypotension2. hypertension3. bradycardia4. fever
    (4) The client with such a low WBC cannot fight infection well, and a fever could indicate the development of such aproblem. The other options are not indicative of a low WBC.
  15. 53. Which cell type is elevated in the client with severe burns?1. neutrophils2. bands3. basophils4. eosinophils
    (1) Neutrophils are increased in conditions with tissue necrosis, such as burns, not the other cell types.
  16. 54. Which cell type is elevated in the client with leukemia?1. neutrophils2. bands3. basophils4. neutrophils
    (3) Basophils are increased with leukemia, not the other cell types.
  17. 55. Which cell type is elevated in the client with asthma?1. lymphocytes2. monocytes3. basophils4. eosinophils
    (4) Eosinophils are increased in asthma, not the other cell types.
  18. 56. Which cell type is elevated in the client with Hodgkin’s disease?1. lymphocytes2. monocytes3. basophils4. eosinophils
    (1) Lymphocytes are increased with Hodgkin’s disease, not the other cell types.
  19. 57. A client with a seizure disorder takes Dilantin (phenytoin) to control seizures. A white blood cell count (WBC)is done, and it is discovered that the client has a low neutrophil count. What conclusion may the nurse make?1. The blood specimen needs to be redrawn.2. The neutrophil count may not indicate a disease.3. The physician needs to be notified immediately.4. The client has developed an infection.
    (2) Dilantin (phenytoin) may decrease the neutrophil count, so it may not be an accurate indication of a diseaseprocess. There is no indication for a blood redraw or to notify the physician immediately. A high neutrophil countwould indicate an infection.
  20. 58. Which type of precautions would the nurse take for the client with a white blood cell (WBC) count less than1,000?1. isolation2. reverse isolation3. respiratory isolation4. skin precautions
    (2) The client is placed in reverse isolation, since they will not be able to fight infection with such a dangerously lowWBC. The other options are not correct, as the client does not have an infection that could be passed to others.