Hall term 3 quiz 2
hich of the following actions should the nurse prioritize when taking care of a pt with a platelet
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count 23,000/mm3 - CORRECT ANSWER-protect the pt from injury
nurse is assessing a pt and finds small red-purple dots over most skin surfaces. the pt denies
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noticing them before. which action should the nurse take first - CORRECT ANSWER-report the
findings immediately to the RN of the HCP
nurse is preparing a pt for lymphangiography. which statement by the pt shows that more
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teaching is needed - CORRECT ANSWER-I will need a sandbag on my groin to prevent bleeding
hich of the following activities should be carried out to keep the pt safe before starting a blood
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transfusion - CORRECT ANSWER--match the blood to the order
-match the pt to the blood
-check the pts vital signs
nurse is monitoring a pt during a blood transfusion. after the blood has been hanging for 30
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mins, the pts temp rises from 98.6 F at baseline to 101.0 F. the pt also experiences severe chills.
which action should the nurse take first - CORRECT ANSWER-stop the transfusion and hang
normal saline solution
the nurse is caring for a pt admitted with pancytopenia with complaints of dyspnea upon exertion.
for which condition should the nurse assess further - CORRECT ANSWER-anemia
nurse is teaching a pt with sickle cell anemia about activities to avoid. which of the following
a
activities the pt plans to do shoes that more teaching is needed - CORRECT ANSWER-running a
marathon
the family of a pt with disseminated intravascular coagulation has questions about the bleeding
that is occurring. which statement by the nurse is the best response to explain why the pt is
bleeding - CORRECT ANSWER-bleeding happens when the bodys clotting factors have all been
used up
the nurse is teaching the parent of a child with hemophilia. which of the following statements by
the parent demonstrates understanding about preventing bleeding episodes - CORRECT
ANSWER-my son will have to avoid contact sports
hich family member should be restricted from visiting a pt with newly diagnosed leukemia -
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CORRECT ANSWER-the one who has a runny nose
hich of the following nursing interventions is a priority for the pt with multiple myeloma found in
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the fibs and femur - CORRECT ANSWER-implement safety measures to prevent falls
hich of the following nursing interventions are appropriate for a pt with thrombocytopenia -
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CORRECT ANSWER--avoid intramuscular injections
-avoid use of aspirin and nonsteroidal anti-inflammatory drugs
-encourage use of shoes and slippers
hat assesment data will best help the nurse determine whether interventions for neutropenia
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have been effective - CORRECT ANSWER-Temperature
, hich circumstance places the pt at most risk for postoperative pneumonia following a
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splenectomy - CORRECT ANSWER-location of surgical incision
hich of the following statements best defines a complementary modality - CORRECT
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ANSWER-an alterative treatment that is used in place of a conventional treatment
A+
hich of the following therapies is most likely to use research based interventions - CORRECT
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ANSWER-allopathy
pt who has high blood pressure tells the nurse he has been taking a ginger supplement in
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addition to his prescribed medications at home. what is the best response by the nurse -
CORRECT ANSWER-you should check with your health care provider to make sure the ginger
doesn't interact with your other medicaitons before you continue to take it
hich of the following complementary modalities are considered relaxation therapies - CORRECT
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ANSWER--progressive muscle relaxation
-biofeedback
-guided imagery
hich of the following statements best describes the most important role of the nurse in
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complementary and alternative modalities - CORRECT ANSWER-the nurse should become skilled
at collecting and reporting data related to pts use of complementary or alternative modalities
the nurse is caring for a pt who is a fall risk. which of these interventions should the nurse
implement to prevent a fall - CORRECT ANSWER--ensure adequate vitamin D and calcium intake
-perform a medication review
-keep environment week kit and clutter free
-encourage exercise that strengthen leg muscles
the nurse is caring for a resident who is confused, has become combative, and strikes out at the
nurse. the nurse would demonstrate the appropriate legal use of restraints for the resident based
on which of these - CORRECT ANSWER--the residents plan of care identifies behaviors requiring
restraints
-the resident may harm others
-the resident may cause self-harm
the home health nurse is collecting data on a pt. which of these is true about the nursing process
step of data collection in home health care - CORRECT ANSWER--data collection is performed
during every visit
-admission data collection may reveal problems unknown to the referrer
-data collection includes family roles
-environmental data is collected
-caregiver data is collected
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