Practice Test Flashcards

A 25-year-old male is admitted in sickle cell crisis. Which of the following interventions would be of highest priority for this client?

Answer: Encouraging fluid intake of at least 200mL per hour

In sickle cell crisis, the primary problem is vaso-occlusion caused by sickled red blood cells, leading to severe pain and tissue ischemia. Aggressive hydration, such as encouraging 200mL of fluid per hour, is a top priority because it helps to dilute the blood, reduce its viscosity, and improve circulation. This action prevents further sickling, promotes blood flow through constricted vessels, and helps alleviate pain and prevent organ damage.

The home health nurse is visiting a client with autoimmune thrombocytopenic purpura (ATP). The client’s platelet count currently is 80, It will be most important to teach the client and family about:

Answer: Bleeding precautions

Autoimmune thrombocytopenic purpura (ATP) is characterized by a low platelet count, which impairs the blood's ability to clot. With a platelet count of 80 (likely 80,000/µL), the client is at a significantly increased risk for bleeding. Therefore, teaching about bleeding precautions, such as avoiding injury, using a soft toothbrush, and watching for signs of bleeding, is the most critical intervention to prevent serious and potentially life-threatening complications.

A nurse is caring for a patient with acute lymphoblastic leukemia (ALL). Which of the following is the most likely age range of the patient?

Answer: 3-10 years.

Acute lymphoblastic leukemia (ALL) is the most common type of cancer in children. Its incidence peaks between the ages of 2 and 5 years. Therefore, the age range of 3-10 years represents the most likely demographic for a patient diagnosed with ALL, making it a predominantly pediatric malignancy.

Which of the following foods would the nurse encourage the client in sickle cell crisis to eat?

Answer: Popsicle

Clients in sickle cell crisis require aggressive hydration to help prevent and treat vaso-occlusive events. Popsicles are an excellent choice because they are a palatable and often soothing way to increase fluid intake, especially for someone who may have a decreased appetite or difficulty drinking large volumes of water. This helps maintain hydration and reduce blood viscosity.

Tissue plasminogen activator (t-PA) is considered for treatment of a patient who arrives in the emergency department following onset of symptoms of myocardial infarction. Which of the following is a contraindication for treatment with t-PA?

Answer: History of cerebral hemorrhage.

Tissue plasminogen activator (t-PA) is a potent thrombolytic agent used to dissolve blood clots. A history of cerebral hemorrhage is an absolute contraindication for t-PA treatment because it significantly increases the risk of intracranial bleeding, which could be fatal. The potential for a recurrent hemorrhage outweighs the benefits of dissolving a myocardial infarction clot.

A client has autoimmune thrombocytopenic purpura. To determine the client’s response to treatment, the nurse would monitor:

Answer: Platelet count

Autoimmune thrombocytopenic purpura (ATP) is a disorder characterized by the immune-mediated destruction of platelets, leading to a low platelet count. The primary goal of treatment is to increase the platelet count to a safe level and reduce the risk of bleeding. Therefore, monitoring the platelet count is the most direct and crucial indicator of the client's response to therapy.

A 21-year-old male with Hodgkin’s lymphoma is a senior at the local university. He is engaged to be married and is to begin a new job upon graduation. Which of the following diagnoses would be a priority for this client?

Answer: Sexual dysfunction related to radiation therapy

For a 21-year-old male who is engaged and planning a future, the potential for sexual dysfunction due to radiation therapy is a significant concern that impacts his future life plans and identity. Radiation can affect fertility and sexual function, making this a priority diagnosis. Addressing these long-term impacts on his reproductive health and relationships is crucial for a young adult facing these life transitions.

Clients with sickle cell anemia are taught to avoid activities that cause hypoxia and hypoxemia. Which of the following activities would the nurse recommend?

Answer: A bus trip to the Museum of Natural History

Clients with sickle cell anemia must avoid activities that cause hypoxia and hypoxemia, as these can trigger a sickle cell crisis. High altitudes (Rocky Mountains, airplane travel) and extreme cold (snow-skiing) can lead to decreased oxygen saturation and vasoconstriction, promoting sickling. A bus trip to a museum is a low-stress activity at normal altitude, making it the safest option that avoids these triggers.

A clinic patient has a hemoglobin concentration of 10.8 g/dL and reports sticking to a strict vegetarian diet. Which of the follow nutritional advice is appropriate?

Answer: The patient should use iron cookware to prepare foods, such as dark green, leafy vegetables and legumes, which are high in iron.

A hemoglobin of 10.8 g/dL indicates mild anemia, which can be common in vegetarians due to the lower bioavailability of non-heme iron from plant sources. Encouraging the use of iron cookware can leach small amounts of iron into food, and emphasizing plant-based iron sources like dark leafy greens and legumes, especially when consumed with vitamin C, helps improve iron absorption and address the deficiency.

St. Raphael Medical Center just opened its new Performance Improvement Department. Ms. Valencia is appointed as the Quality Control Officer. She commits herself to her new role and plans her strategies to realize the goals and objectives of the department. Which of the following is a primary task that they should perform to have an effective control system?

Answer: Identify the values of the department

To establish an effective control system, the foundational step is to identify the department's core values and mission. These values provide the overarching framework and philosophical basis for all subsequent quality control activities. This ensures that all standards, criteria, and performance measures align with the department's fundamental purpose and guiding principles.

Ms. Valencia develops the standards to be followed. Among the following standards, which is considered as a structure standard?

Answer: Rotation of duty will be done every four weeks for all patient care personnel

Structure standards relate to the physical environment, organizational characteristics, and resources available for patient care. The rotation of duty for personnel is an aspect of how the nursing unit is organized and managed, describing a characteristic of the system in place. It defines an organizational resource allocation rather than a direct patient outcome or a specific nursing action.

When she presents the nursing procedures to be followed, she refers to what type of standards?

Answer: Process

Nursing procedures are step-by-step guidelines that describe the actions and interventions nurses perform when providing care. These procedures define *how* care is delivered, focusing on the activities and behaviors of healthcare providers. Therefore, they are examples of process standards, which evaluate the actual delivery of care.

Which of the following statements refers to criteria?

Answer: Characteristics used to measure the level of nursing care

Criteria are specific, measurable indicators or characteristics used to evaluate whether a standard has been met. They provide the observable and quantifiable benchmarks against which the quality or level of nursing care can be assessed. In essence, criteria define how to measure the achievement of a stated standard.

She wants to ensure that every task is carried out as planned. Which of the following tasks is NOT included in the controlling process?

Answer: Instructing the members of the standards committee to prepare policies

The controlling process involves monitoring performance, comparing it to established standards, and taking corrective action to ensure plans are carried out effectively. Instructing a committee to *prepare* policies is a planning or organizing function, establishing the framework for future control. It is not an active task within the ongoing monitoring and adjustment activities of the controlling process itself.

Ms. Valencia prepares the process standards. Which of the following is NOT a process standard?

Answer: Patients’ reports 95% satisfaction rate prior to discharge from the hospital.

Process standards describe the actions or steps taken in providing care, such as performing an initial assessment or providing patient education. "Patients' reports 95% satisfaction rate prior to discharge" is a measurable result or effect of the care provided, indicating the overall impact on the patient. Therefore, it is an outcome standard, not a process standard.