SOLVED

 Question 11 A patient being treated for thrombocytopenia is not responding to therapy. The nurse would begin to prepare the patient for which medical intervention? 1. Intravenous fluids 2. Bone marrow transplant 3. Splenectomy 4. Blood transfusion Question 12 A critically ill patient who is being mechanically ventilated was started on an antibiotic, a steroid, and intravenous heparin one week ago. This morning the nurse notes the patient has red rashlike eruptions across his abdomen and chest. What nursing action is indicated? 1. Notify the primary care provider immediately. 2. Monitor the rash to see if it spreads. 3. Apply a nonpetroleum–based lotion over the affected area. 4. Hold the antibiotic. Question 13 A critically ill patient is diagnosed with disseminated intravascular coagulation. Which history would the nurse evaluate as indicating increased risk for this development? 1. The patient had a transfusion reaction yesterday. 2. The patient was intubated and placed on mechanical ventilation 2 days ago. 3. The patient has a long history of hypertension. 4. The patient passed a kidney stone this morning. Question 14 A patient has developed disseminated intravascular coagulation. Which assessment would the nurse evaluate as reflecting the microthrombosis results of this disorder? 1. Oozing from older intravenous access sites 2. Jaundice 3. Petechiae 4. Ecchymoses Question 15 The nurse is caring for a patient with disseminated intravascular coagulation who is bleeding from the gastrointestinal tract with a platelet count of 45,000. The nurse would anticipate which intervention for this patient? 1. Heparin 2. Intravenous platelets 3. Warfarin 4. Aspirin Question 16 A patient arrives at the emergency department following a gunshot wound to the abdomen. He is unresponsive and has cool, clammy skin. Paramedics were unable to initiate a peripheral IV and the patient’s abdominal wound is bleeding briskly. The nurse bases emergency interventions on which priority nursing diagnoses? 1. Decreased Cardiac Output 2. Fluid Volume Deficit 3. Risk for Shock 4. Ineffective Breathing Pattern Question 17 A patient with thrombocytopenia has developed a nose bleed. She is confused and keeps trying to get out of bed. Which nursing diagnosis is appropriate for this situation? 1. Activity Intolerance 2. Altered Comfort: Pain 3. Ineffective Individual Coping 4. Altered Tissue Perfusion Question 18 The nurse is making a follow-up call to a patient recently released from the acute care unit following treatment for thrombocytopenia. Which patient statements would the nurse consider reason to suggest contacting the primary health provider? 1. “You didn’t tell me that I would have such bad, smelly diarrhea once I got home.” 2. “I feel fine but my skin is a little off color.” 3. “My appetite is coming back slowly.” 4. “I was able to take a walk with my dog yesterday.” 5. “I keep getting headaches in the late afternoon if I am tired.” Question 19 A patient has been admitted with a tentative diagnosis of thrombocytopenia. Which patient statement would the nurse evaluate as significant to that disorder? 1. “I started taking cimetidine for heartburn about a month ago.” 2. “My family and I just got back from a vacation in the mountains.” 3. “I spend a lot of time working at my computer.” 4. “I have been taking a new calcium supplement.” Question 20 A patient has been brought to the emergency department after a traumatic amputation of his leg. His skin is pale and very cool, heart rate is 120, respirations are 28, and systolic blood pressure is dropping. From these findings the nurse would estimate that this patient has lost which percent of blood? 1. Less than 15% 2. 15–30% 3. 30–40% 4. Over 40%