Nursing NUR401 Exam 1 – Practice Questions and Answers Study
Guide
A nurse is caring for a client with sickle cells disease. Which nursing action is most effective in
reducing potential for sepsis in this client
a. check vitals every 4 hours
b. perform frequent and thorough hand washing
c. administer prophylactic drug therapy
d. monitor for abnormal laboratory values - correct answer ✔✔b. Perform frequent and
thorough hand washing
The most effective nursing action to reduce the risk for sepsis in a client with sickle cell anemia
is to perform frequent and thorough handwashing. Prevention and early detection strategies
are used to protect the client in sickle cell crisis from infection. Frequent and thorough
handwashing is of the utmost importance.
Taking vital signs every 4 hours will help with early detection of infection but is not prevention.
Drug therapy is a major defense against infections that develop in the client with sickle cell
disease but is not the most effective way that the nurse can reduce the potential for sepsis.
Continually assessing the client for infection and monitoring the daily complete blood count
with differential white blood cell count is early detection, not prevention.
Which nursing intervention most effectively protects a client with thrombocytopenia
a. take rectal temperatures
b. avoid use of dentures
c. encourage use of an electric shaver
d. apply warm compresses on trauma sites - correct answer ✔✔c. encourage use of electric
razor
,The most effective nursing intervention that protects a client with thrombocytopenia is
encouraging the client to use an electric shaver. This client must be advised to use an electric
shaver instead of a razor. Any small cuts or nicks can cause problems because of the prolonged
clotting time.
To prevent rectal trauma, rectal thermometers would not be used. Oral or tympanic
temperatures would be taken. Dentures may be used by clients with thrombocytopenia as long
as they fit properly and do not rub. Ice (not heat) would be applied to areas of trauma.
A client with leukemia is being discharged from the hospital. The nurse's discharge instructions
say to keep regularly scheduled follow-up primary health care provider appointments. The client
says, "I don't have transportation." Which is the most appropriate nursing response?
a. You can take the bus
b. I may be able to take you
c. the local American Cancer Society may be able to help
d. a pharmaceutical company might be able to help - correct answer ✔✔c. the local American
cancer society may be able to help
The most appropriate nursing response to the client who does not have transportation for
follow-up appointments is that "the local American Cancer Society may be able to help." Many
local units of the American Cancer Society offer free transportation to clients with cancer,
including those with leukemia.
Telling the client to take the bus is dismissive and does not take into consideration the client's
situation (e.g., the client may live nowhere near a bus route). Although the nurse offering to
take the client is compassionate, it is not appropriate for the nurse to offer the client
transportation. Suggesting a pharmaceutical company is not the best answer. Drug companies
typically do not provide this type of service.
Which client statement indicates in-home stem cell transplantation is not a viable option?
,a. I was a nurse, so I can take care of myself
b. I don't feel strong enough, but my wife said she would help
c. We live 5 miles from the hospital
d. I will have lots of medicine to take - correct answer ✔✔a. I was a nurse so I can take care of
myself
The client statement that indicates that in-home stem cell transplantation is not a viable option
is "I was a nurse, so I can take care of myself." Stem cell transplantation in the home setting
requires support, assistance, and coordination from others. The client cannot manage this type
of care on his own.
It is acceptable for the client's spouse to support the client undergoing this procedure. It is not
unexpected for the client to be taking several prescriptions. Five miles is an acceptable distance
from the hospital, in case of emergency.
The nurse is to administer packed red blood cells to a client. How does the nurse ensure proper
client identification?
a. Check the client's armband
b. Review all information with another registered nurse (RN)
c. Ask the client's name
d. Verify the client's room number - correct answer ✔✔b. review all information with another
registered nurse (RN)
With another registered nurse, all information must be reviewed. This process includes verifying
the client by name and number, checking blood compatibility, and noting the expiration time.
Human error is the most common cause of ABO incompatibility reactions, even for experienced
nurses.
Asking the client's name and checking the client's armband are not adequate for identifying the
client before transfusion therapy. Using the room number to verify client identification is never
appropriate.
, What is the most important environmental risk for developing leukemia?
a. Living near high-voltage power lines
b. Direct contact with others with leukemia
c. Smoking cigarettes
d. Family history - correct answer ✔✔c. Smoking cigarettes
The most important environmental risk for developing leukemia is smoking cigarettes. According
to the American Cancer Society (ACS), the only proven lifestyle-related risk factor for leukemia is
cigarette smoking.
Genetics is a strong indicator, but it is not an environmental risk factor. According to the ACS,
living near high-voltage power lines is not a proven risk factor for leukemia. Leukemia is not
contagious.
A client who has been newly diagnosed with leukemia is admitted to the hospital. Avoiding
which potential problem takes priority in the client's nursing care plan?
a. Fluid overload (overhydration)
b. Hemorrhage
c. Infection
d. Hypoxia - correct answer ✔✔c. infection
Avoiding infection is the priority potential problem when caring for a newly diagnosed client
with leukemia.
Fluid overload, hemorrhage, and hypoxia are not priority problems for the client with leukemia.
Guide
A nurse is caring for a client with sickle cells disease. Which nursing action is most effective in
reducing potential for sepsis in this client
a. check vitals every 4 hours
b. perform frequent and thorough hand washing
c. administer prophylactic drug therapy
d. monitor for abnormal laboratory values - correct answer ✔✔b. Perform frequent and
thorough hand washing
The most effective nursing action to reduce the risk for sepsis in a client with sickle cell anemia
is to perform frequent and thorough handwashing. Prevention and early detection strategies
are used to protect the client in sickle cell crisis from infection. Frequent and thorough
handwashing is of the utmost importance.
Taking vital signs every 4 hours will help with early detection of infection but is not prevention.
Drug therapy is a major defense against infections that develop in the client with sickle cell
disease but is not the most effective way that the nurse can reduce the potential for sepsis.
Continually assessing the client for infection and monitoring the daily complete blood count
with differential white blood cell count is early detection, not prevention.
Which nursing intervention most effectively protects a client with thrombocytopenia
a. take rectal temperatures
b. avoid use of dentures
c. encourage use of an electric shaver
d. apply warm compresses on trauma sites - correct answer ✔✔c. encourage use of electric
razor
,The most effective nursing intervention that protects a client with thrombocytopenia is
encouraging the client to use an electric shaver. This client must be advised to use an electric
shaver instead of a razor. Any small cuts or nicks can cause problems because of the prolonged
clotting time.
To prevent rectal trauma, rectal thermometers would not be used. Oral or tympanic
temperatures would be taken. Dentures may be used by clients with thrombocytopenia as long
as they fit properly and do not rub. Ice (not heat) would be applied to areas of trauma.
A client with leukemia is being discharged from the hospital. The nurse's discharge instructions
say to keep regularly scheduled follow-up primary health care provider appointments. The client
says, "I don't have transportation." Which is the most appropriate nursing response?
a. You can take the bus
b. I may be able to take you
c. the local American Cancer Society may be able to help
d. a pharmaceutical company might be able to help - correct answer ✔✔c. the local American
cancer society may be able to help
The most appropriate nursing response to the client who does not have transportation for
follow-up appointments is that "the local American Cancer Society may be able to help." Many
local units of the American Cancer Society offer free transportation to clients with cancer,
including those with leukemia.
Telling the client to take the bus is dismissive and does not take into consideration the client's
situation (e.g., the client may live nowhere near a bus route). Although the nurse offering to
take the client is compassionate, it is not appropriate for the nurse to offer the client
transportation. Suggesting a pharmaceutical company is not the best answer. Drug companies
typically do not provide this type of service.
Which client statement indicates in-home stem cell transplantation is not a viable option?
,a. I was a nurse, so I can take care of myself
b. I don't feel strong enough, but my wife said she would help
c. We live 5 miles from the hospital
d. I will have lots of medicine to take - correct answer ✔✔a. I was a nurse so I can take care of
myself
The client statement that indicates that in-home stem cell transplantation is not a viable option
is "I was a nurse, so I can take care of myself." Stem cell transplantation in the home setting
requires support, assistance, and coordination from others. The client cannot manage this type
of care on his own.
It is acceptable for the client's spouse to support the client undergoing this procedure. It is not
unexpected for the client to be taking several prescriptions. Five miles is an acceptable distance
from the hospital, in case of emergency.
The nurse is to administer packed red blood cells to a client. How does the nurse ensure proper
client identification?
a. Check the client's armband
b. Review all information with another registered nurse (RN)
c. Ask the client's name
d. Verify the client's room number - correct answer ✔✔b. review all information with another
registered nurse (RN)
With another registered nurse, all information must be reviewed. This process includes verifying
the client by name and number, checking blood compatibility, and noting the expiration time.
Human error is the most common cause of ABO incompatibility reactions, even for experienced
nurses.
Asking the client's name and checking the client's armband are not adequate for identifying the
client before transfusion therapy. Using the room number to verify client identification is never
appropriate.
, What is the most important environmental risk for developing leukemia?
a. Living near high-voltage power lines
b. Direct contact with others with leukemia
c. Smoking cigarettes
d. Family history - correct answer ✔✔c. Smoking cigarettes
The most important environmental risk for developing leukemia is smoking cigarettes. According
to the American Cancer Society (ACS), the only proven lifestyle-related risk factor for leukemia is
cigarette smoking.
Genetics is a strong indicator, but it is not an environmental risk factor. According to the ACS,
living near high-voltage power lines is not a proven risk factor for leukemia. Leukemia is not
contagious.
A client who has been newly diagnosed with leukemia is admitted to the hospital. Avoiding
which potential problem takes priority in the client's nursing care plan?
a. Fluid overload (overhydration)
b. Hemorrhage
c. Infection
d. Hypoxia - correct answer ✔✔c. infection
Avoiding infection is the priority potential problem when caring for a newly diagnosed client
with leukemia.
Fluid overload, hemorrhage, and hypoxia are not priority problems for the client with leukemia.
