Prepare for your test with
1. Question
Category: Reduction of Risk Potential
The nurse working the organ transplant unit is caring for a client with a decreased white blood
cell count. During evening visitation, a visitor brings a basket of fruit. What action should the
nurse take?
A. Allow the client to keep the fruit
B. Place the fruit next to the bed for easy access by the client
C. Offer to wash the fruit for the client
D. Tell the family members to take the fruit home
Correct Answer: D. Tell the family members to take the fruit home
The client with neutropenia should not have fresh fruit because it should be peeled and/or cooked
before eating. He should also not eat foods grown on or in the ground or eat from the salad bar.
,The nurse should remove potted or cut flowers from the room as well. Any source of bacteria
should be eliminated, if possible.
2. Question
Category: Physiological Adaptation
The nurse is caring for the client following a laryngectomy when suddenly the client becomes
unresponsive and pale, with a BP of 90/40 systolic. The initial nurse’s action should be to:
A. Place the client in Trendelenburg position
B. Increase the infusion of Dextrose in normal saline
C. Administer atropine intravenously
D. Move the emergency cart to the bedside
Correct Answer: B. Increase the infusion of Dextrose in normal saline
Dextrose in normal saline is indicated as a source of water, electrolytes, and calories. Early
complications after total laryngectomy are bleeding, postoperative edema, and airway
compromise, these, especially in the immediate postoperative, should be carefully monitored.
3. Question
Category: Reduction of Risk Potential
The client admitted 2 days earlier that a lung resection accidentally pulls out the chest tube.
Which action by the nurse indicates understanding of the management of chest tubes?
A. Order a chest x-ray
, B. Reinsert the tube
C. Cover the insertion site with a Vaseline gauze
D. Call the doctor
Correct Answer: C. Cover the insertion site with a Vaseline gauze
If the client pulls the chest tube out of the chest, the nurse’s first action should be to cover the
insertion site with an occlusive dressing. Afterward, the nurse should call the doctor, who will
order a chest x-ray and possibly reinsert the tube. A chest tube may be inserted at the bedside, in
the procedure room, or in the surgical suite. Health care providers often assist physicians in the
insertion and removal of a closed chest tube drainage system.
4. Question
Category: Reduction of Risk Potential
A client being treated with sodium warfarin has a Protime of 120 seconds. Which intervention
would be most important to include in the nursing care plan?
A. Assess for signs of abnormal bleeding
B. Anticipate an increase in the Coumadin dosage
C. Instruct the client regarding the drug therapy
D. Increase the frequency of neurological assessments
Correct Answer: A. Assess for signs of abnormal bleeding
1. Question
Category: Reduction of Risk Potential
The nurse working the organ transplant unit is caring for a client with a decreased white blood
cell count. During evening visitation, a visitor brings a basket of fruit. What action should the
nurse take?
A. Allow the client to keep the fruit
B. Place the fruit next to the bed for easy access by the client
C. Offer to wash the fruit for the client
D. Tell the family members to take the fruit home
Correct Answer: D. Tell the family members to take the fruit home
The client with neutropenia should not have fresh fruit because it should be peeled and/or cooked
before eating. He should also not eat foods grown on or in the ground or eat from the salad bar.
,The nurse should remove potted or cut flowers from the room as well. Any source of bacteria
should be eliminated, if possible.
2. Question
Category: Physiological Adaptation
The nurse is caring for the client following a laryngectomy when suddenly the client becomes
unresponsive and pale, with a BP of 90/40 systolic. The initial nurse’s action should be to:
A. Place the client in Trendelenburg position
B. Increase the infusion of Dextrose in normal saline
C. Administer atropine intravenously
D. Move the emergency cart to the bedside
Correct Answer: B. Increase the infusion of Dextrose in normal saline
Dextrose in normal saline is indicated as a source of water, electrolytes, and calories. Early
complications after total laryngectomy are bleeding, postoperative edema, and airway
compromise, these, especially in the immediate postoperative, should be carefully monitored.
3. Question
Category: Reduction of Risk Potential
The client admitted 2 days earlier that a lung resection accidentally pulls out the chest tube.
Which action by the nurse indicates understanding of the management of chest tubes?
A. Order a chest x-ray
, B. Reinsert the tube
C. Cover the insertion site with a Vaseline gauze
D. Call the doctor
Correct Answer: C. Cover the insertion site with a Vaseline gauze
If the client pulls the chest tube out of the chest, the nurse’s first action should be to cover the
insertion site with an occlusive dressing. Afterward, the nurse should call the doctor, who will
order a chest x-ray and possibly reinsert the tube. A chest tube may be inserted at the bedside, in
the procedure room, or in the surgical suite. Health care providers often assist physicians in the
insertion and removal of a closed chest tube drainage system.
4. Question
Category: Reduction of Risk Potential
A client being treated with sodium warfarin has a Protime of 120 seconds. Which intervention
would be most important to include in the nursing care plan?
A. Assess for signs of abnormal bleeding
B. Anticipate an increase in the Coumadin dosage
C. Instruct the client regarding the drug therapy
D. Increase the frequency of neurological assessments
Correct Answer: A. Assess for signs of abnormal bleeding
