EAQ Chapter 1 Aspects of Medical-Surgical
Nursing
A 27-year-old African American man is admitted in sickle cell crisis. Which event
most likely contributed to the onset of the crisis? - ANS - He walked home in a
cold rain yesterday.
\A 50-year old African American patient is diagnosed with anemia. Where can the
nurse best observe for pallor? - ANS - Conjunctivae
\A nurse is assessing a patient and finds small red-purple dots over most of his
skin surfaces. The patient denies noticing them before. What action should the
nurse take first? - ANS - Report the findings immediately to the RN or HCP
\A nurse is caring for a patient admitted with gastrointestinal tract bleeding and a
hemoglobin level of 6 g/dL. The patient asks the nurse why the low hemoglobin
causes shortness of breath. Which response is best? - ANS - "You do not have
enough hemoglobin to carry oxygen to your tissues."
\A nurse is monitoring a patient during a blood transfusion. After the blood has
been hanging for 30 minutes, the patient's temp rises from 98.6 F at baseline to
101.0 F. The patient also experiences severe chills. Which action should the nurse
take first? - ANS - Stop the transfusion and hang normal saline solution
\A nurse is teaching a patient with sickle cell anemia about activities to avoid.
Which of the following activities the patient plans to do shows that more teaching
is needed? - ANS - Running a marathon
\A patient diagnosed with lymphoma is being discharged from the hospital.
Which of the following statements should the nurse include in the patient
teaching? - ANS - "It is important to avoid crowds to reduce your risk of
infection."
\A patient has hand-foot syndrome related to sickle cell anemia. What findings
does the nurse expect to see as the patient is examined? - ANS - Unequal growth
of fingers and toes
\A patient is admitted for a splenectomy. Why is an injection of Vitamin K ordered
before surgery? - ANS - To correct clotting problems
\A patient is having difficulty coping with a new diagnosis of leukemia. Which
response by the nurse is most helpful initially? - ANS - "Who do you usually go to
when you have a problem?"
, \A patient is on warfarin (Coumadin) therapy and has an INR of 1.6. Which action
by the nurse is appropriate? - ANS - -Notify the physician and expect an order to
increase the warfarin dose
\A patient receiving a transfusion of packed RBCs reports chest and back pain.
How should the nurse respond? - ANS - -Stop the transfusion and call the RN stat
depending on agency policy
\A patient with a history of hemophilia A arrives in the emergency department
with a "funny feeling" in his elbow. The patient states that he thinks he is
bleeding into the joint. Which response by the nurse is correct? - ANS - Notify the
physician immediately and expect an order for fact VIII
\A patient with a new diagnosis of lymphoma is experiencing fatigue. Which of
the following is the best way to assess the fatigue? - ANS - Have the patient rate
the fatigue on a scale of 0 to 10
\Diagnostic tests for Disseminated Intravascular Coagulation - ANS - -Prolonged
prothrombin time (PT) and partial thromboplastin time (PTT)
-Decreased platelet count
-Increased evidence of fibrin degradation products
-Decrease in hemoglobin
-BUN increased
-Serum creatinine levels increased
\Diagnostic tests for ITP - ANS - -Platelet count of less than 20,000
-Prolonged bleeding time
-Instead of 7-10 day life span that platelets usually have, these immature platelets
have a life span of just a few hours
\Diagnostic tests for polycythemia - ANS - CBC and bone marrow aspiration
\Disseminated Intravascular Coagulation - ANS - -has a very high mortality rate
-can develop after any major trauma to the body
-massive tissue necrosis found in severe crush or burn injuries may increase the
risk
\Ecchymoses - ANS - A blue-back discoloration from hemorrhage under the skin
\Erythropoietin (Epogen) - ANS - Stimulates production of RBCs
\Filgrastim (Neupogen) - ANS - Stimulates production of WBCs
\Good food sources of FOLIC ACID - ANS - -Fortified flours, grains, cereals, wheat
germ
-Liver
-Green leafy vegetables: asparagus, endive, lettuce
-Legumes: peanuts, dried peas, beans, and lentils
\Good Sources of IRON - ANS - -Meat
-Fish
-Poultry
Nursing
A 27-year-old African American man is admitted in sickle cell crisis. Which event
most likely contributed to the onset of the crisis? - ANS - He walked home in a
cold rain yesterday.
\A 50-year old African American patient is diagnosed with anemia. Where can the
nurse best observe for pallor? - ANS - Conjunctivae
\A nurse is assessing a patient and finds small red-purple dots over most of his
skin surfaces. The patient denies noticing them before. What action should the
nurse take first? - ANS - Report the findings immediately to the RN or HCP
\A nurse is caring for a patient admitted with gastrointestinal tract bleeding and a
hemoglobin level of 6 g/dL. The patient asks the nurse why the low hemoglobin
causes shortness of breath. Which response is best? - ANS - "You do not have
enough hemoglobin to carry oxygen to your tissues."
\A nurse is monitoring a patient during a blood transfusion. After the blood has
been hanging for 30 minutes, the patient's temp rises from 98.6 F at baseline to
101.0 F. The patient also experiences severe chills. Which action should the nurse
take first? - ANS - Stop the transfusion and hang normal saline solution
\A nurse is teaching a patient with sickle cell anemia about activities to avoid.
Which of the following activities the patient plans to do shows that more teaching
is needed? - ANS - Running a marathon
\A patient diagnosed with lymphoma is being discharged from the hospital.
Which of the following statements should the nurse include in the patient
teaching? - ANS - "It is important to avoid crowds to reduce your risk of
infection."
\A patient has hand-foot syndrome related to sickle cell anemia. What findings
does the nurse expect to see as the patient is examined? - ANS - Unequal growth
of fingers and toes
\A patient is admitted for a splenectomy. Why is an injection of Vitamin K ordered
before surgery? - ANS - To correct clotting problems
\A patient is having difficulty coping with a new diagnosis of leukemia. Which
response by the nurse is most helpful initially? - ANS - "Who do you usually go to
when you have a problem?"
, \A patient is on warfarin (Coumadin) therapy and has an INR of 1.6. Which action
by the nurse is appropriate? - ANS - -Notify the physician and expect an order to
increase the warfarin dose
\A patient receiving a transfusion of packed RBCs reports chest and back pain.
How should the nurse respond? - ANS - -Stop the transfusion and call the RN stat
depending on agency policy
\A patient with a history of hemophilia A arrives in the emergency department
with a "funny feeling" in his elbow. The patient states that he thinks he is
bleeding into the joint. Which response by the nurse is correct? - ANS - Notify the
physician immediately and expect an order for fact VIII
\A patient with a new diagnosis of lymphoma is experiencing fatigue. Which of
the following is the best way to assess the fatigue? - ANS - Have the patient rate
the fatigue on a scale of 0 to 10
\Diagnostic tests for Disseminated Intravascular Coagulation - ANS - -Prolonged
prothrombin time (PT) and partial thromboplastin time (PTT)
-Decreased platelet count
-Increased evidence of fibrin degradation products
-Decrease in hemoglobin
-BUN increased
-Serum creatinine levels increased
\Diagnostic tests for ITP - ANS - -Platelet count of less than 20,000
-Prolonged bleeding time
-Instead of 7-10 day life span that platelets usually have, these immature platelets
have a life span of just a few hours
\Diagnostic tests for polycythemia - ANS - CBC and bone marrow aspiration
\Disseminated Intravascular Coagulation - ANS - -has a very high mortality rate
-can develop after any major trauma to the body
-massive tissue necrosis found in severe crush or burn injuries may increase the
risk
\Ecchymoses - ANS - A blue-back discoloration from hemorrhage under the skin
\Erythropoietin (Epogen) - ANS - Stimulates production of RBCs
\Filgrastim (Neupogen) - ANS - Stimulates production of WBCs
\Good food sources of FOLIC ACID - ANS - -Fortified flours, grains, cereals, wheat
germ
-Liver
-Green leafy vegetables: asparagus, endive, lettuce
-Legumes: peanuts, dried peas, beans, and lentils
\Good Sources of IRON - ANS - -Meat
-Fish
-Poultry
