Chapter 29 High Acuity Nursing 6th Edition by Kathleen Dorman Wagner

Chapter 29 High Acuity Nursing 6th Edition by Kathleen Dorman Wagner

 

Complete Chapter Questions With Answers

 

Sample Questions Are Posted Below

 

Question 1

Type: MCSA

A patient in the acute care unit has developed neutropenia. A nurse would identify which history as a possible etiology of this condition?

1. The patient had symptoms of an untreated bacterial infection for a week prior to admission.
2. The patient’s blood sugar was 120 mg/dL on admission.
3. The patient’s lab work reveals a vitamin C deficiency.
4. The patient has been receiving chemotherapy treatment for lung cancer.

Correct Answer: 4

Rationale 1: Untreated bacterial infections are not implicated in the development of neutropenia.

Rationale 2: Hyperglycemia is not associated with the development of neutropenia.

Rationale 3: Neutropenia can occur with a vitamin B₁₂ deficiency, but is not found with vitamin C deficiency.

Rationale 4: Neutropenia caused by decreased production of neutrophils can occur as a result of bone marrow suppression after chemotherapy.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 29-1

 

Question 2

Type: MCSA

A patient with neutropenia develops a fever. Which nursing action is most important?

1. Discuss the finding with the primary care provider.
2. Encourage oral fluids.
3. Review the medical record for trending.
4. Document this expected finding.

Correct Answer: 1

Rationale 1: Febrile neutropenia is a potentially life-threatening event and must be treated rapidly. This occurrence should be discussed with the primary care provider with the expectation of prescriptions for antibiotics or other treatments.

Rationale 2: Encouraging oral fluids is not a sufficient nursing action in this situation.

Rationale 3: The nurse should take action beyond review of the medical record.

Rationale 4: Fever is not an expected finding and is an especially troubling complication in a patient with neutropenia.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 29-1

 

Question 3

Type: MCMA

A patient is prescribed filgrastim (Neupogen). Which nursing intervention is indicated?

 

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Prepare the medication for intramuscular injection.
2. Allow the medication to warm to room temperature for no longer than 6 hours.
3. Withdraw prescribed amount and return remaining medication to refrigerator for later use.
4. Discard vial if left at room temperature for longer than 4 hours.
5. Give the medication at least 24 hours following cytotoxic chemotherapy.

Correct Answer: 2,5

Rationale 1: The medication is administered either through subcutaneous injection or through an intravenous access line.

Rationale 2: The medication must be used within 6 hours if left at room temperature.

Rationale 3: Each vial is a one-time use, therefore any unused medication in a vial is not to be saved or returned to the refrigerator for later use.

Rationale 4: Medication should be discarded after 6 hours if left at room temperature.

Rationale 5: Cytotoxic chemotherapy could inactivate this medication.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 29-1

 

Question 4

Type: MCSA

A patient receiving a blood transfusion begins gasping for breath 10 minutes into the transfusion. The nurse realizes the patient is experiencing which type of hypersensitivity response?

1. Type I
2. Type III
3. Type IV
4. Type II

Correct Answer: 4

Rationale 1: A type I hypersensitivity response occurs after repeated exposure to an allergen which causes an allergen–antigen response.

Rationale 2: A type III hypersensitivity response is also an allergen–antigen response, however the complexes are found in tissues. Organ rejection is an example of this type of response.

Rationale 3: A type IV hypersensitivity response is a delayed response seen after an insect bite or with poison ivy.

Rationale 4: A transfusion reaction is a major example of a type II hypersensitivity response. The reaction will occur within minutes of beginning the transfusion and is an emergency.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 29-2