NUR445-Exam 5 | Q/A A+ Graded, Exams of Nursing

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1. What is the priority nursing intervention for a patient diagnosed with Tumor Lysis Syndrome (TLS)? A. Administer pain medication B. Provide emotional support C. Initiate large-volume IV fluid administration D. Apply oxygen therapy: Correct Answer: C. Large-volume IV fluids help to flush out the excess electrolytes and uric acid, reducing the risk of renal failure.
2. Which laboratory finding is most indicative of Tumor Lysis Syndrome (TLS)? A. Hypokalemia B. Hyperuricemia C. Hyponatremia D. Hypoglycemia: Correct Answer: B. Hyperuricemia is a hallmark of TLS due to the breakdown of nucleic acids.
3. A patient with TLS is experiencing severe hyperkalemia. What is the most immediate nursing action? A. Administer a loop diuretic B. Prepare for hemodialysis C. Administer Sodium Polystyrene Sulfonate (Kayexalate) D. Provide dietary education on potassium restriction: Correct Answer: C. While all options may be valid, immediate administration of Sodium Polystyrene Sulfonate can help reduce potassium levels rapidly to prevent cardiac complications.
4. For a patient at high risk of developing TLS, which medication is prescribed to prevent hyperuricemia? A. Rasburicase B. Allopurinol C. Spironolactone D. Amphojel: Correct Answer: B. Allopurinol is used to prevent the increase in uric acid levels by inhibiting its production.
5. What electrolyte imbalance in TLS can lead to cardiac arrhythmias and possibly sudden death? A. Hypercalcemia B. Hyperphosphatemia C. Hyperkalemia D. Hypocalcemia: Correct Answer: C. Hyperkalemia can cause fatal cardiac dys- rhythmias.
6. Which symptom is NOT typically associated with hypocalcemia in TLS? A. Cardiac dysrhythmia B. Numbness of fingertips C. Muscle spasms

Study online at https://quizlet.com/_e8jtvy D. Hypertension: Correct Answer: D. Hypertension is not a symptom of hypocal- cemia; symptoms include numbness, muscle spasms, and cardiac dysrhythmias.

7. A patient with TLS shows an ECG with peaked T waves. The nurse recog- nizes this as a sign of: A. Hypocalcemia B. Hypercalcemia C. Hyperkalemia D. Hypokalemia: Correct Answer: C. Peaked T waves on an ECG indicate hyper- kalemia.
8. Which medication is NOT used in the management of TLS? A. Rasburicase B. Allopurinol C. Calcium gluconate D. Metformin: Correct Answer: D. Metformin is not used in TLS management; it's a medication for diabetes.
9. A nurse is educating a patient on dietary restrictions during TLS treatment. Which nutrient should be limited? A. Protein B. Carbohydrates C. Potassium D. Fat: Correct Answer: C. Limiting potassium intake is important to manage hyper- kalemia.
10. What is the primary reason for administering loop diuretics in a patient with TLS? A. To reduce blood pressure B. To decrease serum potassium levels C. To promote uric acid excretion D. To increase urine output and renal perfusion: Correct Answer: D. Increasing urine output and improving renal perfusion helps to eliminate excess electrolytes and uric acid.
11. Which condition is a direct complication of hyperphosphatemia in TLS? A. Renal failure B. Hypocalcemia C. Hyperuricemia D. Cardiac arrest: Correct Answer: A. Hyperphosphatemia can lead to renal failure due to the deposition of calcium phosphate in the kidneys.
12. In the context of TLS, why is Rasburicase administered? A. To decrease calcium levels B. To increase potassium excretion

Study online at https://quizlet.com/_e8jtvy C. To reduce uric acid levels D. To bind phosphate: Correct Answer: C. Rasburicase is used to catalyze the conversion of uric acid into allantoin, which is more easily excreted by the kidneys.

13. What is the most serious concern for a patient experiencing potassium imbalance due to TLS? A. Urinary retention B. Constipation C. Cardiac dysrhythmia D. Muscle weakness: Correct Answer: C. The most serious concern is cardiac dysrhythmia, which can be fatal.
14. For a patient undergoing treatment for TLS, which parameter should a nurse monitor closely? A. Serum sodium B. Serum uric acid C. Blood glucose D. Hemoglobin levels: Correct Answer: B. Monitoring serum uric acid levels is crucial in managing TLS.
15. Which intervention is appropriate for managing hypocalcemia in TLS? A. Administering Calcium Carbonate B. Limiting calcium intake C. Administering IV calcium gluconate D. Increasing phosphorus intake: Correct Answer: C. IV calcium gluconate is administered to treat hypocalcemia quickly.
16. A nurse assesses for neurologic changes in a patient with TLS to monitor for: A. Hyperuricemia B. Hyperkalemia C. Hypocalcemia D. Hyperphosphatemia: Correct Answer: C. Neurologic changes may indicate hypocalcemia, which can cause neuromuscular irritability and seizures
17. Why are phosphate binders prescribed in the management of TLS? A. To increase phosphate excretion B. To decrease serum phosphate levels C. To enhance uric acid solubility D. To prevent potassium elevation: Correct Answer: B. Phosphate binders reduce serum phosphate levels by binding dietary phosphate in the gut.
18. What is the primary goal of administering Allopurinol in TLS prophylaxis? A. To prevent renal failure B. To reduce uric acid production

Study online at https://quizlet.com/_e8jtvy C. To increase calcium levels D. To enhance phosphorus elimination: Correct Answer: B. Allopurinol inhibits xanthine oxidase, reducing uric acid production.

19. Which nursing assessment is critical for early detection of TLS? A. Monitoring for jaundice B. Assessing urine output and concentration C. Checking for skin elasticity D. Measuring body temperature: Correct Answer: B. Monitoring urine output and concentration helps detect renal dysfunction early, a key concern in TLS.
20. A patient with TLS is prescribed Spironolactone. What is the rationale behind this? A. To treat hyperuricemia B. To manage hyperkalemia C. To correct hypokalemia D. To prevent hypocalcemia: Correct Answer: C. Spironolactone is a potassi- um-sparing diuretic, used to correct or prevent hypokalemia, not directly related to TLS management but may be used in broader electrolyte management strategies.
21. Which blood product is most appropriate for replacing clotting factors in a patient with DIC? A. Packed red blood cells B. Fresh frozen plasma C. Platelet concentrate D. Whole blood: Correct Answer: B. Fresh frozen plasma Explanation: Fresh frozen plasma is used in DIC to replace consumed clotting factors.
22. A nurse is caring for a patient with suspected DIC. Which laboratory result is the nurse most likely to monitor? A. Hemoglobin B. D-dimer levels C. Sodium levels D. Blood glucose A nurse is caring for a patient with suspected DIC. Which laboratory result is the nurse most likely to monitor?: Correct Answer: B. D-dimer levels Explanation: D-dimer levels are elevated in DIC due to increased clot breakdown.
23. Which intervention is critical when managing a patient with thrombocy- topenia to prevent bleeding complications? A. Administering aspirin regularly B. Using a soft toothbrush and electric razor C. Encouraging participation in contact sports

Study online at https://quizlet.com/_e8jtvy D. Applying heat packs to bruises: Correct Answer: B. Using a soft toothbrush and electric razor Explanation: Minimizing trauma and injury to the skin can help prevent bleeding in patients with thrombocytopenia.

24. In a patient with DIC, what is the primary goal of administering anticoagu- lant therapy? A. To increase platelet count B. To stop all forms of bleeding C. To prevent further blood clot formation D. To increase fibrinogen levels: Correct Answer: C. To prevent further blood clot formation Explanation: Anticoagulant therapy in DIC is aimed at preventing new thrombosis while the underlying cause is treated.
25. Which condition is a known risk factor for developing thrombocytopenia? A. Hypertension B. Diabetes mellitus C. Viral infections D. Hyperlipidemia: C. Viral infections Explanation: Viral infections can lead to decreased platelet production or increased destruction, causing thrombocytopenia.
26. A patient with DIC expresses fear about their condition. What is the nurse's best response? A. "You should not worry about your condition." B. "Let's talk about your concerns." C. "DIC is easily treated with medication." D. "Most patients do not survive DIC.": Correct Answer: B. "Let's talk about your concerns." Explanation: Providing emotional support and addressing concerns directly sup- ports psychosocial integrity.
27. For a patient with thrombocytopenia, which intervention is essential to prevent skin breakdown? A. Frequent repositioning B. Applying tight bandages to extremities C. High-intensity exercise D. Restricting fluid intake: Correct Answer: A. Frequent repositioning Explanation: Frequent repositioning helps prevent skin breakdown and potential bleeding in susceptible areas.
28. According to current guidelines, what is the initial management strategy for a patient with mild thrombocytopenia and no active bleeding?

Study online at https://quizlet.com/_e8jtvy A. Immediate platelet transfusion B. High-dose corticosteroids C. Observation and monitoring D. Splenectomy: Correct Answer: C. Observation and monitoring Explanation: For mild thrombocytopenia without bleeding, conservative manage- ment with observation is recommended.

29. Which technology is most beneficial for continuous monitoring of platelet counts in hospitalized patients with thrombocytopenia? A. Portable ultrasound devices B. Automated laboratory reporting systems C. Electronic health record alerts D. Wearable heart rate monitors: Correct Answer: B. Automated laboratory report- ing systems Explanation: Automated lab reporting systems ensure timely updates on critical lab values like platelet counts.
30. When caring for a patient with DIC, which interdisciplinary team member is essential for providing dietary consultation to manage nutritional needs? A. Physical therapist B. Registered dietitian C. Occupational therapist D. Respiratory therapist: Correct Answer: B. Registered dietitian Explanation: A dietitian plays a crucial role in managing the nutritional needs of patients with DIC to support overall health and recovery.
31. A patient with DIC is bleeding from a venipuncture site. What is the nurse's first action? A. Apply a tourniquet above the site B. Administer a bolus of fresh frozen plasma C. Apply pressure to the site D. Prepare for emergency surgery: Correct Answer: C. Apply pressure to the site Explanation: The initial nursing action for bleeding is to apply direct pressure to control the bleeding.
32. A nurse advocates for including family members in the care plan discus- sions for a patient with severe thrombocytopenia. Which professional nursing role does this action best demonstrate? A. Clinical skills expert B. Patient educator C. Patient advocate D. Health policy influencer: Correct Answer: C. Patient advocate

Study online at https://quizlet.com/_e8jtvy Explanation: Advocating for patient and family involvement in care decisions exem- plifies the nurse's role as a patient advocate.

33. Effective management of DIC requires collaboration between which of the following healthcare professionals? (Select all that apply.) A. Hematologist B. Pharmacist C. Social worker D. Intensive care nurse E. Physical therapist: Correct Answers: A. Hematologist, B. Pharmacist, D. Inten- sive care nurse Explanation: DIC management involves complex care requiring the expertise of hematologists, pharmacists for medication management, and intensive care nurses for close monitoring.
34. What is a primary prevention strategy for reducing the risk of thrombocy- topenia in the general population? A. Regular exercise B. Vaccinations C. High fiber diet D. Blood pressure control: Correct Answer: B. Vaccinations Explanation: Vaccinations can prevent infections that might lead to thrombocytope- nia by decreasing platelet production or increasing destruction.
35. A nurse maintains confidentiality and privacy while discussing a patient's diagnosis of thrombocytopenia over the phone with a consulting physician. This action best demonstrates adherence to which professional nursing prin- ciple? A. Beneficence B. Nonmaleficence C. Autonomy D. Confidentiality: Correct Answer: D. Confidentiality Explanation: Maintaining confidentiality and privacy of patient information is a fun- damental principle of nursing professionalism.
36. Which finding would a nurse prioritize for immediate intervention in a patient with suspected DIC? A. Elevated blood pressure B. Sudden onset of shortness of breath C. Increased urine output D. Weight gain of 1 kg over 24 hours: Correct Answer: B. Sudden onset of shortness of breath

Study online at https://quizlet.com/_e8jtvy Explanation: Sudden shortness of breath may indicate pulmonary embolism, requir- ing immediate intervention in DIC.

37. For a patient with DIC experiencing bleeding, which nursing intervention is most appropriate? A. Restricting fluid intake B. Administering NSAIDs for pain C. Elevating the legs above heart level D. Applying pressure and cold to bleeding sites: Correct Answer: D. Applying pressure and cold to bleeding sites Explanation: Applying pressure and cold helps control bleeding and reduce inflam- mation at the site.
38. A nurse is evaluating the effectiveness of treatment in a patient with thrombocytopenia. Which lab value indicates improvement? A. Decreased platelet count B. Increased D-dimer levels C. Increased platelet count D. Decreased hemoglobin levels: Correct Answer: C. Increased platelet count Explanation: An increased platelet count indicates an improvement in thrombocy- topenia.
39. When planning care for a patient with thrombocytopenia, which interven- tion should be included to prevent complications? A. Encourage vigorous exercise B. Administer anticoagulants as ordered C. Avoid using intramuscular injections D. Increase intake of vitamin K-rich foods: Correct Answer: C. Avoid using intra- muscular injections Explanation: Avoiding intramuscular injections helps prevent bleeding and hematoma formation in patients with thrombocytopenia.
40. In a patient with DIC and multiple health issues, what should be the nurse's immediate priority? A. Managing pain B. Preventing infection C. Stabilizing cardiovascular status D. Providing nutritional support: Correct Answer: C. Stabilizing cardiovascular status Explanation: Stabilizing cardiovascular status is crucial in DIC to ensure perfusion and prevent organ damage.
41. What is the first step in treating Heparin-Induced Thrombocytopenia (HIT)? A. Administer a platelet transfusion

Study online at https://quizlet.com/_e8jtvy B. Continue heparin and monitor symptoms C. Stop the administration of heparin D. Start warfarin therapy: Correct Answer: C. Stop the administration of heparin. Explanation: The initial step in managing HIT is to cease heparin administration due to its role in inducing the condition.

42. Which anticoagulant is contraindicated in patients with Heparin-Induced Thrombocytopenia (HIT) due to the risk of skin gangrene? A. Argatroban B. Warfarin C. Lepirudin D. Danaparoid: Correct Answer: B. Warfarin. Explanation: Warfarin is contraindicat- ed in HIT patients because it can lead to skin gangrene in this population.
43. Which interventions are appropriate for a patient diagnosed with HIT? A. Frequent monitoring of platelet count B. Platelet transfusions C. Administration of approved anticoagulants like Argatroban D. Using intramuscular injections for medication administration E. Stopping heparin administration: Correct Answers: A, C, E. Explanation: For HIT management, monitoring platelet count, ceasing heparin, and using alternative anticoagulants like Argatroban are recommended. Platelet transfusions and intra- muscular injections are contraindicated.
44. What is the primary cause of Heparin-Induced Thrombocytopenia (HIT)? A. Direct toxicity of heparin on platelets B. An autoimmune response leading to antibody production C. A bacterial infection introduced during heparin administration D. Genetic predisposition to adverse drug reactions: Correct Answer: B. An autoimmune response leading to antibody production. Explanation: HIT is caused by an immune response where the body generates antibodies against heparin, leading to platelet aggregation and thrombocytopenia.
45. Which laboratory test is crucial for the diagnosis of Heparin-Induced Thrombocytopenia (HIT)? A. Complete Blood Count (CBC) with differential B. Prothrombin Time (PT) C. Activated Partial Thromboplastin Time (aPTT) D. Enzyme-linked immunosorbent assay (ELISA) for antibodies: Correct An- swer: D. Enzyme-linked immunosorbent assay (ELISA) for antibodies. Explanation: ELISA is used to detect the presence of heparin-induced antibodies, which is key for diagnosing HIT.

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46. (SATA) Nursing interventions for a patient with HIT include: A. Minimize blood draws B. Use a soft-bristle toothbrush C. Administer IV heparin at a reduced dose D. Use an electric razor for shaving E. Avoid the use of shoes or slippers to prevent falls: Correct Answers: A, B, D. Explanation: To reduce the risk of bleeding, it's advised to minimize blood draws, use a soft-bristle toothbrush, and shave with an electric razor. Heparin administration should be stopped, not reduced, and wearing shoes or slippers can prevent falls.
47. How should bleeding be managed in patients with HIT? A. Immediate administration of platelet transfusions B. Apply direct pressure and/or ice to the site of bleeding C. Initiate anticoagulant therapy with warfarin D. Perform frequent intramuscular injections to stimulate clotting: Correct An- swer: B. Apply direct pressure and/or ice to the site of bleeding. Explanation: For bleeding management in HIT, direct pressure and/or ice can help control bleeding without increasing the risk of thrombosis.
48. (SATA) Which of the following are approved anticoagulants for the treat- ment of HIT? A. Danaparoid B. Warfarin C. Lepirudin D. Argatroban E. As heparin D. Start warfarin therapy: Correct Answer: C. Stop the administration of heparin. Explanation: Stopping heparin is crucial as HIT is an immune response to heparin, exacerbating the condition.
49. SATA: Which anticoagulants are approved for use in the treatment of HIT? A. Danaparoid B. Lepirudin C. Argatroban D. Warfarin: Correct Answers: A, B, C. Explanation: Danaparoid, Lepirudin, and Argatroban are used because they do not provoke HIT antibodies. Warfarin is contraindicated.
50. Which laboratory test is NOT directly used to diagnose HIT? A. Complete Blood Count (CBC) with platelet count B. Enzyme-linked immunosorbent assay (ELISA) for antibodies C. Coagulation panel (PT, PTT, INR) D. Liver function tests (LFTs): Correct Answer: D. Liver function tests (LFTs).

Study online at https://quizlet.com/_e8jtvy Explanation: LFTs are not directly related to the diagnosis of HIT, which is primarily identified through platelet counts and specific antibody tests.

51. (SATA) Which nursing interventions are appropriate for patients with HIT? A. Administer platelet transfusions as needed B. Use a soft-bristle toothbrush C. Avoid intramuscular injections D. Encourage the use of shoes or slippers when out of bed: Correct Answers: B, C, D. Explanation: To prevent bleeding and injury, soft-bristle toothbrushes, avoiding IM injections, and protective footwear are recommended. Platelet transfusions are contraindicated.
52. Warfarin is contraindicated in the treatment of HIT because it can cause: A. Hypertension B. Skin gangrene C. Hepatotoxicity D. Acute renal failure: Correct Answer: B. Skin gangrene. Explanation: Warfarin, when used in HIT patients, may lead to skin gangrene due to microvascular throm- bosis.
53. When monitoring a patient with HIT, the nurse should report a platelet count less than: A. 150,000/mm³ B. 100,000/mm³ C. 50,000/mm³ D. 200,000/mm³: Correct Answer: A. 150,000/mm³. Explanation: A platelet count below 150,000/mm³ indicates thrombocytopenia, a key feature of HIT.
54. (SATA) What precautions should be implemented for a patient with HIT to prevent bleeding? A. Use electric razors for shaving B. Perform frequent venipunctures C. Use a stool softener daily D. Encourage vigorous exercise: Correct Answers: A, C. Explanation: Electric razors minimize cut risks, and stool softeners prevent straining during bowel move- ments. Frequent venipunctures and vigorous exercise are not recommended.
55. Which of the following is a primary reason to avoid platelet transfusions in HIT? A. Risk of allergic reaction B. Increased risk of thrombus formation C. Ineffective in increasing platelet count D. High cost of platelets: Correct Answer: B. Increased risk of thrombus formation.

Study online at https://quizlet.com/_e8jtvy Explanation: In HIT, platelet transfusions may exacerbate thrombosis due to the immune response involved.

56. (SATA) Signs and symptoms of hemorrhage in HIT patients include: A. Ecchymosis B. Tachycardia C. Petechiae D. Hematuria: Correct Answers: A, C, D. Explanation: Ecchymosis, petechiae, and hematuria are signs of bleeding, important to monitor in HIT.
57. Frequent monitoring of which laboratory value is essential in the manage- ment of HIT? A. Hemoglobin B. White blood cell count C. Platelet count D. Blood urea nitrogen (BUN): Correct Answer: C. Platelet count. Explanation: Monitoring platelet count is crucial for assessing the severity and progression of HIT.
58. Which action is contraindicated in a patient diagnosed with HIT? A. Monitoring for signs of bleeding B. Administering IV fluids as ordered C. Starting warfarin therapy immediately D. Implementing bleeding precautions: Correct Answer: C. Starting warfarin ther- apy immediately. Explanation: Warfarin can cause severe complications in HIT and is contraindicated.
59. Which nursing actions are appropriate for managing a patient with HIT? A. Avoid rectal temperatures B. Implement falls precautions C. Provide a high-fiber diet D. Minimize blood draws: Correct Answers: A, D. Explanation: Avoiding rectal temperatures and minimizing blood draws help reduce the risk of bleeding.
60. The presence of antiplatelet antibodies in HIT is confirmed by: A. Platelet aggregation test B. Enzyme-linked immunosorbent assay (ELISA) C. Direct Coombs test D. Blood culture: Correct Answer: B. Enzyme-linked immunosorbent assay (ELISA). Explanation: ELISA is used to detect the specific antibodies responsible for HIT.
61. Which symptom is least likely to be associated with HIT? A. Nosebleeds B. Fever C. Black, tarry stools

Study online at https://quizlet.com/_e8jtvy D. Hypertension: Correct Answer: D. Hypertension. Explanation: HIT primarily in- volves bleeding complications, not hypertension.

62. Essential patient education for someone recovering from HIT should in- clude: A. The importance of frequent laboratory tests B. Signs and symptoms of bleeding to report C. Continuing heparin at a lower dose D. Avoiding sexual intercourse when platelet count is <50,000/mm³: Correct Answers: A, B, D. Explanation: Frequent lab tests, awareness of bleeding signs, and precautions during low platelet counts are crucial. Continuing heparin is contraindi- cated.
63. Why is frequent monitoring of platelet count every 4-6 hours recommended in the initial treatment of HIT? A. To determine the need for blood transfusions B. To monitor the effectiveness of anticoagulant therapy C. To assess for progression to disseminated intravascular coagulation (DIC) D. To adjust heparin dosage appropriately: Correct Answer: B. To monitor the effectiveness of anticoagulant therapy. Explanation: Monitoring helps assess the response to treatment and adjust as necessary, not for adjusting heparin, which is discontinued.
64. Which interventions help minimize blood loss in a patient with HIT? A. Applying ice to a laceration for at least 5 minutes B. Using a sharp knife for cutting to reduce force C. Avoiding the use of soft-bristle toothbrushes D. Minimizing the number of intramuscular injections: Correct Answers: A, B, D. Explanation: These measures help reduce the risk of bleeding. Soft-bristle toothbrushes should be used, not avoided.
65. The risk of skin gangrene in HIT patients treated with warfarin is due to: A. Direct toxicity of warfarin on the skin B. Warfarin-induced reduction in Vitamin K C. Microvascular thrombosis and necrosis D. Warfarin's interaction with anticoagulants: Correct Answer: C. Microvascular thrombosis and necrosis. Explanation: The risk is due to the potential for microvas- cular thrombosis, leading to necrosis, not direct toxicity or vitamin K reduction.
66. (SATA) Nursing assessments for a patient with DIC and HIT should include: A. Checking for ecchymosis and petechiae B. Monitoring blood pressure for hypertension C. Assessing for signs of hemorrhage D. Evaluating liver function tests: Correct Answers: A, C. Explanation: Checking

Study online at https://quizlet.com/_e8jtvy for bleeding signs like ecchymosis and petechiae and assessing for hemorrhage are key. Hypertension and liver function tests are less directly relevant.

67. When educating a patient about bleeding precautions with HIT, which activity should be avoided due to the risk of bleeding? A. Walking in a well-lit area B. Using an electric razor for shaving C. Engaging in non-contact sports D. Flossing teeth: Correct Answer: D. Flossing teeth. Explanation: Flossing can increase the risk of bleeding gums, so it's recommended to use a soft-bristle toothbrush or gauze instead.