Situation: A nursing student was assigned to take care of a client who was diagnosed with polycythemia vera.56. You planned the nursing care of the client together with the nursing student. You asked the nursing student to enumerate the clinical manifestations of a client with polycythemia vera. You expected the nursing student to enumerate the following manifestations, except:*1 pointA. splenomegalyB. ruddy complexionC. generalized pruritusD. hepatomegaly57. The nursing student reviews laboratory findings and finds which blood results are elevated?*1 pointA. RBC, WBC, platelet countB. WBC, platelet and cholesterolC. bilirubin, RBC and plateletD. BP, WBC, and hematocrit58. Phlebotomy was ordered as part of the therapy. You instructed the client and emphasized that the procedure can be repeated. The client inquired, “What is the primary aim of the procedure?” Your appropriate response is:*1 pointA. “Remove the excess blood and donate to patients of the same blood type.”B. “Prevent headache and dizziness.”C. “Keep the BP reading within normal range.”D. “Keep the hematocrit within normal range.”59. The companion asks why the client was advised to avoid iron supplements or vitamins. The correct response of the nurse would be:*1 pointA. “These supplements enhance the production of RBC.”B. “The vitamins and iron can suppress bone marrow function.”C. “Actually, the patient does not need these supplements.”D. “It is best that the client gets these supplements from natural sources.”60. The client complained of generalized pruritus. The following are appropriate nursing interventions, except:*1 pointA. administer routine antihistamine round the clockB. regulate room temperature to 25 degrees or lowerC. bathe in tepid or cool water followed by coca-based lotion applicationD. wearing light material, loose-fitting camisa61.Which of the following foods would the nurse encourage the mother to offer to her child with iron deficiency anemia?*1 pointA. Rice cereal, whole milk, and yellow vegetablesB. Potato, peas, and chickenC. Macaroni, cheese, and hamD. Pudding, green vegetables, and rice62. Which of the following diagnostic findings are most likely for a client with aplastic anemia?*1 pointA. Decreased production of T-helper cellsB. Decreased levels of white blood cells, red blood cells, and plateletsC. Increased levels of WBCs, RBCs, and plateletsD. Reed-Sternberg cells and lymph node enlargement63. The nurse is assessing a client’s activity intolerance by having the client walk on a treadmill for 5 minutes. Which of the following indicates an abnormal response?*1 pointA. Pulse rate increased by 20 bpm immediately after the activityB. Respiratory rate decreased by 5 breaths/minuteC. Diastolic blood pressure increased by 7 mm HgD. Pulse rate within 6 bpm of resting phase after 3 minutes of rest.64. Which of the following would the nurse identify as the priority nursing diagnosis during a toddler’s vaso-occlusive sickle cell crisis?*1 pointA. Ineffective coping related to the presence of a life-threatening diseaseB. Decreased cardiac output related to abnormal hemoglobin formationC. Pain related to tissue anoxiaD. Excess fluid volume related to infection65. A client with pernicious anemia asks why she must take vitamin B12 injections for the rest of her life. What is the nurse’s best response?*1 pointA. “The reason for your vitamin deficiency is an inability to absorb the vitamin because the stomach is not producing sufficient acid.”B. “The reason for your vitamin deficiency is an inability to absorb the vitamin because the stomach is not producing sufficient intrinsic factor.”C. “The reason for your vitamin deficiency is an excessive excretion of the vitamin because of kidney dysfunction.”D. “The reason for your vitamin deficiency is an increased requirement for the vitamin because of rapid red blood cell production.”SITUATION: Ego defense mechanisms are methods of attempting to protect the self and cope with basic drives or emotionally painful thoughts, feelings, or events.66. Rona’s favorite love team had a concert but she was not able to go. However, her bestfriend went and said to Rona that the concert was fun and spectacular. Rona said, “It’s fine. I don’t really like them that much.” What defense mechanism did Rona use?*1 pointA. DenialB. ProjectionC. Sweet LemoningD. Sourgraping67. Dona’s boss reprimanded her because of her late reports. When she went home, she saw her daughter and yelled at her out of nowhere. What ego defense mechanism does she use?*1 pointA. DenialB. ProjectionC. DisplacementD. Fixation

39. A person may become asymptomatic but confirmatory test will reveal the presence of which if the following in the blood? *1 pointA. CercariaeB. MerozoitesC. MicrofilariaeD. Larvae40. As the infection control nurse in an acute care hospital, which action will you take to most effectively reduce the incidence of health-care-associated infections? *1 pointA. Develop policies that automatically start antibiotic therapy for clients colonized by multidrug resistant organisms.B. Screen all newly admitted clients for colonization or infection with MRSA.C. Require nursing staff to don gowns to change wound dressings for all clients.D. Ensure that dispensers for alcohol-based hand rubs are readily available in all client care areas of the hospital.41. A client with a vancomycin-resistant enterococcus (VRE) infection is admitted to the medical unit. Which action can be delegated to a nursing assistant who is assisting with the client’s care? *1 pointA. Monitor the results of the laboratory culture and sensitivity test.B. Educate the client and family members on ways to prevent transmission of VRE.C. Implement contact precautions when handling the client.D. Collaborate with other departments when the client is transported for an ordered test.42. You are preparing to leave the room after performing oral suctioning on a client who is on contact and airborne precautions. In which order will you perform the following actions? 1. Remove N95 respirator 2. Perform hand hygiene 3. Remove gloves 4. Take off goggles 5. Take off the gown *1 pointA. 1, 4, 5, 3, 2B. 3, 5, 4, 1, 2C. 3, 4, 5, 1, 2D. 3, 4, 1, 5, 243. Which of the following infection control activities should be delegated to an experienced nursing assistant? *1 pointA. Screening clients for upper respiratory tract symptomsB. Disinfecting blood pressure cuffs after clients are dischargedC. Demonstrating correct handwashing techniques to client and familyD. Asking clients about the duration of antibiotic therapy44. You happened to glace another client in the health center who appears gaunt looking apprehensive with maculopapular rashes. Upon history taking the patient has been experiencing loss of appetite, marked weight loss, fever, malaise, cough for long duration. History reveals that 2 years ago, the patient received blood transfusion because of surgery. The nurse will suspect *1 pointA. Hepa AB. Hepa BC. HIVD. Anthrax45. Which of the following will you advice the client to submit for in order to detect the presence of schistosomiasis organism *1 pointA. Chest x rayB. UrinalysisC. Stool examinationD. Platelet count46. The mother of a 2-month-old baby calls the nurse 2 days after the first DTaP, IPV, Hepatitis B and HIB immunizations.  She reports that the baby feels very warm, cries inconsolably for as long as 3 hours, and has had several shaking spells. In addition to referring her to the emergency room, the nurse should document the reaction on the baby's record and expect which of the following? *1 pointA. DTaPB. Hepatitis BC. PolioD. Influenza47. Filiarisis is transmitted to man through bites from *1 pointA. SnailB. Infected male mosquitoC. Infected female mosquitoD. Rats48. The age group with the highest risk for TB of developing the disease is between *1 pointA. Children under three years oldB. Children entering grade oneC. 8-12 years oldD. 13-15 years old49. A newly admitted client with streptococcal pharyngitis (tonsillitis) has been placed on droplet precaution. Which of the following statements indicates the best understanding for this type of isolation?*1 pointA. Must maintain a spatial distance of 3 feetB. The client can be placed in a room with another client with measles (rubeola)C. A special mask (N95) should be worn when working with the clientD. Gloves should be only worn when giving direct care50. This a cutaneous infection that can be contacted uncontaminated wool, fur. The exposed part of skin begins to itch and papules appear in the inoculation sites. The papules become vesicles and developed into black eschars*1 pointA. AnthraxB. ScabiesC. PsoriasisD. Chickenpox

2. What is the most likely diagnosis for the patient?

Upon assessing the patient’s back, she found an elevated skin lesion which contains fluid of inflammatory cells and is more than 1 cm. She is correct if she identifies this as a _____.*1 pointa. papuleb. plaquec. pustuled. vesicl

The nurse is caring for a client in acute renal failure. Which of the following clinical manifestations is a priority for the nurse to monitor in this client? A. Infection B. Pain C. Oliguria D. Anemia

The nurse in a clinic is triaging clients. Which of the following clients should the nurse see first?A. A 17-year-old complaining of abdominal cramping with moderate bloody vaginal dischargeB. A 25-year-old primigravida reporting blurred vision.C. A 50-year-old menopausal client expelling dark red blood clots.D. A 70-year-old client who states her uterus is going to “fall out.”