A&C I practice Anemia/ Coagulation #2

A nurse is caring for a client who has a pulmonary

167 mg

A nurse is teaching a client who has septic shock about the development of DIC. Which of the following statements should the nurse make?

"DIC is caused by abnormal coagulation involving fibrinogen." DIC is caused by abnormal coagulation involving the formation of multiple small clots that consume clotting factors and fibrinogen faster than the body can produce them, increasing the risk for hemorrhage.

A nurse is caring for a client who develops a pulmonary embolism. Which of the following interventions should the nurse implement first.

Administer oxygen therapy The greatest risk to the safety of a client who has a pulmonary embolism is hypoxemia with respiratory distress and cyanosis. Oxygen therapy should be applied by the nurse using a nasal cannula or mask. Pulse oximetry should be initiated to monitor oxygen saturation.

A nurse is caring for a client who is well hydrated and who demonstrates no evidence of anemia. Which of the following lab values gives the nurse an assessment of the adequacy of the client's protein uptake and synthesis?

Albumin Albumin levels reflect the overall body protein status and is used to detect metabolic and liver dysfunction.

A nurse if teaching a client who has a new diagnosis of aplastic anemia. Which of the following information should the nurse include in the teaching?

Aplastic anemia is a hypoproliferative anemia resulting from decreased production of RBC within the bone marrow.

A nurse is planning care for a client who has deep vein thrombosis (DVT) and is receiving anticoagulation therapy. Which of the following interventions should the nurse include in the plan of care?

Encourage the client to walk The client should avoid sitting or standing for long periods of time. After the client begins anticoagulant therapy, the nurse should encourage the client to walk.

A nurse is receiving a client who is immediately postoperative following hip arthroplasty. Which of the following medications should the nurse plant to administer for DVT prophylaxis?

Enoxaparin subcutaneous Enoxaparin is a low molecular heparin that inhibits thrombus and clot formation. Preventive doses of enoxaparin are low and the client does not require monitoring of prothrombin time or activated partial thromboplastin time, making it the preferred treatment for DVT prophylaxis following orthopedic surgery.

A nurse is assessing a client who has disseminated intravascular coagulation (DIC). Which of the following findings should the nurse expect?

Excessive thrombosis and bleeding The nurse should expect excessive thrombosis and bleeding of mucous membranes because both DIC impairs both coagulation and anticoagulation pathways.

A nurse is caring for a young female adult client who reports weakness, fatigue, and heavy menstrual periods. The client has a hemoglobin level of 8 g/dL and a hematocrit level of 28 g/dl. The nurse suspects which fi the following types of anemia

Iron-deficiency anemia Iron-deficiency anemia results from poor gastrointestinal absorption of iron, a diet that is deficient in iron, or blood loss. The nurse should expect a client who has iron-deficiency anemia to have weakness, pallor, fatigue, reduced tolerance for activity, and cheilosis (ulcerations of the corners of the mouth).

A nurse is planning care for a client who has DVT of the lower leg. Which of the following interventions should the nurse include in the plan of care?

Keep the client's affected leg elevated while in bed. The nurse should keep the client's leg elevated when he is in bed to decrease edema.

A nurse is giving a presentation about preventing DVT. Which of the following should the nurse include as a risk factor for this disorder?

Oral contraceptive use is correct. Thromboembolic events are an adverse effect of oral contraceptives Immobility is correct. Immobility leads to stasis of blood, thus increasing the risk for clot formation.

A nurse is assessing a child who is in sickle cell crisis. Which of the following findings should the nurse expect?

Pain A client who is in sickle cell crisis has severe pain resulting from tissue hypoxia and necrosis.

A nurse is reviewing the lab data on a client who has a new prescription for heparin for treatment of pulmonary embolism. Which of the following data should the nurse report to the provider?

Platelets 74,000/mm3 Heparin-induced thrombocytopenia is a disorder characterized by low platelet counts. It is an adverse effect of heparin that causes the activation of platelets, resulting in widespread clot formation and depletion of platelets. The expected reference range for platelets is 150,000-400,000/mm3.

A nurse is caring for an antepartum client who has iron-deficient anemia. When teaching the client about nutrition, the nurse should emphasize the need for an increased intake of which of the following foods?

Red meat and organ meat This client has a deficiency in iron and needs instruction about foods that are rich sources of iron. A diet rich in red and organ meat provides iron, which is what the client needs to improve anemia.

A nurse is assessing a client who is receiving a blood transfusion. Which of the following findings is a manifestation of a hemolytic transfusion reaction?

Report of low-back pain Low-back pain, fever, and chills are manifestations of a hemolytic transfusion reaction. The nurse should discontinue the transfusion and administer 0.9% sodium chloride through new IV tubing

A nurse is teaching a client who is postpartum and has been diagnosed with iron deficiency anemia. Which of the following dietary recommendations should the nurse include in the teaching plan?

Spinach and beef Spinach and beef are high in iron and would be recommended for this client.

A nurse is assessing a client who is postoperative following a vaginal hysterectomy. Which of the following findings is a manifestation of deep-vain thrombosis?

Unilateral leg edema Unilateral edema is a manifestation of DVT.

A nurse is planning care for a client who has pernicious anemia. Which of the following interventions should the nurse plant to implement?

Vitamin B12 injections The nurse should administer vitamin B12 injections to treat pernicious anemia when diet fails to improve the anemia due to poor absorption.

A nurse is teaching a parent of a child who has hemophilia how to control a minor bleeding episode. Which of the following statements by the parent indicates a need for further teaching?

"I will apply heat." Supportive measures to control a minor bleeding episode include applying cool compresses.

A nurse is discharging a child who has sickle cell anemia after an acute crisis episode. Which of the following instructions should the nruse include in the teaching?

"Offer fluids to your child multiple times every day." Preventing dehydration is an important step in preventing a sickle cell crisis. The nurse should provide the parents with a specific fluid goal for the child to reach each day.

A nurse is caring for a client who has a new prescription for ferrous sulfate tablets twice daily for iron-deficiency anemia. The client asks the nurse why the provider instructed that she take the ferrous sulfate between meals. Which of the following responses should the nurse make?

"Taking the medication between meals will help you absorb the medication more efficiently." Ferrous sulfate provides the iron needed by the body to produce red blood cells. Taking iron supplements between meals helps to increase the bioavailability of the iron.

A nurse is caring for a client who has deep vein thrombosis and has been on heparin continuous infusion for 5 days. The provider prescribed warfarin PO without discontinuing the heparin. The client asks the nurse why both anticoagulants are necessary. Which of the following statements should the nurse make

"Warfarin takes several days to work, so the IV heparin will be used until the warfarin reaches a therapeutic level." Heparin and warfarin are both anticoagulants that decrease the clotting ability of the blood and help prevent thrombosis formation in the blood vessels. However, these medications work in different ways to achieve therapeutic coagulation and must be given together until therapeutic levels of anticoagulation can be achieved by warfarin alone, which is usually within 1 to 5 days. When the client's PT and INR are within therapeutic range, the heparin can be discontinued.

A nurse if planning a menu for a client who has folic acid deficient anemia. Which of the following foods should the nurse include as high in folate

1/2 cup of asparagus A half cup of asparagus contains 132 mcg of folate.

A nurse is administering a unit of RBC 350mL over 3 hr to a client who has anemia. The nurse should set the IV pump to deliver how many mL/hr?

117mL/hr

A nurse is caring for a client who has a deep vein thrombosis and is prescribed heparin by continuous IV infusion at 1,200 units/hr. Available is heparin 25,000 units in 500mL D5W. The nurse should set the IV pump to deliver how many mL/hr?

24 mL/hr

A nurse is planning to perform a blood transfusion for a client. Which of the following actions should the nurse plan to take?

Check vital signs before transfusion is correct. The nurse should check the client's vital signs immediately before starting the transfusion to create a baseline in order to assess a change in the vital signs during the transfusion. Insert an IV with a 19-gauge needle is correct. The nurse should insert a large bore IV to transfuse the blood easily. Check the expiration date of the blood product with a second nurse is correct. The expiration date, the client's name, the hospital number, and the blood compatibility are checked with two nurses to reduce the risk for a transfusion reaction.

A nurse is assessing a client who is postoperative and has anemia due to excess blood loss following surgery. Which of the following findings should the nurse expect?

Fatigue The nurse should identify that the client who has anemia due to blood loss following surgery will experience fatigue. This is due to the body's decreased ability carry oxygen to vital tissues and organs.

A nurse is providing discharge instructions to a client who developed DVT postoperatively and is prescribed anticoagulant therapy. Which of the following instructions should the nurse include.

Flexing her knees and feet frequently Leg, ankle, and foot exercises can help improve circulation and prevent venous stasis while the client is resting.

A nurse is monitoring a client who is receiving a blood transfusion. Which of the following findings indicates an allergic transfusion reaction?

Generalized urticaria. The nurse should recognize urticaria as an indicator of an allergic transfusion reaction. Other clinical manifestations include itching and signs of anaphylaxis with bronchospasm.

A nurse is assessing a client who is at risk for deep-vein thrombosis (DVT). Which of the following findings is a manifestation of DVT?

Groin tenderness Calf pain, groin pain, and unilateral leg swelling are manifestations of DVT.

A nurse is monitoring a client who reports having chills and back pain during a blood transfusion. Which of the following actions is the nurse's priority?

Stopping the transfusion The greatest risk to this client is injury from a transfusion reaction, which is indicated by chills and back pain. Therefore, the priority intervention is to stop the infusion.

A nurse is providing teaching for a client who has anemia and a new prescription for ferrous sulfate liquid. Which of the following instructions should the nurse provide?

Take the medication with orange juice to enhance absorption. Ascorbic acid (vitamin C), which is found in orange juice, will enhance the absorption of iron and increase its bioavailability. This will also help to decrease the gastrointestinal side effects of iron.

A nurse is reviewing the PT, aPTT, and INR laboratory values for a client who is experiencign an acute episode of disseminated DIC. Which of the following laboratory results should the nurse expect?

The laboratory values are prolonged. MY ANSWER These laboratory values measure clotting time. Because DIC results in the formation of multiple, small clots that consume key clotting factors, the nurse should expect the laboratory values to be prolonged.

A nurse is planning care for a client who has quadriplegia. Which of the following actions should the nurse take to prevent a pulmonary embolism (PE)

The nurse should assess the client's legs for redness, which would be an indication of thrombophlebitis formation, which can lead to a PE without appropriate treatment.The nurse should apply elastic compression stockings to prevent thrombophlebitis formation and possible PE and improve blood return to the heart. The nurse should perform passive range of motion exercises to improve blood return to the heart and prevent thrombophlebitis formation and possible PE.

A charge nurse is supervising a newly licensed nurse caring for a client who is receiving a transfusion of packed RBC. The nurse suspects a possible hemolytic reacting. After stopping the blood transfusion, which of the following actions by the new nurse requires intervention by the charge nurse?

The nurse starts the transfusion of another unit of blood product. When suspecting a hemolytic reaction, the nurse should immediately stop the transfusion of all blood products. The transfusion of additional products can increase the client's risk for further complication.