Adult Health Exam 1 in Class Questions

The nurse is teaching the client with a platelet disorder about signs of bleeding. What statement from the client indicates the client has understood the teaching?

"Eccymoses are large, purple skin bruises."

A client with a diagnosis of hemolytic anemia has gone to a community-based laboratory for follow-up blood work. The lab technician confirms with the client that hematocrit is one of the components of the blood work. The client replies, "I thought the point of the blood work was to see how many red blood cells I have today." How could the technician best respond to the client's statement?

"The hematocrit measures the mass that your red blood cells account for in a quantity of your blood." Rationale: Hematocrit measures the mass of erythrocytes in a given quantity of blood plasma. It does not measure the number of red cells, their size, or their production rate and age.

A nurse is preparing to administer packed RBCs to a client who has a Hgb of 8 g/dL. Which of the following actions should the nurse plan to take during the first 15 minutes of the transfusion?

Assess for an acute hemolytic reaction.

The nurse is developing a teaching plan for the client with aplastic anemia. Which is most important to include in the plan?

Avoid exposure to others with acute infections. Rationale: Clients with aplastic anemia are severely immunocompromised and at risk for infection and possible death related to bone marrow suppression and pancytopenia.

The nurse is preparing to administer platelets. What should the nurse do first?

Gently rotate the bag Rationale: The bag containing platelets needs to be gently rotated to prevent clumping

A nurse is teaching a newly licensed nurse about heparin‐induced thrombocytopenia. Which of the following risk factors for this disorder should the nurse include in the teaching?

Heparin therapy for deep‐vein thrombosis rationale: The client who is receiving heparin therapy for longer than 1 week is at increased risk for the development of HIT.

In hemolytic anemia, the RBCs are destroyed prematurely. What distinguishes almost all types of hemolytic anemia?

Normocytic normochromic cells Rationale: Almost all types of hemolytic anemia are distinguished by normocytic and normochromic red cells. Because of the RBC's shortened life span, the bone marrow is usually hyperactive, resulting in an increased number of reticulocytes in the circulation blood.

Interpret Bill Morris's ABG results: pH 7.30, PaCO2 65 mm Hg, PaO2 60 mm Hg, HCO3 30 mEq/L

Partially compensated respiratory acidosis with hypoxemia

Laboratory studies are performed for a client suspected to have iron deficiency anemia. The nurse reviews the laboratory results, knowing that which result indicates this type of anemia?

Red blood cells that are microcytic and hypochromic Rationale: In iron deficiency anemia, iron stores are depleted, resulting in a decreased supply of iron for the manufacture of hemoglobin in red blood cells.

The nurse is administering packed red blood cells to the client. What should the nurse do first?

Stay with the client during the first 15 minutes of infusion Rationale: The most likely time for a blood transfusion reaction to occur is during the first 15 minutes or first 50 mL of the infusion.

The client with idiopathic thrombocytopenic purpura (ITP) asks the nurse why it is necessary to take steroids. The nurse should base the response on which information?

Steroids alter the spleen's recognition of platelets rationale: ITP is treated with steroids to suppress the splenic macrophages from phagocytizing the antibody‐coated platelets, which are recognized as foreign bodies, so that the platelets live longer. The steroids also suppress the binding of the autoimmune antibody to the platelet surface. Steroids do not destroy the antibodies on the platelets, neutralize antigens, or increase phagocytosis.

A client is having a blood transfusion reaction. List the nursing actions in order of priority from first to last.

Stop the transfusion, keep the IV open with normal saline infusion, notify the healthcare provider and the blood bank, complete the appropriate transfusion reaction forms

Because M.N.'s magnesium level is 1.0 mEq/L, a magnesium sulfate bolus is initiated. The student nurse knows that a magnesium level of 1.0 mEq/L may result in the following signs and symptoms:

Tachycardia and Chovestk's Sign Rationale: Hypomagnesemia usually occurs in conjunction with hypocalcemia and hypokalemia, producing neurologic manifestations: personality changes, tetany, Chvostek and Trousseau signs and nystagmus as well as cardiac manifestations such as tachycardia, hypertension, and cardiac arrhythmias. Hypotension and bradycardia occur with increased magnesium levels.

A client who follows a vegetarian diet was referred to a dietitian for nutritional counseling for iron deficiency anemia. Which client outcome indicates that the client needs further nutritional counseling?

The client drinks coffee or tea with meals.

A nurse in a clinic receives a phone call from a client seeking information about a new prescription for erythropoietin. Which of the following information should the nurse review with the client?

The client should have their hemoglobin checked twice a week. rationale: Include in the teaching that hemoglobin and hematocrit are monitored twice a week until the targeted levels are reached.

An A positive patient is anemic and needs a blood transfusion. Which blood types can be given to this patient? SATA

a. A positive b. A negative c. O positive d. O negative Rationale: An A+ patient can safely receive A+, A-, O+, and O- blood. This patient cannot receive B or AB blood because they have anti-B antibodies to the B antigen on B and AB blood types

3. A nurse is providing discharge teaching to a client who had a gastrectomy for stomach cancer. Which of the following information should the nurse include in the teaching? Select all that apply.

a. CORRECT: The client who had a gastrectomy will require monthly injections of vitamin B12 for the rest of their life due to lack of intrinsic factor being produced by the parietal cells of the stomach. b. CORRECT: Cyanocobalamin nasal spray used daily is an option for a client who had a gastrectomy.

A nurse is planning care for a client who has a Hb 7.5 g/dl and a Hct 21.5%. Which of the following actions should the nurse include in the plan of care? Select all that apply.

a. Provide assistance with ambulation b. Monitor oxygen saturation c. Obtain stool specimen for occult blood e. Schedule daily rest periods.

A client with pernicious anemia is receiving vitamin B12. The nurse should evaluate the client for which expected outcome?

absence of paresthesias Rationale: Pernicious anemia is caused by a lack of vitamin B12. Primary symptoms include neuropathy with paresthesias of hands and feet.

The patient with emphysema has an increased anterior-posterior chest diameter. The nurse attributes this finding to:

air trapping Rationale: Patients who present with emphysema often have a barrel chest due to air trapped in their lungs.

A client with thrombocytopenia presents to the ER with a severe headache. What does the triage nurse interpret that this may indicate?

cerebral bleeding Rationale: When the platelet count is very low, RBCs leak out of the blood vessels and into the tissue. If the BP is elevated and the platelet count falls to < 15,000/μL, internal bleeding in the brain can occur.

interpret the following ABG results: pH 7.36, PaCO2 64 mmHg, HCO3 35 mEq/L

fully compensated respiratory acidosis

A patient with a history of emphysema is experiencing hypoxemia after a taxing physical therapy appointment. Which of the following physiologic phenomena will occur as a consequence of hypoxemia?

increased heart rate Rationale: Hypoxemia will trigger a SNS response to increase oxygen delivery to the tissues, leading to increased heart rate, peripheral vasoconstriction, and tachypnea

You teach G.C. ( a patient with iron deficit anemia) about foods she should include in her diet. You determine that she understands your teaching if she states she will increase her intake of which of the following foods? Select all that apply

lean cuts of poultry, pork and beef, beans and dark, leafy green veggies

The nurse should instruct the client with vitamin B12 deficiency to eat which foods to obtain the best supply of vitamin B12?

meats and dairy products Rationale: Good sources of vitamin B12 include meats and dairy products. Whole grains are a good source of thiamine. Green, leafy vegetables are good sources of niacin and folate. Broccoli and Brussels sprouts are good sources of ascorbic acid (vitamin C).

interpret the following ABG results:pH 7.46, PaCO2 49 mmHg, HCO3 34 mEq/L

metabolic alkalosis with partial compensation

the nurse is caring for a client with heart failure is notified by the hospital laboratory that the clients serum magnesium level is 1.0. Which would be the most appropriate nursing action for this client?

monitor the client for dysrhythmias

the nurse reviews a clients records and determines the client is at risk for developing a potassium deficient if which situation is documented?

requires nasogastric suction

Interpret the following ABG results:pH 7.48, PaCO2 28 mmHg, HCO3 20 mEq/L

respiratory alkalosis partially compensated

As a result of cyanosis and fluid retention, persons with chronic obstructive bronchitis are prone to:

right sided heart failure Rationale: People with clinical syndrome of chronic bronchitis are classically labeled blue bloaters, a reference to cyanosis and fluid retention associated with right-sided heart failure.

M.N. tells the student nurse that she feels weak. The NG drainage canister contains a moderate amount of watery bile-colored fluid. Which laboratory values should be checked first?

sodium, potassium, and pH levels . rationale: With continuous NG suction, there is a loss of sodium, potassium, magnesium, and hydrogen ions. The loss of acid via suctioning will result in an increase in blood pH or metabolic alkalosis

A nurse is completing an integumentary assessment of a client who has iron deficiency anemia. Which of the following findings should the nurse expect?

spoon shaped nails. rationale: Deformities of the nails, such as being spoon‐shaped, are findings in a client who has anemia.

The nurse should instruct the client with a platelet count of < 150,000/μL to avoid which activity?

straining to have a bowel movement. rationale: When the platelet count is < 150,000/μL prolonged bleeding can occur from trauma, injury, or straining such as with Valsalva's maneuver.

A client with thrombocytopenia has developed a hemorrhage. The nurse should assess the client for which finding?

tachycardia Rationale: The nurse should assess the client who is bleeding for tachycardia because the heart beats faster to compensate for decreased circulating volume and decreased numbers of oxygen-carrying RBCs.

the nurse is assessing a client with a lactose intolerance disorder for a suspected diagnosis of hypocalcemia. Which clinical manifestation would the nurse expect to note in the client?

twitching. rationale: a client with lactose intolerance is at risk of developing hypocalcemia.