ATI Adult Medical-Surgical Nursing: Hematologic & Fluid Imbalances

A nurse is monitoring a client who began receiving a unit of packed RBCs 10 min ago. Which of the following findings should the nurse identify as an indication of a febrile transfusion reaction? (Select all that apply.) A. Temperature change from 37° C (98.6° F) pretransfusion to 37.2° C (99.0° F) B. Current blood pressure 178/90 mm Hg C. Heart rate change from 88/min pretransfusion to 120/min D. Client report of itching E. Client appears flushed

A. A temperature increase of 1° F (0.5° C) is an indication of a febrile transfusion reaction. B. Hypotension is an indication of a febrile transfusion reaction. C. CORRECT: Tachycardia is an indication of a febrile transfusion reaction. D. Itching is an indication of an allergic transfusion reaction. E. CORRECT: A flushed appearance of the client can indicate a febrile transfusion reaction.

A nurse is completing an integumentary assessment of a client who has anemia. Which of the following findings should the nurse expect? A. Absent turgor B. Spoon-shaped nails C. Shiny, hairless legs D. Yellow mucous membranes

A. Absent skin turgor is a finding in a client who has dehydration. B. CORRECT: Deformities of the nails, such as being spoon-shaped, are findings in a client who has anemia. C. Shiny, hairless legs are present in a client who has peripheral vascular disease. D. Yellow mucous membranes are found in a client who has jaundice. The client who has anemia will have pale nail beds and mucous membranes.

A nurse is caring for a client who has a nasogastric tube attached to low intermittent suctioning. The nurse should monitor for which of the following electrolyte imbalances? A. Hypercalcemia B. Hyponatremia C. Hyperphosphatemia D. Hyperkalemia

A. An increase in calcium is not indicated with nasogastric losses due to suctioning. B. CORRECT: Monitor the client for hyponatremia. Nasogastric losses are isotonic and contain sodium. C. Hyperphosphatemia is not indicated with nasogastric losses due to suctioning. D. A decrease in potassium can occur from nasogastric losses due to suctioning.

A nurse is caring for a client who is receiving a blood transfusion. Which of the following actions should the nurse plan to take if an allergic transfusion reaction is suspected? (Select all that apply.) A. Stop the transfusion. B. Monitor for hypertension. C. Maintain an IV infusion with 0.9% sodium chloride. D. Position the client in an upright position with the feet lower than the heart. E. Administerdiphenhydramine.

A. CORRECT: Immediately stop the infusion if an allergic transfusion reaction is suspected. B. Monitor for hypotension if an allergic transfusion reaction is suspected due to the risk for shock. C. CORRECT: Administer 0.9% sodium chloride solution through new IV tubing if an allergic transfusion reaction is suspected. D. Position the client with the feet elevated and the head flat or elevated no more than 30° to prevent or treat hypotension associated with an allergic reaction. E. CORRECT: Administer an antihistamine, such as diphenhydramine, if an allergic transfusion reaction is suspected.

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? A. The client needs an erythrocyte sedimentation rate (ESR) test weekly. B. The client should have their hemoglobin checked twice a week. C. Oxygen saturation levels should be monitored. D. Folic acid production will increase.

A. Include in the teaching that the effectiveness of erythropoietin is evaluated by changes in the hematocrit. B. CORRECT: Include in the teaching that hemoglobin and hematocrit are monitored twice a week until the targeted levels are reached. C. Monitor the client's blood pressure for an increase and determine if the provider should prescribe an antihypertensive. D. Inform the client that erythropoietin promotes increased production of RBCs.

A nurse is providing teaching for a client who is scheduled for a bone marrow biopsy of the iliac crest. Which of the following statements made by the client indicates an understanding of the teaching? A. "This test will be performed while I am lying flat on my back." B. "I will need to stay in bed for about an hour after the test." C. "This test will determine which antibiotic I should take for treatment." D. "I will receive general anesthesia for the test."

A. Inform the client that they will be placed in a prone or side-lying position during the test in order to expose the iliac crest. B. CORRECT: Inform the client of the need to stay on bed rest for 30 to 60 min following the test to reduce the risk for bleeding. C. Inform the client that a culture and sensitivity test determines the type of antibiotics needed to treat an infection. D. Inform the client that they will receive a sedative prior to the test and that a local anesthetic will be used at the site.

A nurse is caring for a client in a long-term care facility who has become weak, confused, and experienced dizziness when standing. The client's temperature is 38.3° C (100.9° F), pulse 92/min, respirations 20/min, and blood pressure 108/60 mm Hg. Which of the following actions should the nurse take? A. Initiate fluid restrictions to limit intake. B. Check for peripheral edema. C. Encourage the client to ambulate to promote oxygenation. D. Monitor for orthostatic hypotension.

A. Offer fluids when the client has manifestations of dehydration. B. Monitor for poor skin turgor when the client has manifestations of fluid volume deficit. C. Keep the client in bed and assist them to the bathroom as needed because they are at risk for falling due to manifestations of dehydration. D. CORRECT: Monitor for orthostatic hypotension because they have manifestations of dehydration due to decreased circulatory volume.

A nurse is caring for a client who has idiopathic thrombocytopenic purpura (ITP). The nurse should notify the provider and report possible small-vessel clotting when which of the following is assessed? A. Petechiae on the upper chest B. Hypotension C. Cyanotic nail beds D. Severe headache

A. Petechiae on the upper chest can indicate impaired clotting. B. Hypotension can indicate impaired clotting. C. CORRECT: Cyanotic nail beds indicate microvascular clotting is occurring and should be immediately reported to avoid ischemic loss of the fingers or toes. D. Severe headache can indicate cerebral bleeding.

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? A. Warfarin therapy for atrial fibrillation B. Placental abruption C. Systemic lupus erythematosus D. Heparin therapy for deep-vein thrombosis

A. Warfarin therapy and atrial fibrillation are not related to development of HIT. B. Placental abruption is a risk factor for development of DIC. C. Systemic lupus erythematosus is an autoimmune disorder that places the client at risk for development of ITP. D. CORRECT: The client who is receiving heparin therapy for longer than 1 week is at increased risk for the development of HIT.

A nurse is caring for a client who is receiving warfarin for anticoagulation therapy. Which of the following laboratory test results indicates to the nurse that the client needs an increase in the dosage? A. aPTT 38 seconds B. INR 1.1 C. PT 22 seconds D. D-dimer negative

A. aPTT is monitored for clients receiving heparin therapy. An aPTT of 38 seconds is within the expected reference range for clients not receiving heparin therapy. B. CORRECT: INR of 1.1 is within the expected reference range for a client who is not receiving warfarin. However, this value is subtherapeutic for anticoagulation therapy. Expect the client to receive an increased dosage of warfarin until the INR is 2 to 3. C. PT of 22 seconds is above the expected reference range for a client receiving warfarin therapy. This result indicates the client is at an increased risk for bleeding. D. A negative D-dimer test indicates the absence of a pulmonary embolus or deep vein thrombosis and is not used to determine the dosage needs for warfarin therapy.

A nurse in a clinic is caring for a client who has suspected anemia. Which of the following laboratory test results should the nurse expect? A. Iron 90 mcg/dL B. RBC 6.5 million/uL C. WBC 4,800 mm3 D. Hgb 10 g/dL

A. An iron level of 90 mcg/dL is within the expected reference range and is not an expected finding of anemia. B. RBC count of 6.5 million/uL is above the expected reference range. A decreased RBC count is an expected finding of anemia. C. WBC count of 4800 mm3 is below the expected reference range and is not an expected finding of anemia. D. CORRECT: Hgb of 10 g/dL is below the expected reference range and is an expected finding of anemia.

A nurse is assessing a client for Chvostek's sign. Which of the following techniques should the nurse use to perform this test? A. Apply a blood pressure cuff to the client's arm. B. Place the stethoscope bell over the client's carotid artery. C. Tap lightly on the client's cheek. D. Ask the client to lower their chin to their chest.

A. Applying a blood pressure cuff to the client's arm is performed to assess for Trousseau's sign. B. Placing the stethoscope bell over the client's carotid artery is performed to auscultate a carotid bruit. C. CORRECT: Tap the client's cheek over the facial nerve just below and anterior to the ear to elicit Chvostek's sign. A positive response is indicated when the client exhibits facial twitching on this side of the face. D. Asking the client to lower their chin to their chest is performed to assess for range of motion of the neck.

A nurse is caring for a client who was in a motor-vehicle accident. The client reports chest pain and difficulty breathing. A chest x-ray reveals the client has a pneumothorax. Which of the following arterial blood gas findings should the nurse expect? A. pH 7.06 PaO2 86 mm Hg PaCO2 52 mm Hg HCO3− 24 mEq/L B. pH 7.42 PaO2 100 mm Hg PaCO2 38 mm Hg HCO3− 23 mEq/L C. pH 6.98 PaO2 100 mm Hg PaCO2 30 mm Hg HCO3− 18 mEq/L D. pH 7.58 PaO2 96 mm Hg PaCO2 38 mm Hg HCO3− 29 mEq/L

A. CORRECT: A pneumothorax can cause alveolar hypoventilation and increased carbon dioxide levels, resulting in a state of respiratory acidosis. B. These ABGs are within the expected reference range and reflect homeostasis. C. Metabolic acidosis is not indicated for this client. D. Metabolic alkalosis is not indicated for this client.

A nurse is caring for a client who has a blood potassium 5.4 mEq/L. The nurse should assess for which of the following manifestations? A. ECG changes B. Constipation C. Polyuria D. Paresthesia

A. CORRECT: Assess for ECG changes. Potassium levels can affect the heart and result in arrhythmias. B. Constipation is a manifestation of hypokalemia. C. Polyuria is a manifestation of hypokalemia. D. Paresthesia is a manifestation of hypokalemia.

A nurse is planning care for a client who has Hgb 7.5 g/dL and 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. Weigh the client weekly. D. Obtain stool specimen for occult blood. E. Schedule daily rest periods.

A. CORRECT: Assist the client when ambulating to prevent a fall because the client who has anemia can experience dizziness. B. CORRECT: Monitor oxygen saturation when the client has anemia due to the decreased oxygen-carrying capacity of the blood. C. Weigh the client daily to determine if the client is losing weight from inadequate oral intake or gaining weight, which can indicate a complication of heart failure due to lack of oxygen from low hemoglobin level. D. CORRECT: Obtain the client's stool to test for occult blood, which can identify a possible cause of anemia caused from gastrointestinal bleeding. E. CORRECT: Schedule the client to rest throughout the day because the client who has anemia can experience fatigue. Rest periods should be planned to conserve energy.

A nurse is admitting a client who reports nausea, vomiting, and weakness. The client has dry oral mucous membranes and blood pressure 102/64 mm Hg. Which of the following findings should the nurse identify as manifestations of fluid volume deficit? (Select all that apply.) A. Decreased skin turgor B. Concentrated urine C. Bradycardia D. Low-grade fever E. Tachypnea

A. CORRECT: Decreased skin turgor is a manifestation present with fluid volume deficit. Skin turgor is decreased due to the lack of fluid within the body and results in dryness of the skin. B. CORRECT: Concentrated urine is a manifestation present with fluid volume deficit. Urine is concentrated due to lack of fluid in the vascular system, causing a decreased profusion of the kidneys and resulting in an increased urine specific gravity. C. Tachycardia is a manifestation present with fluid volume deficit due to an attempt to maintain a normal blood pressure. D. CORRECT: Low-grade fever is a manifestation present with fluid volume deficit. Low-grade fever is one of the body's ways to maintain homeostasis to compensate for lack of fluid within the body. E. CORRECT: Tachypnea is a manifestation present with fluid volume deficit. Increased respirations are the body's way to obtain oxygen due to the lack of fluid volume within the body.

A nurse is admitting an older adult client who reports a weight gain of 2.3 kg (5 lb) in 48 hr. Which of the following manifestations of fluid volume excess should the nurse expect? (Select all that apply.) A. Dyspnea B. Edema C. Bradycardia D. Hypertension E. Weakness

A. CORRECT: Dyspnea is a manifestation present with fluid volume excess. Dyspnea is due to an excess of fluids within the body and lungs, and the client is struggling to breathe to obtain oxygen. B. CORRECT: Edema is a manifestation present with fluid volume excess. Weight gain can be a result of edema. C. Tachycardia and bounding pulses are manifestations related to fluid volume excess. D. CORRECT: Hypertension is a manifestation related to fluid volume excess. Blood pressure rises as the heart must work harder due to the excess fluid. E. CORRECT: Weakness is a manifestation present with fluid volume excess. Weakness is due to the excess fluid that is retained, which depletes energy and increases the workload for the body.

A nurse is caring for a client who has DIC. Which of the following medications should the nurse anticipate administering? A. Heparin B. Vitamin K C. Mefoxin D. Simvastatin

A. CORRECT: Heparin can be administered to decrease the formation of microclots, which deplete clotting factors. B. Vitamin K promotes blood coagulation and is not prescribed for a client who has DIC. C. Mefoxin is an antibiotic given to treat bacterial infection and is not a medication that should be administered to a client who has DIC. D. Simvastatin is an antilipemic given to treat hyperlipidemia and is not a medication that should be administered to a client who has DIC.

A nurse is assessing a client who has hyperkalemia. The nurse should identify which of the following conditions as being associated with this electrolyte imbalance? A. Diabetic ketoacidosis B. Heart failure C. Cushing's syndrome D. Thyroidectomy

A. CORRECT: Hyperkalemia, an increase in blood potassium, is a laboratory finding associated with diabetic ketoacidosis. B. Hyponatremia, a decrease in blood sodium, is a laboratory finding associated with heart failure. C. Hypernatremia, an increase in blood sodium, is a laboratory finding associated with Cushing's syndrome. D. Hypocalcemia, a decrease in blood calcium, is a laboratory finding that is found in clients following a thyroidectomy.

A nurse is caring for a client who has disseminated intravascular coagulation (DIC). Which of the following laboratory values indicates the client's clotting factors are depleted? (Select all that apply.) A. Platelets 100,000/mm3 B. Fibrinogen levels 120 mg/dL C. Fibrin degradation products 4.3 mcg/mL D. D-dimer 0.03 mcg/mL E. Sedimentation rate 38 mm/hr

A. CORRECT: In DIC, platelet levels are decreased, causing clotting factors to become depleted. Clotting times are increased, which raises the risk for fatal hemorrhage. B. CORRECT: In DIC, fibrinogen levels are decreased, causing clotting factors to become depleted. Clotting times are increased, which raises the risk for fatal hemorrhage. C. Fibrin degradation products are increased when DIC occurs. D. A D-dimer level is increased when DIC occurs. E. The sedimentation rate is increased, but it is not an indicator of DIC.

A charge nurse is teaching a group of nurses about conditions related to metabolic acidosis. Which of the following statements by a unit nurse indicates the teaching has been effective? A. "Metabolic acidosis can occur due to diabetic ketoacidosis." B. "Metabolic acidosis can occur in a client who has myasthenia gravis." C. "Metabolic acidosis can occur in a client who has asthma." D. "Metabolic acidosis can occur due to cancer."

A. CORRECT: Metabolic acidosis results from an excess production of hydrogen ions, which occurs in diabetic ketoacidosis. B. Respiratory acidosis can occur in a client who has myasthenia gravis. C. Respiratory acidosis can occur in a client who has asthma. D. Respiratory acidosis can occur due to cancer.

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. "You will need a monthly injection of vitamin B12 for the rest of your life." B. "Using the nasal spray form of vitamin B12 on a daily basis can be an option." C. "An oral supplement of vitamin B12 taken on a daily basis can be an option." D. "You should increase your intake of animal proteins, legumes, and dairy products to increase vitamin B12 in your diet." E. "Add soy milk fortified with vitamin B12 to your diet to decrease the risk of pernicious anemia."

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. C. Oral supplements of vitamin B12 will not be absorbed due to the lack of intrinsic factor produced by the parietal cells of the stomach. D. Dietary sources of vitamin B12 will not be absorbed due to the lack of intrinsic factor produced by the parietal cells of the stomach. E. Dietary sources of vitamin B12 will not be absorbed due to the lack of intrinsic factor produced by the parietal cells of the stomach.

A nurse is caring for a client who has a blood sodium level 133 mEq/L and blood potassium level 3.4 mEq/L. The nurse should recognize that which of the following treatments can result in these laboratory findings? A. Three tap water enemas B. 0.9% sodium chloride solution IV at 50 mL/hr C. 5% dextrose with 0.45% sodium chloride solution with 20 mEq of K+ IV at 80 mL/hr D. Antibiotic therapy

A. CORRECT: Three tap water enemas can result in a decrease in blood sodium and potassium. Tap water is hypotonic, and gastrointestinal losses are isotonic. This creates an imbalance and solute dilution. B. 0.9% sodium chloride is an isotonic solution and will not produce these results. C. 5% dextrose with 0.45% sodium chloride is an isotonic solution with 20 mEq of K+ at 80 mL/hr and would not produce these results. D. Antibiotic therapy would not produce these results.

A nurse is assessing a client who is dehydrated. Which of the following findings should the nurse expect? A. Moist skin B. Distended neck veins C. Increased urinary output D. Tachycardia

A. Moist skin is a manifestation of fluid volume excess. B. Distended neck veins are a manifestation of fluid volume excess. C. Increased urinary output is a manifestation of fluid volume excess. D. CORRECT: Tachycardia is an attempt to maintain blood pressure, a manifestation of fluid volume deficit.

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 min of the transfusion? A. Obtain consent from the client for the transfusion. B. Assess for an acute hemolytic reaction. C. Explain the transfusion procedure to the client. D. Obtain blood culture specimens to send to the lab.

A. Obtain consent from the client for the transfusion prior to initiating the transfusion. B. CORRECT: Assess for an acute hemolytic reaction during the first 15 min of the transfusion. This form of a reaction can occur following the transfusion of as little as 10 mL of blood product. C. Explain the transfusion procedure to the client prior to initiating the transfusion. D. Obtain blood culture specimens from the client if a bacterial reaction is suspected.

A nurse is obtaining arterial blood gases for a client who has vomited for 24 hr. The nurse should expect which of the following acid-base imbalances to result from vomiting for 24 hr? A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis

A. Respiratory acidosis is not indicated for this client. B. Respiratory alkalosis is not indicated for this client. C. Metabolic acidosis is not indicated for this client. D. CORRECT: Excessive vomiting causes a loss of gastric acids and an accumulation of bicarbonate in the blood, resulting in metabolic alkalosis.

A nurse is teaching a client who has a new prescription for ferrous sulfate. Which of the following information should the nurse include in the teaching? A. Stools will be dark red. B. Take with a glass of milk if gastrointestinal distress occurs. C. Foods high in vitamin C will promote absorption. D. Take for 14 days.

A. Stools will be dark green to black in color when taking iron. B. Milk binds with iron and decreases its absorption. C. CORRECT: Vitamin C enhances the absorption of iron by the intestinal tract. D. Iron therapy usually takes 4 to 6 weeks for Hgb and Hct to return to the expected reference range.

A nurse is assessing a client and suspects the client is experiencing DIC. Which of the following physical findings should the nurse anticipate? A. Bradycardia B. Hypertension C. Epistaxis D. Xerostomia

A. Tachycardia is a finding that is indicative of DIC. B. Hypotension is a finding that is indicative of DIC. C. CORRECT: Epistaxis is unexpected bleeding of the gums and nose and is a finding indicative of DIC. D. Xerostomia is dryness of the mouth and is not indicative of DIC.

A nurse is assessing a client who has pancreatitis. The client's arterial blood gases reveal metabolic acidosis. Which of the following are expected findings? (Select all that apply.) A. Tachycardia B. Hypertension C. Bounding pulses D. Hyperreflexia E. Dysrhythmia F. Tachypnea

A. Tachycardia is an expected finding for a client who has respiratory acidosis or metabolic alkalosis. B. Hypertension is an expected finding of respiratory acidosis. C. Bounding pulses is an expected finding for respiratory acidosis due to hypertension. D. Hyperreflexia is an expected finding for a client who has metabolic alkalosis. E. CORRECT: Dysrhythmia is an expected finding in a client who has pancreatitis and metabolic acidosis. F. CORRECT: Tachypnea is an expected finding in a client who has pancreatitis and metabolic acidosis.

A nurse is providing preoperative teaching for a client who requests autologous donation in preparation for a scheduled orthopedic surgical procedure. Which of the following statements should the nurse include in the teaching? A. "You should make an appointment to donate blood 8 weeks prior to the surgery." B. "If you need an autologous transfusion, the blood your brother donates can be used." C. "You can donate blood each week if your hemoglobin is stable." D. "Any unused blood that is donated can be used for other clients."

A. The client should donate blood for an autologous transfusion 6 weeks prior to surgery. B. An autologous donation refers to the client's donation of blood for their own personal use. C. CORRECT: Beginning 6 weeks prior to surgery, the client can donate blood each week for autologous transfusion if their Hgb and Hct remain stable. D. An autologous donation is for use only by the client.

A nurse is caring for a client admitted with confusion and lethargy. The client was found at home unresponsive with an empty bottle of aspirin lying next to the bed. Vital signs reveal blood pressure 104/72 mm Hg, heart rate 116/min with regular rhythm, and respiratory rate 42/min and deep. Which of the following arterial blood gas findings should the nurse expect? A. pH7.68 PaO2 96 mm Hg PaCO2 38 mm Hg HCO3− 28 mEq/L B. pH 7.48 PaO2 100 mm Hg PaCO2 28 mm Hg HCO3− 23 mEq/L C. pH 6.98 PaO2 100 mm Hg PaCO2 30 mm Hg HCO3− 18 mEq/L D. pH 7.58 PaO2 96 mm Hg PaCO2 38 mm Hg HCO3− 29 mEq/L

A. These arterial blood gases indicate metabolic alkalosis. B. These arterial blood gases indicate respiratory alkalosis. C. CORRECT: An aspirin toxicity would result in arterial blood gas findings of metabolic acidosis. D. These arterial blood gases indicate metabolic alkalosis.

A nurse preceptor is observing a newly licensed nurse on the unit who is preparing to administer a blood transfusion to an older adult client. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure? A. Inserts an 18-gauge IV catheter in the client B. Verifies blood compatibility and expiration date of the blood with an assistive personnel (AP) C. Administers dextrose 5% in 0.9% sodium chloride IV with the transfusion D. Obtains vital signs every 15 min throughout the procedure.

A. Use no larger than a 19-gauge needle in the older adult client. B. Verify the client's identity and blood compatibility, and expiration date of the blood with another nurse. This task is beyond the scope of practice for an assistive personnel. C. Administer blood products with 0.9% sodium chloride. IV solutions containing dextrose cannot be used. D. CORRECT: Check the older adult client's vital signs every 15 min throughout the transfusion to allow for early detection of fluid overload or other transfusion reaction.