Hematological-Saunders-Health Problems

The nurse is assisting in performing an arterial blood gas (ABG) analysis on a client. The nurse initially implements which intervention after the blood gas is drawn to minimize the risk for uncontrolled bleeding? 1. Applying cold packs to the site 2. Applying direct pressure to the site 3. Covering the site with 4 x 4 gauze 4. Performing range of motion to the fingers

correct answer 2. Applying direct pressure to the site Rationale: Pressure should be applied to the site following an ABG draw. The pressure in the artery is higher than in the veins. It is therefore necessary to apply pressure to the punctured artery to control bleeding usually for 5 minutes. Cold causes vasoconstriction and so decreases bleeding, but it is not as effective in this case as applying pressure. Placing gauze may protect the site but will not control bleeding. Exercise will increase circulation to the area.

The nurse is caring for a client with a diagnosis of aplastic anemia. Which are the most likely signs/symptoms associated with aplastic anemia? Select all that apply. 1. Pain 2. Nausea 3. Fatigue 4. Infection 5. Petechiae 6. Shortness of breath

correct answer 3. Fatigue 4. Infection 5. Petechiae 6. Shortness of breath Rationale: Aplastic anemia is a decrease in red blood cells, white blood cells, and platelets. A reduced number of red blood cells will cause the hemoglobin to drop, and clients commonly report fatigue and shortness of breath. A reduced number of white blood cells will make the client susceptible to infection. A reduced number of platelets will cause the blood to not clot properly and can result in bleeding manifested as petechiae. Pain is a symptom of sickle cell disease, chronic myelogenous leukemia, and multiple myeloma. Nausea is not a symptom of aplastic anemia.

The nurse is admitting a client to the hospital who has been scheduled for gastrointestinal (GI) surgery later in the day. When asking the client whether the client has taken any scheduled or over-the-counter medications in the past 24 hours, which statements would concern the nurse? Select all that apply. 1. "Yes, I take a full-strength aspirin every day." 2"Yesterday I took a daily multiple vitamin medication." 3"I have stopped the medications my doctor told me to stop taking." 4"I have taken my medication for my blood pressure this morning." 5"I took the bowel preparation medications as prescribed starting 2 days ago."

correct answer 1. "Yes, I take a full-strength aspirin every day." 4"I have taken my medication for my blood pressure this morning." Rationale: Clients who are scheduled for GI surgery will be instructed by their primary health care provider or surgeon at least 2 weeks before surgery to stop any medications that can cause bleeding tendencies. Abnormal bleeding during surgery can place the client at risk for adverse surgical complications and increase the need for blood transfusions. Medications that are prescribed to lower the blood pressure may cause problems with anesthesia. The nurse should make sure the surgeon is aware that the client has taken an aspirin and the blood pressure medication. Adjustments may be made in the medications administered during surgery. A multiple vitamin taken the day before, stopping medications as prescribed, and taking the prescribed bowel preparation medications are not concerns that the nurse needs to report.

The nurse is reviewing the complete blood count (CBC) laboratory results of a female adult client suspected of having iron deficiency anemia. The nurse reviews the results and determines that which results are consistent with this diagnosis? Select all that apply. 1. Hematocrit (Hct) 30% 2. Hemoglobin (Hgb) 8.8 g/dL 3. Platelet count 300,000 mm3 4. White blood count (WBC) 7500 mm3 5. Decreased mean corpuscular volume (MCV) 66 fL

correct answer 1. Hematocrit (Hct) 30% 2. Hemoglobin (Hgb) 8.8 g/dL 5. Decreased mean corpuscular volume (MCV) 66 fL Rationale: Iron deficiency anemia is a low red blood cell count caused by inadequate iron intake or absorption from the diet or blood loss. The low Hgb and Hct indicate an anemia. The normal hemoglobin level for an adult female is 12 to 16 g/dL, and the normal hematocrit is 37% to 47%. The low MCV (normal 80 to 95 fL) indicates a microcytic anemia (red blood cells smaller than normal), which is consistent with iron deficiency anemia. The platelet count and the WBC count are within the normal ranges. The normal platelet count is 150,000 to 400,000 mm3. The normal WBC count is 5000 to 10,000 mm3.

The nurse is reviewing the laboratory results of a client who is receiving chemotherapy and notes that the platelet count is 10,000 mm3 (10 × 109/L). On the basis of this laboratory value, the nurse would perform which interventions? Select all that apply. 1. Monitor stools for occult blood. 2. Keep away from persons who have colds or feel ill. 3. Instruct the client not to bend over at the waist or lift. 4. Floss teeth and rinse mouth with mouthwash after every meal. 5. Instruct the client to blow nose very gently without blocking either nostril.

correct answer 1. Monitor stools for occult blood. 3. Instruct the client not to bend over at the waist or lift. 5. Instruct the client to blow nose very gently without blocking either nostril. Rationale: Platelets or thrombocytes are necessary for a client to clot. A high risk of hemorrhage exists when the platelet count drops below 20,000 mm3 (20 × 109/L). Fatal central nervous system hemorrhage or massive GI hemorrhage can occur when the platelet count is less than 10,000 mm3 (10 × 109/L). The client may be treated with medications or platelet or blood transfusions to improve the platelet count. The nurse should monitor the client's stools for blood, both obvious and occult. The client should be very gentle if blowing the nose and not cause any pressure to build up in the head. The client also needs to avoid starting bleeding from epistaxis (nosebleed). The client should not bend over at the waist because this action would increase the pressure within the head and increase the risk for an intracerebral bleed. Clients with decreased immunity, which is not stated in the question, should avoid ill persons. The client should not floss the teeth and only use a soft toothbrush to avoid bleeding in the mouth.

The nurse is planning interventions for counseling a maternity client newly diagnosed with sickle cell anemia. The nurse understands that the important psychosocial intervention at this time is which action? 1. Provide emotional support. 2. Avoid the topic of the disease. 3. Allow the client to be alone if she is crying. 4. Provide all information regarding the disease immediately.

correct answer 1. Provide emotional support. Rationale: Probably the most important of all nursing functions is providing emotional support to the client and family. Supportive therapy allows the client to express feelings; explore alternatives; and make decisions in a safe, caring environment. Option 2 is nontherapeutic. Option 3 is only appropriate if the client requests to be alone; if not requested, the nurse is abandoning the client in time of need. Option 4 overwhelms the client with information while the client is trying to cope with the news of the disease.

During an initial prenatal visit, the nurse notes that the primary health care provider documents that the client is experiencing iron deficiency anemia. Which client data support this finding? Select all that apply. 1. Reports of fatigue 2. Pink mucous membranes 3. Increased vaginal secretions 4. Hemoglobin level of 10.2 g/dL5Increased frequency of voiding

correct answer 1. Reports of fatigue 2. Pink mucous membranes Rationale: Anemia is a common problem in pregnancy and is characterized by a hemoglobin level of less than between 10.5 and 11 g/dL. Iron deficiency anemia and folic acid deficiency are two common types of anemia that present a concern during pregnancy. Although fatigue may be seen in some pregnant women, its presence may reflect complications caused by decreased oxygen supply to vital organs, thus supporting the laboratory findings. The other options are normal observations during pregnancy.

Iron dextran is prescribed to be administered intramuscularly to a client. The nurse prepares the medication and determines that the appropriate method of administration is which? 1. Using the Z-track technique 2. Injecting into the deltoid muscle 3. Using a ⅝-inch needle on a large syringe 4. Applying heat to the injection site before administration

correct answer 1. Using the Z-track technique Rationale: A disadvantage of administering iron dextran intramuscularly is that it causes pain and discoloration at the injection site. When intramuscular administration is prescribed, the medication should be injected deep into the buttock with the Z-track technique. Z-track injection keeps the iron dextran deep in the muscle, thereby minimizing leakage and surface discoloration. The Z-track technique is used for injection of medications that can stain or irritate the skin. A ⅝-inch needle is used for subcutaneous injections. Applying heat to an injection site before administration is an incorrect action.

A client requiring upcoming surgery is extremely anxious about the need for a possible blood transfusion and is concerned about the risk of infection from contaminated blood. The nurse suggests that the client consider which as an effective method to minimize this risk? 1. Ask a friend or family member to donate blood ahead of time. 2. Arrange an autologous blood donation before the planned surgery. 3. Take iron supplements before surgery to boost hemoglobin levels. 4. Request that any donated blood be screened twice by the blood bank.

correct answer 2. Arrange an autologous blood donation before the planned surgery. Rationale: Donating autologous blood to be reinfused as needed during or after surgery minimizes the risk of cross-infection from contaminated blood. The next most effective way is to ask a family member to donate blood before surgery. Blood banks do not provide extra screening on request. Preoperative iron supplements are helpful for iron deficiency anemia but are not helpful in affecting the possibility of infection.

The nurse is assisting in caring for a client immediately following an abdominal surgical procedure who lost a significant amount of blood during surgery. Which findings would indicate a sign of a potential complication? Select all that apply. 1. Absent bowel signs 2. Increasing restlessness 3. A pulse rate of 108 beats per minute 4. A blood pressure (BP) of 88/58 mm Hg 5. Increasing pain unrelieved by analgesics

correct answer 2. Increasing restlessness 3. A pulse rate of 108 beats per minute 4. A blood pressure (BP) of 88/58 mm Hg 5. Increasing pain unrelieved by analgesics Rationale: Shock that occurs after surgery is most often related to hypovolemia secondary to hemorrhage or inadequate fluid replacement. Increasing restlessness noted in a client is a sign that requires continuous and close monitoring because it could indicate shock. The client may have increasing pain from a buildup of blood internally. Vital sign changes that eventually occur include a drop in BP and an increased pulse rate. Absent bowel sounds are normal in the immediate postoperative period following abdominal surgery. The restlessness may progress to other signs of shock quickly. Remember that early treatment improves the outcome.

A client is admitted to the hospital with vitamin B12 deficiency. When taking the client's history, which symptoms would the nurse expect the client to report? Select all that apply. 1. Craving to eat ice 2. Muscle weakness 3. Dry and brittle hair 4. Difficulty in walking 5. Numbness in hands

correct answer 2. Muscle weakness 4. Difficulty in walking 5. Numbness in hands Rationale: Vitamin B12 is necessary for red blood cell production, myelin maintenance, and nerve function. Lack of vitamin B12 can lead to anemia, as well as damage to the spinal cord, peripheral nerves, and brain. Neurological symptoms include muscle weakness, difficulty in walking, and numbness in hands. Dry and brittle hair and a craving to eat ice are symptoms of iron deficiency anemia.

A client arrives in the emergency department after an automobile crash. The client's forehead hit the steering wheel, and a hyphema has been diagnosed. Which position would the nurse prepare to position the client? 1. Flat on bed rest 2. On bed rest in a semi-Fowler's position 3. In lateral position on the unaffected side 4. In the lateral position on the affected side

correct answer 2. On bed rest in a semi-Fowler's position Rationale: A hyphema is the presence of blood in the anterior chamber. It is produced when a force is sufficient to break the integrity of the blood vessels in the eye. It can be caused by direct injury, such as a penetrating injury from a BB pellet, or indirectly, such as from striking the forehead on a steering wheel during an accident. The client is treated by bed rest in a semi-Fowler's position to assist gravity in keeping the hyphema away from the optical center of the cornea.

The nurse is caring for a client with sickle cell disease who is in labor. The nurse ensures that the client receives appropriate intravenous (IV) fluid intake and oxygen consumption to primarily accomplish which goal? 1. Stimulate the labor process. 2. Prevent dehydration and hypoxemia. 3. Avoid the necessity of a cesarean delivery. 4. Eliminate the need for analgesic administration.

correct answer 2. Prevent dehydration and hypoxemia. Rationale: A variety of conditions, including dehydration, hypoxemia, infection, and exertion, can stimulate the sickling process during labor. Maintaining adequate IV fluid intake and the administration of oxygen via face mask will help ensure a safe environment for maternal and fetal health during labor. These measures will not stimulate the labor process, avoid the need for a cesarean delivery, or eliminate the need for analgesic administration.

The nurse is asked to assist in preparing a heparin sodium infusion for a client with a diagnosis of thrombophlebitis. Which items would the nurse have available for this procedure? Select all that apply. 1. Phytonadione 2. Protamine sulfate 3. Intravenous tubing 4. Intravenous infusion controller 5. Intravenous insertion equipment

correct answer 2. Protamine sulfate 3. Intravenous tubing 4. Intravenous infusion controller 5. Intravenous insertion equipment Rationale: Phytonadione is the antidote for warfarin sodium, so this is an unnecessary item. Protamine sulfate is the antidote for heparin and should be available if heparin overdose occurs. Heparin is administered by the intravenous (IV) route, so IV insertion equipment is needed. IV tubing will be necessary for connection of the IV solution with the prescribed heparin dosage to the client's IV catheter. Heparin is always infused via an IV pump or controller.

A client is seen in the clinic for a physical examination. Laboratory studies are performed and reveal that the hemoglobin and hematocrit are low, indicating the need for further diagnostic studies and possibly a blood transfusion. The client is a Jehovah's Witness and states he will never have a blood transfusion. Which would be an appropriate action by the clinic nurse? 1. Try to convince the client of the need for the transfusion. 2. Support the client's decision not to receive a blood transfusion. 3. Speak to the family regarding the need for a blood transfusion. 4. Discuss with the client the results of the low hemoglobin and hematocrit levels.

correct answer 2. Support the client's decision not to receive a blood transfusion. Rationale: Cultural and ethnic background influences an individual's response to health, illness, surgery, and death. Awareness of cultural differences enhances the nurse's knowledge of how a health care experience may be perceived by the client or family. In the Jehovah's Witness religion, the administration of blood and blood products is forbidden. Therefore, the nurse should support the client's decision. The nurse should respect the autonomy of the client and not try to convince the client or the family that a transfusion must be taken. The nurse may explain the laboratory tests, but this should not be done in an effort to convince the client of the need for a blood transfusion.

The nurse is reviewing laboratory results and notes that the client's international normalized ratio (INR) is 2.2. The nurse would realize this test is performed to monitor the effectiveness of which medication? 1. Heparin 2. Warfarin 3. Dabigatran 4. Dipyridamole

correct answer 2. Warfarin Rationale: The prothrombin time and INR are names for a laboratory assay that measures the extrinsic pathway of coagulation including liver function making vitamin K. The effectiveness of warfarin is monitored by the INR. Heparin is an anticoagulant that is monitored by the partial thromboplastin time (PTT). Dabigatran is an anticoagulant used for clients with atrial fibrillation and does not require laboratory testing. Dipyridamole is a medication that will cause a decrease in platelet agglutination (stickiness) and does not require any laboratory monitoring.

The nurse collects data from a pregnant client diagnosed with iron deficiency anemia during her third trimester for additional risk factors associated with the anemia. Which statement made by the client would the nurse question to receive more information? 1. "I will drink at least 6 to 8 glasses of water each day." 2. "I will take a nap each afternoon to help me feel more rested." 3. "I have had mild vaginal spotting twice since my last prenatal visit." 4. "I will continue to take the extra iron that was prescribed for me by the primary health care provider."

correct answer 3. "I have had mild vaginal spotting twice since my last prenatal visit." Rationale: A variety of factors can further complicate the potential maternal and fetal effects of iron deficiency anemia during pregnancy. Such factors include geographic location, socioeconomic status, daily nutrition and fluid intake, compliance with supplemental medication regimens, and blood loss during pregnancy. A history of vaginal spotting may compromise maternal hemoglobin levels even further during the antenatal period. Drinking at least 6 to 8 glasses of water each day represents appropriate client behaviors during pregnancy to ensure adequate nutrition and fluid balance. Requiring an afternoon nap is not unusual during pregnancy.

The nurse is monitoring the laboratory results of a female client receiving an antineoplastic medication by the intravenous (IV) route. The nurse plans to initiate bleeding precautions if which laboratory result is noted? 1. A clotting time of 10 minutes 2. A hemoglobin of 11 g/dL (110 mmol/L) 3. A platelet count of 40,000 mm3 (40 × 109/L) 4. A white blood cell (WBC) count of 3,000 mm3 (3 × 109/L)

correct answer 3. A platelet count of 40,000 mm3 (40 × 109/L) Rationale: Bleeding precautions need to be initiated when the platelet count decreases. The normal platelet count is 150,000 to 400,000 mm3 (150 to 400 × 109/L). When the platelets are lower than 50,000/mm3 (50 × 109/L), any small trauma can lead to episodes of prolonged bleeding. The client has lower than normal hemoglobin and WBC counts. The client is anemic with a lower than normal hemoglobin; normal for a female is 12 to 16 g/dL (120 to 160 mmol/L). The normal WBC count is 5000 to 10,000 mm3 (5 to 10 × 109/L). When the WBC count drops, the absolute neutrophil count is monitored and neutropenic precautions are implemented when the absolute neutrophil count is severely decreased. The normal clotting time is 8 to 15 minutes.

A client arrives in the emergency department with a bloody nose. Which is the initial nursing action? 1. Place the client in a supine position. 2. Apply an ice collar around the client's neck. 3. Assist the client to a sitting position with the head tilted slightly forward. 4. Instruct the client to swallow the blood until the bleeding can be controlled.

correct answer 3. Assist the client to a sitting position with the head tilted slightly forward. Rationale: The initial nursing action to treat the client with a bloody nose is to loosen clothing around the neck to prevent pressure on the carotid artery. The client should be assisted to a sitting position with the head tilted slightly forward, and pressure should be applied to the nares by pinching the nose toward the septum for 10 minutes. Ice packs can be applied to the nose and forehead. If these actions are not successful in controlling the bleeding, an ice collar may be applied along with a topical vasoconstrictive medication. The primary health care provider may also prescribe packing to the nostrils. The client should be provided with an emesis basin and should be instructed not to swallow blood to reduce the risk of nausea and vomiting.

A client has experienced several episodes of sickle cell crisis. Which reinforced instructions would be included in the client's teaching plan to prevent recurrence? Select all that apply. 1. Vigorous exercise is encouraged to maintain cardiovascular function. 2. Iced liquids will combat dehydration and should be consumed regularly. 3. Wear shoes and socks when walking outside to prevent damage to the feet. 4. To prevent opioid tolerance, avoid taking pain medication at the beginning of the crisis 5. Recognize early symptoms of infection and contact the primary health care provider (PHCP).

correct answer 3. Wear shoes and socks when walking outside to prevent damage to the feet. 5. Recognize early symptoms of infection and contact the primary health care provider (PHCP). Rationale: Wearing socks and shoes will prevent wounds to the legs and feet, which heal slowly and frequently become infected in clients with sickle cell disease. Recognizing the early symptoms of an infection and seeking medical assistance may lessen the severity and avoid a crisis. Vigorous exercise and iced liquids can precipitate a crisis and should be avoided. Opioid tolerance is not a priority or immediate concern for clients experiencing a sickle cell crisis. These clients experience a great deal of pain and require opioids for pain relief. Pain medication should be taken when the client recognizes a crisis.

During the intrapartum period, the nurse assists the health care team to ensure appropriate intravenous (IV) fluid intake and oxygen consumption for the laboring client with sickle cell disease. Which rationale would the nurse provide to the client for these interventions? 1. "Adequate IV fluids and oxygen will stimulate and accelerate the labor process." 2. "Administering IV fluids and oxygen will reduce the need for analgesic administration." 3. "Providing adequate IV fluids and oxygen during the labor process will minimize the necessity of a cesarean delivery." 4. "Administering adequate IV fluids and oxygen during your labor will assist in preventing dehydration and hypoxemia, which can lead to sickling."

correct answer 4. "Administering adequate IV fluids and oxygen during your labor will assist in preventing dehydration and hypoxemia, which can lead to sickling." Rationale: A variety of conditions, including dehydration, hypoxemia, infection, and exertion can stimulate the sickling process during the intrapartum period. Maintaining adequate IV fluid intake and the administration of oxygen via face mask will help ensure a safe environment for both the mother and fetus during labor. Options 1, 2, and 3 are incorrect.

A client with sickle cell anemia is being treated for sickle cell crisis. The primary health care provider prescribes morphine sulfate 2 mg. The concentration of the vial is 10 mg/mL of solution. How many milliliters of solution would the nurse administer? Fill in the blank. Record the answer to one decimal place. Formula: Desired ___________ x Volume = mL per dose Available 2mg _______ x 1mL = 0.2 mL 10mg

correct answer 0.2ml

A client has been diagnosed with pernicious anemia. In planning care for the client, the nurse anticipates that the client will be treated with which vitamin or mineral? 1. Iron 2. Folic acid 3. Thiamine 4. Vitamin B12

correct answer 4. Vitamin B12 Rationale: Pernicious anemia is caused by a deficiency of the intrinsic factor, which results in the inability to absorb vitamin B12 in the intestine. Treatment consists of weekly at first and then monthly injections of vitamin B12. Thiamine is most often prescribed for the client with alcoholism. Iron is administered for iron deficiency anemia, and folic acid is prescribed for folic acid deficiency.

The licensed practical nurse is assisting the registered nurse (RN) in the care of a child who is receiving a blood transfusion and notifies the RN if the child displays which signs/symptoms of fluid overload? Select all that apply. 1. Chills 2. Itching 3. Back pain 4. Dry cough 5. Distended neck veins

correct answer 4. Dry cough 5. Distended neck veins Rationale: Signs/symptoms of a circulatory overload include: dyspnea, precordial pain, wheezing, cyanosis, dry cough, and distended neck veins. Signs/symptoms of a transfusion reaction include chills, itching, rash, fever, headache, and pain in the back.

A client is having problems with blood clotting. Which food item would the nurse encourage the client to eat? 1. Legumes 2. Citrus fruits 3. Vegetable oils 4. Green, leafy vegetables

correct answer 4. Green, leafy vegetables Rationale: Green, leafy vegetables are high in vitamin K, which acts as a catalyst for facilitating blood-clotting factors. Legumes are high in folic acid and thiamine. Citrus fruits are high in vitamin C, which helps with wound healing. Vegetable oil is high in vitamin E, which acts as an antioxidant.

The nurse reinforces instructions to a pregnant client regarding the administration of iron. The nurse determines that the teaching is effective if the client states that she will take the iron with which food items? 1. Tea 2. Milk 3. Water 4. Tomato juice

correct answer 4. Tomato juice Rationale: Foods containing ascorbic acid (vitamin C), such as tomato juice, may increase absorption of iron. Additionally, absorption of iron is affected by many substances. Calcium and phosphorus in milk and tannin in tea decrease iron absorption. Water will not act to increase the absorption of the iron.

A client who is receiving a blood transfusion pushes the call light for the nurse. When entering the room, the nurse notes that the client is flushed, dyspneic, and complaining of generalized itching. How would the nurse correctly interpret these findings? 1. Bacteremia 2. Fluid overload 3. Hypovolemic shock 4. Transfusion reaction

correct answer 4. Transfusion reaction Rationale: The signs and symptoms exhibited by the client are consistent with a transfusion reaction. With bacteremia, the client would have a fever, which is not part of the clinical picture presented. With fluid (circulatory) overload, the client would have crackles in addition to dyspnea. There is no correlation between the signs mentioned in the question and hypovolemic shock. The signs identified in the question are indicative of an allergic reaction, which is one type of blood transfusion reaction.

The nurse is assisting with caring for a client who will receive a unit of blood. Just before the infusion, it is most important for the nurse to check which item? 1. Vital signs 2. Skin color 3. Oxygen saturation 4. Latest hematocrit level

correct answer 1. Vital signs Rationale: A change in the vital signs may indicate that a transfusion reaction is occurring. The nurse assesses the client's vital signs before the procedure to obtain a baseline every 15 minutes for the first half hour after beginning the transfusion and every half hour thereafter. Skin color, oxygen saturation, and most recent hematocrit may be checked but are not the most important.

The primary health care provider prescribes one unit of packed red blood cells to infuse over 4 hours. One unit of blood contains 250 mL, and the drop factor is 10 gtts/1 mL. Although an infusion pump will be used, the registered nurse asks the licensed practical nurse (LPN) to assist with monitoring the flow rate during the infusion. The LPN monitors the flow rate, knowing that how many gtt/min would infuse? Fill in the blank and round answer to the nearest whole number.

correct answer 10 gtts/min Rationale: The prescribed 250 mL is to be infused over 4 hours. Follow the formula and multiply 250 mL by 10 (gtt factor). Then divide the result by 240 minutes (4 hours × 60 minutes). The infusion is to run at 10.4 or 10 gtts/min.

A registered nurse has just hung a 250-mL bag of packed red blood cells (PRBCs) on a client. The licensed practical nurse assisting in caring for the client plans to remain with the client for at least how many minutes following the start of the infusion? 1. 5 minutes 2. 15 minutes 3. 30 minutes 4. 60 minutes

correct answer 2. 15 minutes Rationale: The nurse must remain with the client for the first 15 minutes of a transfusion, which is the most frequent period during which a transfusion reaction may occur. This enables the nurse to quickly detect a reaction and intervene quickly. Option 1 is not enough time to remain with the client. The time frames in options 3 and 4 are unnecessary.

A client brought to the emergency department states that he has accidentally been taking two times his prescribed dose of warfarin for the past week. After noting that the client has no evidence of obvious bleeding, the nurse plans to assist the registered nurse with which action? 1. Administering an antidote 2. Drawing a sample for type and crossmatch and transfuse the client 3. Drawing a sample for an activated partial thromboplastin time (aPTT) level 4. Drawing a sample for prothrombin time (PT) and international normalized ratio (INR)

correct answer 4. Drawing a sample for prothrombin time (PT) and international normalized ratio (INR) Rationale: The action that the nurse should take is to draw a sample for PT and INR level to determine the client's anticoagulation status and risk for bleeding. These results will provide information as to how to best treat this client (e.g., if an antidote such as vitamin K or a blood transfusion is needed). The aPTT monitors the effects of heparin therapy.

Which test would the nurse expect to have done for a client suspected of having pernicious anemia? 1. D-dimer 2. Myoglobin 3. Schilling test 4. Hemoglobin A1c

correct answer 3. Schilling test Rationale: The Schillling test determines the ability to absorb vitamin B12 and is used to diagnose pernicious anemia. D-dimer is used for diagnosis of pulmonary embolism and disseminated intravascular coagulation. Myoglobin is used to detect damage to the myocardium. Hemoglobin A1c is a test to tell average glucose control over a 3-month period.

During the intrapartum period, the nurse is caring for a laboring client diagnosed with sickle cell disease. The nurse recognizes that which conditions are most likely to lead to a sickling crisis? Select all that apply. 1. Exertion 2. Infection 3. Hypoxemia 4. Dehydration 5. Analgesic administration

correct answer 1. Exertion 2. Infection 3. Hypoxemia 4. Dehydration Rationale: Maintaining adequate IV fluid intake and administering oxygen via face mask will help ensure a safe environment for maternal and fetal health during labor when the mother has sickle cell disease. A variety of conditions, including exertion, infection, hypoxemia and dehydration can stimulate the sickling process during the intrapartum period. Administering pain medication will not cause a sickle cell crisis.

The nurse is caring for a client with thrombocytopenia. Which data would the nurse monitor for related to this condition? Select all that apply. 1. Purpura 2. Ecchymoses 3. Hemoglobin at 14.0 g/dL 4. Thrombocytes at 300,000 mm3 5. Prothrombin time (PT) 14 seconds 6. Platelet count less than 150,000 mm3

correct answer 1. Purpura 2. Ecchymoses 6. Platelet count less than 150,000 mm3 Rationale: Purpura, which is small areas of petechiae, is a sign of thrombocytopenia. Ecchymoses, areas of hemorrhage under the skin, are seen with thrombocytopenia. A platelet count under 150,000 mm3 is indicative of thrombocytopenia. A hemoglobin of 14.0 is within normal range for a male or female. Thrombocytes are platelets, and 300,000 mm3 is within normal range. A prothrombin time of 14 seconds is within the normal coagulation time of 12 to 14 seconds.

Which food sources would the nurse include in the discharge teaching plan of a client with vitamin B12 deficiency anemia? Select all that apply. 1. Eggs 2. Liver 3. Ice cream 4. Red meats 5. Citrus fruits

correct answer 1. Eggs 2. Liver 4. Red meats Rationale: Eggs, enriched grain products, and red meats, especially liver, are food sources high in vitamin B12. Ice cream (high in calcium and fat) and citrus fruits (high in vitamin C) are not food sources high in vitamin B12.

A client has been diagnosed with disseminated intravascular coagulation (DIC). Which laboratory tests would the nurse anticipate being prescribed? Select all that apply. 1. D-dimer 2Amylase 3. Albumin 4. Potassium 5. Hemoglobin 6. Prothrombin time

correct answer 1. D-dimer 5. Hemoglobin 6. Prothrombin time Rationale: The D-dimer is elevated with DIC. There is decreased hemoglobin due to bleeding. The prothrombin time is increased because clotting factors are being used up. Albumin is checked for disorders of the liver and/or edema, and amylase is checked for disorders of the liver or pancreas, not for DIC. The potassium level should not be greatly affected by DIC, either.

The nurse who is assisting in caring for a client with a tracheostomy tube notes heavy bleeding from the stoma. The nurse also notes that the tracheostomy tube pulsates with the client's heartbeat. The nurse immediately performs which action? 1. Transports the client to surgery 2. Administers supplemental oxygen 3. Initiates an intravenous (IV) line 4. Applies pressure to the artery at the stoma site

correct answer 4. Applies pressure to the artery at the stoma site Rationale: Heavy bleeding from a tracheostomy site is a life-threatening complication. Direct pressure is applied to the innominate artery at the stoma site. The client is then prepared for immediate surgical repair. An IV line will need to be initiated, but this is not the immediate action.

A client with sickle cell disease has been admitted to the hospital complaining of a sudden onset of severe pain in the extremities, abdomen, back, and chest. Which interventions would the nurse expect to be included in the care of the client? Select all that apply. 1. Administer oxygen per nasal cannula. 2. Apply ice bags to joints of extremities. 3. Administer the prescribed opioid analgesic. 4. Keep room temperature at or below 65°F. 5. Encourage the client to keep extremities extended. 6. Hydrate the client with 0.9% normal saline 125 mL/hr intravenously.

correct answer 1. Administer oxygen per nasal cannula. 3. Administer the prescribed opioid analgesic.4Keep room temperature at or below 65°F. 5. Encourage the client to keep extremities extended. 6. Hydrate the client with 0.9% normal saline 125 mL/hr intravenously. Rationale: A client in a sickle cell crisis will have pain as the body's tissues become hypoxic. A state of adequate hydration is important. The nurse administers oxygen, an opioid analgesic to control the pain, and isotonic intravenous fluids to achieve and maintain hydration. Keeping the extremities extended and not bent decreases sickling risk. The client should be kept warm to counteract the sickling. The room should be 72 degrees or higher, and ice bags should not be applied to joints.

The nurse is assigned to care for a pregnant client with a diagnosis of sickle cell anemia. The nurse plans care, knowing that which problem would receive highest priority? 1. Dehydration 2. Inability to perform activities 3. Verbalizing fear about delivery 4. Expressing concern about appearance

correct answer 1. Dehydration Rationale: For the client with sickle cell anemia, dehydration will precipitate sickling of the red blood cells. Sickling can lead to life-threatening consequences for the pregnant woman and the fetus, such as an interruption of blood flow to the respiratory system and placenta. Although options 2, 3, and 4 may be components of the plan of care at some point, fluid volume deficit is the priority.

A client is diagnosed with disseminated intravascular coagulopathy (DIC). The nurse would become concerned with which laboratory values? Select all that apply. 1. Increased D-dimer 2. Decreased hemoglobin 3. Increased platelet count 4. Decreased fibrinogen level 5. Decreased prothrombin level

correct answer 1. Increased D-dimer 2. Decreased hemoglobin 4. Decreased fibrinogen level Rationale: DIC laboratory studies will reveal a decreased hemoglobin and low platelet count. The prothrombin and activated partial thromboplastin times will be increased. The fibrinogen level is reduced, and the fibrin degradation products level is increased. The D-dimer result is elevated.

The nurse is doing discharge teaching with a client who has sickle cell disease. The nurse reinforces instructions to the client to avoid which factors that could precipitate a sickle cell crisis? Select all that apply. 1. Infection 2. Mild exercise 3. Fluid overload 4. Warm weather 5. Emotional stress

correct answer 1. Infection 5. Emotional stres Rationale: The client should avoid infections and emotional stress, which can increase metabolic demand and cause dehydration, precipitating a sickle cell crisis. The client should also avoid dehydration from other causes. Warm weather and mild exercise do not need to be avoided, but the client should take measures to avoid dehydration during these conditions. Fluids are important to prevent dehydration. Finally, the client should avoid being in areas of high altitude, or flying in a nonpressurized aircraft because of lesser oxygen tension in these areas.

A client with cancer is receiving chemotherapy and develops thrombocytopenia. Which intervention is a priority in the nursing plan of care? 1. Monitor the client for bleeding. 2Monitor the client's temperature. 3Ambulate the client three times daily. 4Monitor the client for pathological fractures.

correct answer 1. Monitor the client for bleeding. Rationale: Thrombocytopenia indicates a decrease in the number of platelets in the circulating blood. A major concern is monitoring for and preventing bleeding. Monitoring the temperature relates to infection, particularly if leukopenia is present. The options indicating to ambulate the client and monitor for pathological fractures are also important to the plan of care but are not directly related to thrombocytopenia.

The nurse has conducted dietary teaching with the client diagnosed with iron deficiency anemia. The nurse determines that the client understands the information if the client states the intention to increase intake of which foods? Select all that apply. 1. Oysters 2. Spinach 3. Pineapple 4. Egg whites 5. Kidney beans 6. Refined white bread

correct answer 1. Oysters 2. Spinach 5. Kidney beans Rationale: The client with iron deficiency anemia should increase intake of foods that are naturally high in iron. The best sources of dietary iron are red meat, liver, other organ meats, blackstrap molasses, and oysters. Other good sources of iron are kidney beans, whole wheat bread, egg yolk, spinach, kale, turnip tops, beet greens, carrots, raisins, and apricots. Pineapple, egg whites, and refined white bread are not rich sources of iron.

The nurse is caring for a client with a suspected diagnosis of aplastic anemia. Which test would the nurse anticipate to be performed to confirm the diagnosis? 1. Schilling test 2. Sickle cell screen 3. Bone marrow aspiration 4. Complete blood cell count

correct answer 3. Bone marrow aspiration Rationale: A bone marrow aspiration will identify aplastic anemia and will identify pancytopenia, a deficiency in erythrocytes, leukocytes, and thrombocytes, and confirm that the source of the problem is bone marrow dysfunction. A Schilling test is diagnostic for pernicious anemia. A sickle cell screen is diagnostic for sickle cell anemia. A complete blood cell count will identify anemia but may not identify the specific type and also the leukopenia and thrombocytopenia.

A client in labor has an underlying diagnosis of sickle cell anemia. During labor the client is at high risk for sickling crisis. The nurse would take which action to assist in preventing a crisis from occurring during labor? 1. Reassure the client. 2. Maintain strict asepsis. 3. Prevent bearing down. 4. Administer oxygen as prescribed.

correct answer 4. Administer oxygen as prescribed. Rationale: During the labor process, the client is at high risk for being unable to meet the oxygen demands of labor and becoming unable to prevent sickling. An intervention to prevent sickle cell crisis during labor includes administering oxygen as needed. Options 1, 2, and 3 are accurate information but not for the situation described in the question.

A client is receiving supplemental therapy with folic acid. The nurse evaluates the effectiveness of this therapy by monitoring the results of which laboratory study? 1. Blood glucose 2. Blood urea nitrogen 3. Alkaline phosphatase 4. Complete blood count

correct answer 4. Complete blood count Rationale: Folic acid is necessary for red blood cell production and is classified as a vitamin and an antianemic agent. The effectiveness of therapy can be measured by monitoring the results of periodic complete blood count levels, noting particularly the hematocrit level. Blood glucose, Blood urea nitrogen, and alkaline phosphatase are not associated with the use of this medication.

The nursing student is presenting a clinical conference and discusses the causative factors related to beta-thalassemia. Which group is at greatest risk of developing this disorder? 1. A child of Mexican descent 2. A child of Mediterranean descent 3. A child whose intake of iron is extremely poor 4. A child breast-fed by a mother with chronic anemia

correct answer 2. A child of Mediterranean descent Rationale: Beta-thalassemia is an autosomal recessive disorder. This disorder is found primarily in individuals of Mediterranean descent. The disease also has been reported in Asian and African populations. Options 1, 3, and 4 are not risk factors for this disorder.

The nurse is assisting with caring for a client who has received a transfusion of platelets. The nurse determines that the client is benefiting most from this therapy if the client exhibits which finding? 1. An increased hematocrit level 2. An increased hemoglobin level 3. A decline of the temperature to normal 4. A decrease in oozing from puncture sites and gums

correct answer 4. A decrease in oozing from puncture sites and gums Rationale: Platelets are necessary for proper blood clotting. The client with insufficient platelets may exhibit frank bleeding or the oozing of blood from puncture sites, wounds, and mucous membranes. The client's temperature would decline to normal after the infusion of granulocytes if those transfused cells were then instrumental in fighting infection in the body. Increased hemoglobin and hematocrit levels would be seen when the client has received a transfusion of red blood cells.

The nurse is reviewing the laboratory results of a client scheduled for surgery. Which laboratory result would indicate to the nurse that the surgery might be postponed? 1. Sodium, 140 mEq/L 2. Hemoglobin, 8.4 g/dL 3. Platelets, 200,000 mm3 4. Serum creatinine, 0.9 mg/dL

correct answer 2. Hemoglobin, 8.4 g/dL Rationale: Routine screening tests include a complete blood cell count, serum electrolyte analysis, coagulation studies, and serum creatinine tests. The complete blood count includes the hemoglobin analysis. All these values are within normal range except the hemoglobin. If a client has a low hemoglobin level, the surgery may be postponed.

The nurse would monitor for which laboratory result as indicating an adverse reaction in the client who is receiving chemotherapy? 1. Hemoglobin 12.5 g/dL 2. Platelet count 20,000 mm3 3. Blood urea nitrogen (BUN) 20 mg/dL 4. White blood cell count (WBC) 7000 mm3

correct answer 2. Platelet count 20,000 mm3 Rationale: A normal platelet count ranges from 150,000 mm3 to 400,000 mm3. A platelet count of 20,000 mm3 places the client at severe risk for bleeding. All of the other values, hemoglobin, BUN, and WBC, are within normal limits.

The nurse is reviewing the laboratory studies of a client receiving epoetin alfa. When would the nurse expect to note a therapeutic effect of this medication on the hemoglobin and hematocrit? 1. Immediately 2. 3 days after therapy 3. After 1 week of therapy 4. 2 months after therapy

correct answer 4. 2 months after therapy Rationale: Epoetin alfa stimulates erythropoiesis. Initial effects are noted within 1 to 2 weeks, and hematocrit levels reach normal levels in 2 to 3 months. Therefore, this medication is not intended for clients who require immediate correction of severe anemia, and it is not a substitute for emergency transfusions.

A pregnant anemic client is concerned about her baby's condition following delivery. Which nursing response best supports the client? 1. "I wouldn't worry about your baby's health; complications from this condition are generally rare." 2"Your baby will likely need to spend a few days in the neonatal intensive care unit for observation following delivery." 3"Your baby will not have any problems if you follow all the advice the primary health care provider has given you during your pregnancy." 4"The effects of anemia on your baby are difficult to predict, but let's review your plan of care to ensure you are providing the best nutrition and growth potential."

correct answer 4"The effects of anemia on your baby are difficult to predict, but let's review your plan of care to ensure you are providing the best nutrition and growth potential." Rationale: The effects of maternal iron deficiency anemia on the developing fetus and neonate are unclear. In general, it is believed that the fetus will receive adequate maternal stores of iron, even if a deficiency is present. Neonates of severely anemic mothers have been reported to experience reduced red cell volume, hemoglobin, and iron stores. Option 4 provides the most realistic support for the client and allows the nurse an opportunity to review the client's plan of care to clarify information and reassure the mother.

An adult female client has a hemoglobin level of 10.8 g/dL (108 g/L). The nurse interprets that this result is most likely caused by which condition noted in the client's history? 1. Dehydration 2. Heart failure 3. Iron deficiency anemia 4. Chronic obstructive pulmonary disease

correct answer 3. Iron deficiency anemi Rationale: The normal hemoglobin level for an adult female client is 12 g/dL to 16 g/dL (120-160 g/L). Iron deficiency anemia can result in lower hemoglobin levels. Dehydration may increase the hemoglobin level by hemoconcentration. Heart failure and chronic obstructive pulmonary disease may increase the hemoglobin level as a result of the body's need for more oxygen-carrying capacity.

A pregnant client tells the nurse that she has been craving "unusual foods." On further data collection, the nurse discovers that the client has been ingesting daily amounts of white clay dirt from her backyard. Which laboratory result indicates a physiological consequence of a result of this practice? 1. Hematocrit 37% 2. Glucose 86 mg/dL 3. Hemoglobin 9.1 g/dL 4. White blood cell count 12,400/mm3

correct answer 3. Hemoglobin 9.1 g/dL Rationale: Pica cravings often lead to iron deficiency anemia, resulting in a lowered hemoglobin. The other three laboratory values are within normal limits for the pregnant woman.

A client who has had a radical neck dissection begins to hemorrhage at the incision site. Which action by the nurse would be contraindicated? 1. Monitoring the client's airway 2. Applying manual pressure over the site 3. Lowering the head of the bed to a flat position 4. Calling the primary health care provider immediately

correct answer 3. Lowering the head of the bed to a flat position Rationale: If the client begins to hemorrhage from the surgical site following radical neck dissection, the nurse elevates the head of the bed to maintain airway patency and prevent aspiration. The nurse applies pressure over the bleeding site, contacts the registered nurse immediately who will then call the primary health care provider immediately.

The nurse is reinforcing instructions to a client with iron deficiency anemia about eating a diet with iron-rich foods. Which food sources would the nurse include in the discharge teaching plan of a client with iron deficiency anemia? Select all that apply. 1. Milk 2. Fish 3. Eggs 4. Liver 5. Cheese

correct answer 3. Eggs 4. Liver Rationale: Liver and muscle meats; eggs; dried fruits; and dark green, leafy vegetables are iron-rich foods. Milk, fish, and cheese are not significant sources of iron.

The nurse is caring for a client following a total hip replacement. The client has been diagnosed with iron deficiency anemia. The nurse instructs the client to increase intake of which foods? Select all that apply. 1. Milk and yogurt 2. Clams and mussels 3. Apples and mangos 4. Potatoes and carrots 5. Lean beef and chicken liver

correct answer 2. Clams and mussels 5. Lean beef and chicken liver Rationale: The client with iron deficiency anemia should increase intake of foods that are naturally high in iron. The best sources of dietary iron are red meat, liver and other organ meats, blackstrap molasses, clams, mussels, and oysters. Milk products are lowest in iron of all of the food sources listed. Potatoes, carrots, apples, and mangos are not rich sources of iron.

The nurse is caring for a client receiving chemotherapy and determines that the client has developed myelosuppression. Which laboratory value would support the client's diagnosis of myelosuppression? 1. Protein 7 g/dL 2Magnesium 1.8 mg/dL 3Hemoglobin 9.4 g/dL, hematocrit 26% 4Blood urea nitrogen (BUN) 15 mg/dL, creatinine 0.9 mg/dL

correct answer 3Hemoglobin 9.4 g/dL, hematocrit 26% Rationale: The client has been diagnosed with myelosuppression, which is bone marrow depression. The correct option is the hemoglobin and hematocrit, which is decreased. Hemoglobin is the main component of erythrocytes. Hematocrit represents red blood cell mass and is an important measurement in the identification of blood abnormalities. Red blood cells are produced in the bone marrow. BUN and creatinine address renal function. Protein levels address the amount of albumin in serum and low levels reflect decreased functioning by the liver and/or poor protein intake. These other laboratory values are within normal range.