NUR 242 exam 1

Which is the most likely cause of anemia in a child with celiac disease? Select all that apply. One, some, or all responses may be correct.

Incomplete absorption of iron, Incomplete absorption of folic acid

The nurse is caring for a client on bed rest. Which nursing intervention would prevent a pulmonary embolus?

Teach the client how to exercise the legs.

Cyanocobalamin (vitamin B) 0.2 mg intramuscularly (IM) is prescribed for a client with pernicious anemia. Each vial of the medication contains 100 mcg/mL. How many milliliters will the nurse administer?___mL

2

A client needs a continuous intravenous infusion of heparin at a rate of 1000 units per hour. There are 25,000 units of heparin in 500 mL of 5% dextrose solution. The nurse will set the infusion control device to deliver how many milliliters per hour?___ mL/h

20 ml/hr

A client who has renal failure asks the nurse why anemia keeps recurring. Which reason would the nurse explain to the client?

Decrease in erythropoietin

Which instruction would the nurse give to the pregnant client with anemia?

Drink orange juice with an iron supplement

A client at 36 hours' postpartum is being treated with subcutaneous enoxaparin for deep vein thrombosis of the left calf. Which client adaptation is of most concern to the nurse?

Dyspnea

The nurse provides education related to self-management techniques for a client newly diagnosed with polycystic kidney disease. Which statement made by the client indicates the need for further teaching?

I should weigh myself once a week.

After the nurse has finished teaching a postoperative client about prevention of pulmonary embolism, which client statement indicates that the teaching has been effective?

I will avoid crossing my legs.

The nurse instructs a client who had an endarterectomy on the administration of clopidogrel. The nurse concludes that teaching was effective when the client makes which statement?

Taking this medication will help prevent further clogging of my arteries

How would the nurse explain physiological anemia to a pregnant client?

Plasma volume increases

What would the nurse include in the plan of care to minimize the potential for a sickling episode in a child with sickle cell anemia?

Promoting adequate oxygenation

Which information will the nurse include when teaching a client with venous insufficiency about prevention of venous thrombosis?

Put on compression stockings before arising

A client who has atrial fibrillation with rapid ventricular response is started on a continuous heparin infusion. Which clinical finding enables the nurse to conclude that the heparin therapy is effective?

An activated partial thromboplastin time (aPTT) is twice the usual value

Which medication is most beneficial to the client with sickle cell anemia on a blood transfusion regimen who has cardiac dysrhythmias due to iron overdose toxicity?

Deferoxamine

After the nurse completes teaching for a client with foot pain who has peripheral arterial disease, which client statement indicates that further teaching is needed?

"I will elevate my foot."

Which statement would the nurse include when discharging a school-aged child who underwent a splenectomy for beta-thalassemia (Cooley anemia)?

A high fever should be reported to the child's health care provider

When a client develops iron-deficiency anemia, which of the client's laboratory test results would the nurse expect to be decreased?

Ferritin level

Which step in the nursing process would involve promoting a safe environment for the client?

Implementation

Which is the cause of milk anemia in toddlers?

Increased milk intake

A client develops hemolytic anemia. Which client medication can cause this adverse effect?

Methyldopa

Which technique would the nurse use to administer ferrous sulfate to a 12-month-old infant

Syringe directed toward the back of the mouth

When a client has venous insufficiency, which finding by the nurse will be of most concern?

Calf pain when the feet are dorsiflexed

The international normalized ratio (INR) results of a client receiving warfarin have been variable. Which factor can help the nurse identify the cause of the INR fluctuations

Adherence to the prescribed medication regimen

Which nursing intervention is correct for a client with venous insufficiency?

Elevate the client's legs above heart level.

Which action of a nursing student regarding The Joint Commission recommendations for creating a safe and welcoming environment for lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) clients needs revision?

Arranging exclusive waiting rooms for LGBTQ clients and their families

For the client taking clopidogrel, the nurse will monitor for which adverse effect?

Epistaxis

Polycythemia is frequently associated with chronic obstructive pulmonary disease (COPD). Which would the nurse monitor for when assessing for this complication?

Elevated hemoglobin

Which is the priority nursing intervention to prevent thrombus formation in a child with sickle cell anemia?

Encouraging fluids

A client with a partial occlusion of the left common carotid artery is to be discharged while still receiving warfarin. Which adverse effect will the nurse identify as a reason for the client to seek medical consultation? Select all that apply. One, some, or all responses may be correct.

Hematuria, hemoptysis, Vomiting coffee-ground emesis

A client develops a deep vein thrombophlebitis in her leg 3 weeks after giving birth and is admitted for anticoagulant therapy. The nurse would anticipate developing a teaching plan for which anticoagulant?

Heparin

Warfarin is prescribed for a client who has been receiving intravenous (IV) heparin for a partial occlusion of the left common carotid artery. The client expresses concern about why both medications are needed at the same time. Which rationale would the nurse include to address the client's concern?

Heparin provides anticoagulant effects until warfarin reaches therapeutic levels.

A child who has iron-deficiency anemia tells the school nurse, "I get dizzy in gym class." Which is the most likely explanation for this symptom?

Insufficient cerebral oxygenation

Which cause of anemia would the nurse recognize as the most common cause of anemia in 1-year-olds?

Iron deficiency

A client with upper gastrointestinal (GI) bleeding develops mild anemia. Which agent is indicated for treatment of this condition?

Iron salts

A client develops thrombophlebitis in the right calf. Bed rest is prescribed, and an intravenous (IV) infusion of heparin is initiated. Which drug action will the nurse include when describing the purpose of this medication to the client?

It prevents extension of the clot

A child presents with iron poisoning from having ingested several chewable mineral supplement pills containing iron. Which symptoms would the nurse recognize as indicating that the poisoning has progressed to stage IV? Select all that apply. One, some, or all responses may be correct

Jaundice, hypoglycemia

The nurse is teaching the parents of a child who is prescribed iron supplements for iron-deficiency anemia. Which food would the nurse encourage to provide to enhance absorption of iron?

Orange juice

Which drink would the nurse instruct a client with iron deficiency anemia to choose to drink with the supplement for efficient absorption?

Orange juice

Which adverse effect of heparin would the nurse assess a client for during pregnancy?

Osteoporosis

Which task can be delegated safely by the registered nurse (RN) to unlicensed nursing personnel (UNP) for a client with thrombocytopenia?

Positioning the client

Which task can be safely delegated by the registered nurse (RN) to unlicensed assistive personnel (UAP) for a client with thrombocytopenia?

Positioning the client

When a client develops a venous thrombosis in the left calf, the nurse will monitor for which possible complication?

Pulmonary embolism

The nurse concludes that the teaching about sickle cell anemia has been understood when an adolescent with the disorder makes which statement?

"I'll start to have symptoms when I drink less fluid."

Which iron-rich foods would the nurse recommend for a toddler diagnosed with iron deficiency anemia? Select all that apply. One, some, or all responses may be correct.

Chicken, broccoli, lean steak

Which infant is likely to need iron supplementation throughout the first year?

A 3-month-old receiving formula

The nurse is caring for a variety of clients. In which client is it most essential for the nurse to implement measures to prevent pulmonary embolism?

A 59-year-old who had a knee replacement

When caring for a client with peripheral arterial disease, which assessment findings will the nurse expect? Select all that apply. One, some, or all responses may be correct.

Absence of hair on the toes, Reports of pain associated with exercising

A child is admitted to the pediatric unit with a diagnosis of thalassemia major (Cooley anemia). The parents are told that there is no cure, but that the anemia can be treated with frequent blood transfusions. How do blood transfusions treat children with the diagnosis of thalassemia major?

Correct the anemia, but they may cause other problems

The nurse teaches a client about warfarin and concludes the teaching is effective when the client agrees to avoid which drink?

Cranberry juice

When a client who has sickle cell anemia has been admitted with acute chest syndrome, which prescribed treatment would the nurse question?

Daily iron supplement

The nurse teaches the client about appropriate foods to consume when taking warfarin. The nurse evaluates that the client needs further teaching when the client makes which statement?

Dark green leafy vegetables are high in vitamin K, so I should eat them more often.

Which assessments beyond the standard would be made at every prenatal visit when the client has sickle cell anemia? Select all that apply. One, some, or all responses may be correct.

Evidence of urinary tract infection, Presence of hyperemesis gravidarum

A child with iron-deficiency anemia is prescribed oral iron therapy. Anticipatory guidance regarding which side effect would the nurse provide?

Greenish-black stool

The parents of a child with sickle cell anemia (SSA) tell the nurse, "We have never had any symptoms of SSA and do not understand why our child has this problem." Which information will the nurse include when teaching the parents?

If both parents are carriers of SSA, there is a 25% chance that offspring will have SSA.

The nurse is teaching a health awareness class. Which situation would the nurse teach as being the highest risk factor for the development of a deep vein thrombosis (DVT)?

Inactivity

Assessment findings of a client include fatigue, hair loss, weight gain, and diagnostic tests indicating anemia. The nurse anticipates a prescription for which therapy?

Levothyroxine

Which discharge education would the nurse provide the parents of a 3-year-old child with thalassemia (Cooley anemia)?

Minimize the risk of infection

Which topic will the nurse include when teaching a client who has a new diagnosis of polycythemia vera?

Need for high fluid intake

Which parent education would the nurse provide when teaching an infant's parents about the major cause of iron-deficiency anemia?

Overfeeding of milk

A child with beta-thalassemia (Cooley anemia) is admitted to the ambulatory care unit for a transfusion. Which instruction would the nurse include in the plan of care?

Protect from infections

The student nurse demonstrates correct understanding of anemia related to chronic disease with which statement

Red blood cells (RBCs) are normal in size and color; however, the number of cells produced is decreased."

A client sustains a crushing injury to the lower left leg, and a below-the-knee amputation is performed. For which common clinical manifestations of a pulmonary embolus would the nurse assess this client? Select all that apply. One, some, or all responses may be correct.

Sharp chest pain, Acute onset of dyspnea

Which dietary choices by a client with iron deficiency anemia indicate that the nurse's dietary teaching has been effective? Select all that apply. One, some, or all responses may be correct.

Scrambled eggs, Baked potato, Spinach salad, Dried apricots

The nurse is developing a teaching plan for a client with lower extremity arterial disease (LEAD). Which directions will the nurse include in the teaching plan?

Seeking professional treatment for any minor injuries to the extremities

A client with coronary artery disease and a recent diagnosis of venous thrombosis calls the outpatient clinic to report sudden onset of shortness of breath. Which action by the nurse is best?

Suggest that the client call 911

A client with which diagnosis will be at risk for development of a pulmonary embolism?

Atrial fibrillation

Which foods will the nurse discuss when teaching a client who has a new prescription for warfarin?

Green leafy vegetables

When a staff nurse is instructed by the charge nurse to give the scheduled warfarin dose to a client whose current international normalized ratio (INR) is 6, which action would the staff nurse take first?

Remind the charge nurse of the INR result

The nurse is teaching a pregnant client with sickle cell anemia about the importance of taking supplemental folic acid. Which response by the nurse explains how folic acid would help?

"It will promote production of hemoglobin

A 4-year-old child develops thrombocytopenia after vaccination. The nurse would suspect which vaccination may be responsible?

Measles, mumps, and rubella virus vaccine (MMR)

The nurse manager is teaching the licensed practical nurse (LPN) the evidence-based practice regarding use of normal saline and low-dose heparin flush solutions for capped angiocatheters. Which statements by the LPN indicate they understood the teaching? Select all that apply. One, some, or all responses may be correct.

The use of heparin flushes disappeared in the late 1990s.", The use of high doses of heparin solutions is not recommended in adults.

Which instructions will the home health nurse include when teaching a client with peripheral artery disease? Select all that apply. One, some, or all responses may be correct.

Avoid crossing your legs, Inspect your feet daily, Do not use compression stocking

Which information will the nurse plan to include in the discharge teaching plan for a client who has been admitted for a pulmonary embolism and has a new prescription for an oral anticoagulant? Select all that apply. One, some, or all responses may be correct.

Avoid eating hot food or liquid that can burn the mouth, Use an electric shaver instead of a straight-bladed razor, Apply ice to any areas of trauma like bumps and scrapes

To prevent excessive bruising when administering subcutaneous heparin, which technique will the nurse employ?

Avoid massaging the injection site after the injection

Which assessment finding indicates that disseminated intravascular coagulation (DIC) is occurring in a postpartum client who has experienced an abruptio placentae?

Bleeding at the venipuncture site

An adolescent child with sickle cell anemia is admitted to the pediatric unit during a vaso-occlusive crisis. Which pathophysiology is correct?

Blockage of small blood vessels as a result of clumping of RBCs

Which foods will the nurse include when suggesting dietary sources of iron to a client with anemia? Select all that apply. One, some, or all responses may be correct.

Boiled spinach, Dried prunes

When a client with venous insufficiency has questions about the brownish discoloration of the skin on the legs, which response will the nurse make to explain the discoloration?

There is leakage of red blood cells [RBCs] through the vein wall

The nurse is reviewing the laboratory report of an infant with tetralogy of Fallot that shows an increased red blood cell (RBC) count. Which would the nurse identify as the cause of the polycythemia?

Tissue oxygen needs

Which education would the nurse provide the parents of a 3-year-old child with sickle cell anemia about splenomegaly during a pain crisis?

Triggered by a vasoocclusive crisis

A client develops a deep vein thrombosis after surgery. Which alteration in the client's condition may indicate that the client is experiencing a pulmonary embolus?

Unilateral chest pain

A client is evaluated at a clinic, and the health care provider suspects that the client has anemia and a peptic ulcer. To determine if the client has a peptic ulcer, the nurse expects that which diagnostic test will be performed?

Gastric culture

Which foods would the nurse suggest for inclusion in a toddler's diet who has been diagnosed with iron-deficiency anemia?

Gingerbread molasses cookies

Which postpartum client is at the highest risk for disseminated intravascular coagulation (DIC)?

Gravida I who has had an intrauterine fetal death

A 3-year-old child is prescribed a liquid iron preparation. The nurse would include which intervention when teaching the parent about the administration of this medication?

Have the child drink the diluted iron preparation through a straw.

A client who is underweight has autoimmune hemolytic anemia that has been unresponsive to corticosteroids. A splenectomy is scheduled. For which complication would the nurse assess the client in the immediate postoperative period?

Hemorrhage

A client with a pulmonary embolus is intubated and placed on mechanical ventilation. Which nursing action is important when suctioning the endotracheal tube?

Hyperoxygenating with 100% oxygen before and after suctioning

The nurse is teaching the parents of a child with sickle cell anemia about ways to prevent sickling. Which would the nurse explain as the primary cause of sickling?

Hypoxia

The nurse provides teaching regarding vitamin B 12 injections to a client with pernicious anemia. Which statement by the client indicates that teaching was understood?

I must take this medication for the rest of my life

The client with pernicious anemia is prescribed cyanocobalamin (vitamin B 12). Which client statement demonstrates an understanding of this treatment?

I should have a vitamin B 12 injection every month.

After the nurse has taught a client with peripheral arterial disease about a heart-healthy diet, which client statement best indicates that the teaching has been effective?

I will need to eat more vegetables and less steak

After the nurse teaches a client with varicose veins about prevention of venous thromboembolism (VTE), which client statement indicates the client requires further teaching?

I will try to keep my legs lower than my heart.

When a client with a venous thrombosis is receiving warfarin, which test result would the nurse use to determine whether the daily dose of warfarin is therapeutic?

INR

Which symptoms would the nurse expect in a 3-year-old child with mild iron-deficiency anemia and fatigue?

Increased pulse rate

When a client with peripheral arterial disease tells the nurse about having leg pain and weakness after walking a short distance, how will the nurse document this information?

Intermittent claudication

A child with sickle cell anemia is admitted to the unit in vasoocclusive crisis (VOC). After the child has been given the prescribed analgesic, which intervention is the priority to minimize the effects of the crisis?

Intravenous fluids

Which dietary choices would the nurse teach for the client with peripheral arterial disease? Select all that apply. One, some, or all responses may be correct.

Limit salt intake, Eat whole-grain breads, Use liquid vegetable oils, Avoid processed meats

A 68-year-old client has multiple risk factors for peripheral arterial disease, including client age, siblings with diabetes, a sedentary lifestyle, and family history of heart disease. Which risk factor is the highest priority for client teaching?

Low activity level

Which action would the home health nurse suggest to decrease risk for injury for an older adult with peripheral arterial disease?

Lower the thermostat setting on the hot water tank

When a client who has peripheral arterial disease of the lower extremities tells the nurse, "I walk so slowly that no one wants to walk with me," which response by the nurse is best?

Perhaps you might consider a supervised exercise training program.

Which laboratory value will the nurse review to determine whether treatment for a client with a megaloblastic anemia has been successful?

Folate level

While counseling the parents of an adolescent with anemia related to an inadequate diet, the nurse explains that several different nutrients, including protein, iron, and vitamin B 12, are involved. Which other nutrient would the nurse include in the teaching?

Folic acid

When caring for a client hospitalized with deep vein thrombosis, which topic would the nurse include when doing discharge teaching about ways to avoid another venous thrombosis?

Frequent ambulation

When teaching a client with atrial fibrillation about a new prescription for warfarin, the nurse will include information about which vitamin?

Vitamin K

Warfarin is prescribed for the client who takes phenytoin for a seizure disorder. Which medication interaction complicates seizure therapy?

Warfarin inhibits the metabolism of phenytoin.

Which parental statements would the nurse recognize as indicating the need for further education about iron supplements for their preschooler? Select all that apply. One, some, or all responses may be correct.

We will mix the iron with milk to enhance absorption.", We will mix the iron with black tea to enhance absorption."

Which client with chronic anemia who is on blood transfusion therapy would require immediate treatment?

Wheezing

The nurse is administering 5000 units of heparin to a prenatal client on prolonged bed rest. The label indicates there are 20,000 units of heparin in each milliliter of solution. How much solution would the nurse give the client?___ mL

0.25 ml

Ferrous fumarate 30 mg is prescribed for an infant. The ferrous fumarate solution contains 45 mg/0.6 mL. How much solution will the nurse administer? Record your answer using one decimal place. Include a leading zero if applicable. _____ mL Use ratio and proportion to solve the problem. 45 mg : 0.6 mL : : 30 mg : × mL. 45× = 18.0. × = 0.4 mL.

0.4 ml

A health care provider prescribes heparin 6000 units subcutaneously daily. The pharmacy dispenses a vial containing 10,000 units per milliliter. How many milliliters of heparin will the nurse administer?_____ mL

0.6 ml

After the nurse has finished teaching a client about sickle cell anemia, which statement indicates that the client has a correct understanding of the condition?

"I have abnormal hemoglobin."

A client is receiving epoetin for the treatment of anemia associated with chronic renal failure. Which client statement indicates to the nurse that further teaching about this medication is necessary?

"I realize it is important to take this medication because it will cure my anemia.

Which medication is often contraindicated when taking warfarin?

Acetylsalicylic acid

Which finding would the nurse expect when assessing the nasal passages of a client with thrombocytopenia?

Blood clots

Which statements demonstrate acting in an appropriate manner in a professional environment? Select all that apply. One, some, or all responses may be correct.

Care that is consistent with my level of expertise would be provided., "It is important to remember and follow the policies and procedures of the institution I would use restraints on a client only after obtaining a written order from a primary health care provider

Which action would the nurse include in the postprocedure plan of care for a client with peripheral arterial disease who is scheduled for a femoral angiogram?

Check pedal pulses every 15 minutes postprocedure

Which condition can be prevented when a client with chronic kidney disease receives medication to manage anemia?

Chronic fatigue

Which finding by the nurse would be most important to report to the health care provider before a client undergoes a spiral computed tomography (CT) scan for possible pulmonary embolism? Select all that apply. One, some, or all responses may be correct.

Client has poor skin turgor and dry oral mucosa

Which finding would be of most concern when the nurse is assessing a client with pulmonary embolism diagnosis who is receiving intravenous heparin?

Client reports stools are black

A client had part of the ileum surgically removed. The nurse monitors the client closely for anemia based on which rationale?

Cobalamin is absorbed in the ileum.

Which nursing interventions are most important in the care of an infant with iron-deficiency anemia? Select all that apply. One, some, or all responses may be correct.

Conserving the infant's energy, Protecting the infant from infection, Teaching the parents about nutrition

Which decreased hormone level may cause a client's anemia?

Erythropoietin

The nurse develops a teaching plan for a client with diabetes who has been diagnosed with lower extremity arterial disease (LEAD). Which measures would the nurse include to increase arterial blood flow to the extremities?

Exercises that promote muscular activity

A pregnant client is prescribed heparin to prevent the risk of thromboembolism. Which adverse effects would the nurse anticipate with this medication? Select all that apply. One, some, or all responses may be correct.

Osteoporosis, Compression fractures of the spine

Which finding in a client with right calf venous thrombosis is most important to communicate to the health care provider?

Oxygen saturation 89%

Which common concern of most parents of children with sickle cell anemia would the nurse address at a family education conference?

Sharing feelings regarding the transmission of the disorder

Which foods will the nurse recommend to a client with iron deficiency anemia? Select all that apply. One, some, or all responses may be correct.

Spinach, Beef liver

Which is the most appropriate nursing intervention for an adolescent child with sickle cell anemia?

Teaching the family how to limit sickling episodes

A pregnant client and her husband tell the nurse they have a 1-year-old daughter with sickle cell anemia, but that they themselves do not have the disease. Which response would correctly answer the clients' question, "Will this baby also have sickle cell anemia?"

The chance that another child will have sickle cell anemia is 25%.

A 37-year-old woman with a history of fibroids and menorrhagia that have not been responsive to hormonal treatments is admitted with severe menorrhagia with resulting anemia. She also has depression and pelvic pain. She is crying and states, "I don't know what to do—my primary health care provider is recommending a hysterectomy, but I haven't had children yet!" Which response would the nurse provide?

This must feel so difficult for you. Children are really important to you?

Which child would the nurse consider at risk for beta thalassemia (Cooley anemia)?

Two-year-old child of Greek descent with a large abdomen

Which iron-rich foods would the nurse encourage the client with mild anemia in early pregnancy to eat? Select all that apply. One, some, or all responses may be correct.

liver, meats, whole grain or enriched breads, dark green leafy vegetables, legumes, and dried fruits

When caring for a client with iron-deficiency anemia, which abnormal laboratory value will the nurse expect?

Increased total iron-binding capacity (TIBC)

Which information would the nurse include when teaching a client about warfarin?

Periodic blood testing is necessary

The client undergoing therapy with an antiproliferative immunosuppressant medication has developed thrombocytopenia. Which medication may have caused the client's condition?

Azathioprine

When caring for a client with a possible pulmonary embolism, the nurse will anticipate preparing the client for which test?

Helical computed tomography (CT)

A 9-month-old infant with iron-deficiency anemia has been getting supplements but shows no improvement. The nurse recognizes which action by the parents as the reason for the lack of improvement?

Administering iron supplements with whole cow's milk

For which medication would the nurse monitor a client closely for hemolytic anemia?

Methyldopa

The nurse is helping an adolescent with iron-deficiency anemia make breakfast meal choices. Which food would the nurse suggest?

Bowl of raisin bran

A client is taking warfarin. If an antidote is needed, which agent will be used?

Vitamin K

A health care provider prescribes 0.2 mg of cyanocobalamin (vitamin B) intramuscularly. A vial of the medication labeled 100 mcg = 1 mL is available. How many milliliters of solution will the nurse administer?___ mL The prescribed dose is 0.2 mg. The available concentration is 100 mcg/mL. Use dimensional analysis and/or ratio and proportion to determine the appropriate dose in milliliters. Test-Taking Tip: when taking the NCLEX exam, an on-screen calculator will be available for you to determine your response, which you will then type in the provided space.

2 ml

A client is receiving heparin sodium intravenously at 1500 units/h. The concentration in the bag is 25,000 units/500 milliliters. How many milliliters will infuse during the nurse's 8-hour shift?___ mL

240 ml

A transfusion of packed red blood cells is prescribed for a client with anemia. List the actions in the order in which they will be performed by the nurse.

A client must sign a consent for the transfusion before the procedure; clients have the right to refuse. Vital signs should be obtained immediately before the transfusion to serve as a baseline for comparison if a reaction is suspected. Two nurses must verify that the numbers, ABO type, and Rh type on the blood label and laboratory record match before hanging the transfusion to minimize risk of transfusion reactions. Clean gloves must be worn before inserting the spike of the blood administration set. The transfusion is run slowly for the first 15 to 20 minutes, but only after other steps have been completed.

Which action by a client who requires an above-the-knee amputation for peripheral arterial disease best indicates emotional readiness for the surgery?

Participates in learning perioperative care

A 4-year-old child diagnosed with sickle cell anemia is at a high risk of acquiring pneumococcal diseases. The child has previously received two doses of the pneumococcal conjugate vaccine (PCV). Based on the immunization protocol, which dose of PCV should the nurse administer?

Administer two more doses of PCV

A child with sickle cell anemia is experiencing a painful episode (vaso-occlusive crisis). The nurse assesses the child, obtains the child's vital signs, and reviews the child's laboratory test results. Which is the priority nursing action? O2 is 92%

Administering an analgesic

Which laboratory value would the nurse use to determine whether a client is receiving a therapeutic dose of intravenous heparin?

Activated partial thromboplastin time (APTT) is 70 seconds

Which actions will the nurse take for a client with a suspected pulmonary embolus? Select all that apply. One, some, or all responses may be correct.

Administer oxygen at high flow rate Notify the Rapid Response Team Place the client on a cardiac monitor

Which collaborative and nursing actions would help prevent venous thrombosis in a client during the perioperative period? Select all that apply. One, some, or all responses may be correct.

Administer subcutaneous heparin injections, Assist the client to don antiembolism stockings,

The nurse is caring for clients on a medical-surgical unit and identifies that which client has the highest risk for developing a pulmonary embolism?

An obese client with leg trauma

When a client with a suspected pulmonary embolism is scheduled for a spiral computed tomography (CT) scan, which action would the nurse take before the procedure?

Assess if the client is allergic to shellfish

When a client with peripheral arterial disease returns to the nursing unit after a femoral angiogram, which action will the nurse take first?

Assess the client's affected leg

The parents of a 3-month old infant who is breast-fed ask the nurse how to prevent nutritional anemia. Which is the best response by the nurse?

Baby cereal or an iron supplement should be given around 4 months of age

When assessing a client with a diagnosis of peripheral arterial disease before a scheduled arteriogram, the nurse is unable to palpate the pedal pulses. Which action would the nurse take next?

Check the pulses with a Doppler device

A client with type 1 diabetes has an above-the-knee amputation because of severe lower extremity arterial disease. Two days after surgery, which intervention is appropriate when preparing the client to eat dinner?

Checking the client's serum glucose level

A client with known peripheral arterial disease calls the clinic and tells the nurse about experiencing several symptoms. Which symptom requires the most rapid action by the nurse?

Chest pain

Which is the nurse's priority when evaluating a child with sickle cell anemia whose spleen autoinfarcted 2 years prior?

Determining parental knowledge about infection

The primary health care provider has diagnosed the overweight client who is experiencing infertility with the condition polycystic ovarian syndrome (PCOS). Which intervention is the most important?

Discussing weight loss, exercise, and a balanced low-fat diet

When a client is admitted to the emergency department with disseminated intravascular coagulation caused by sepsis, which prescribed action will the nurse take first?

Draw blood for culture and sensitivity

Which diagnostic study is used to detect deep vein thrombosis in the client's lower extremities?

Duplex venous Doppler

The nurse would monitor postoperative clients for which clinical manifestations of a pulmonary embolus? Select all that apply. One, some, or all responses may be correct.

Dyspnea Hemoptysis Feeling of impending doom

Which findings in a client who has had major abdominal surgery indicate a possible venous thrombosis of the leg? Select all that apply. One, some, or all responses may be correct.

Edema of the ankle, Tender area in the posterior lower leg, Warmth along the course of the involved vessel

A client who was admitted with a diagnosis of acute lymphoblastic leukemia is receiving chemotherapy. Which assessment findings would alert the nurse to the possible development of thrombocytopenia? Select all that apply. One, some, or all responses may be correct.

Melena, Hematuria, Ecchymosis

A client receiving chemotherapy develops bone marrow suppression. The nurse will monitor for which thrombocytopenic effect? Select all that apply. One, some, or all responses may be correct.

Melena, purpura, hematuria

When reviewing the results of a toddler's complete blood count, the nurse notes decreased hemoglobin and hematocrit levels. Which other laboratory findings would the nurse expect in iron-deficiency anemia? Select all that apply. One, some, or all responses may be correct.

Microcytic red blood cells, Slightly reduced reticulocyte count

A client with a diagnosis of anemia is receiving packed red blood cells. Which nursing action is important when administering the transfusion?

Monitoring the client's response, particularly within the first 10 minutes

The parent of a child with sickle cell anemia tells the nurse that the family is going camping by a lake in the mountains this summer. The parent inquires what activities are appropriate. Which activity would the nurse suggest?

Motorboat rides around the lake

A client's laboratory report indicates severe neutropenia and thrombocytopenia. Which medication may have caused this condition?

Mycophenolate mofetil

When performing a focused assessment on a client with a possible diagnosis of iron deficiency anemia, which locations would the nurse examine? Select all that apply. One, some, or all responses may be correct.

Nail beds, Conjunctivae, Palms of hands

Which clinical findings would the nurse expect to identify when caring for a client with a left leg venous thrombosis? Select all that apply. One, some, or all responses may be correct.

Pain in the left calf, Redness in the affected area, Swelling of the lower left leg, Localized warmth in the lower left leg

Which clinical manifestations would the nurse expect to identify when performing an admission history and physical for a client with chronic peripheral arterial disease?

Pain when exercising and thickening of the toenails

When the home health nurse is caring for a client with chronic occlusive arterial disease, which finding will be of most concern?

Pale and dry-appearing ulcer on great toe

Which assessment finding would the nurse expect when assessing an 11-month-old infant with iron-deficiency anemia whose hemoglobin is 8 g/dL (80 mmol/L)?

Pallor

Which findings would the nurse expect when assessing a client with peripheral arterial disease? Select all that apply. One, some, or all responses may be correct.

Pallor of feet, Ulcers on the toes, Delayed capillary refill

The nurse assesses a client for the development of pernicious anemia after reviewing the client's history. Which condition did the nurse most likely find in the history?

Partial gastrectomy

After surgery, a client reports sudden, severe chest pain and begins coughing. The nurse suspects the client has a pulmonary embolus based on which characteristic of the client's sputum?

Pink

A client with sickle cell anemia is experiencing a painful episode (vaso-occlusive crisis) and has a patient-controlled analgesia (PCA) pump. The current pain rating is 5 on a scale of 1 to 10 at the right elbow. The nurse observes that the pump is "locked out" for another 10 minutes. Which action would the nurse implement?

Placing the prescribed as-needed warm, wet compress on the elbow

A client is admitted to the hospital with a diagnosis of deep vein thrombosis, and intravenous (IV) heparin sodium is prescribed. If the client experiences excessive bleeding, which medication will the nurse be prepared to administer?

Protamine sulfate

A client with Crohn disease is admitted to the hospital with a history of chronic, bloody diarrhea, weight loss, and signs of general malnutrition. The client has anemia, a low serum albumin level, and signs of negative nitrogen balance. The nurse concludes that the client's health status is related to which major deficiency?

Protein

A client with chronic kidney disease is admitted to the hospital with severe infection and anemia. The client reports feeling depressed and irritable. The client's spouse asks the nurse about the anticipated plan of care. Which response would the nurse provide?

Protein foods will be restricted so the kidneys can clear the waste products.

A child with sickle cell anemia is admitted to the pediatric unit in a vasoocclusive crisis. Which interventions would be implemented after the pain is under control? Select all that apply. One, some, or all responses may be correct.

Rehydration, Oxygen (O 2) therapy

A 12-year-old child with sickle cell anemia is admitted during a vasoocclusive crisis. Which is the priority of care for this child?

Relieving pain

During a period of heavy play activity, a first-grader with a known history of anemia complains of feeling "woozy." Which would be the school nurse's initial response?

Sitting the child on a chair until the dizziness subsides

A client who had a femoropopliteal bypass graft is receiving clopidogrel postoperatively. Which instruction will the nurse teach the client related to the medication?

Report any occurrence of multiple bruises

After the nurse provides teaching about diet to a client who has a new prescription for warfarin, which food selected by the client indicates that further teaching may be needed?

Spinach salad

When a client has a prescription for warfarin, which foods would the nurse teach the client to limit? Select all that apply. One, some, or all responses may be correct.

Spinach, Broccoli

A client with a continuous intravenous (IV) heparin drip is prescribed IV vancomycin every 12 hours. Which action will the nurse take when it is time to administer the vancomycin?

Start a second IV line for the vancomycin and continue the heparin as prescribed

When teaching a client with peripheral arterial disease about the prescribed walking program, which action will the nurse tell the client to take if leg cramps occur with walking?

Stop to rest until the pain resolves

Which clinical manifestations indicate a possible pulmonary embolism in a client after a total hip replacement? Select all that apply. One, some, or all responses may be correct.

Sudden chest pain, Abrupt onset of shortness of breat

Parents of a child with sickle cell anemia ask about their child taking iron supplements to help treat the anemia. How will the nurse respond?

Taking supplements will not help with this condition

Which action by a client with peripheral arterial disease indicates that more teaching about how to manage the disease is needed?

Using a heating pad to warm the extremities

Which mechanism would the nurse attempt to increase to prevent postoperative deep vein thrombosis?

Velocity of the venous return

Which action would the nurse take after having difficulty in palpating the pedal pulse of a client with venous insufficiency?

Verify the pulse by using a Doppler

A 60-year-old client with gastric cancer has a shiny tongue, paresthesias of the limbs, and ataxia. The laboratory results show cobalamin levels of 125 pg/mL. Which medication would the nurse expect to be prescribed for the client?

Vitamin B 12 injections

A pregnant client with iron-deficiency anemia is prescribed iron supplements daily. To help the client increase iron absorption, the nurse would suggest the client eat foods high in which substance?

Vitamin C

The laboratory report establishes that the client has a warfarin overdose. Which antidote would the nurse anticipate administering?

Vitamin K

Which laboratory result in a client who has just been admitted with anemia of unknown etiology requires the most rapid action by the nurse?

White blood cell count 950 mm 3 (950 × 10 9/L

A client with chronic venous insufficiency has ankle edema. Which action would the nurse take?

elevate legs

Which type of cytokine is used to treat anemia secondary to chronic kidney disease?

erythropoietin

A client has a hysterectomy, salpingo-oophorectomy, tumor removal, and multiple abdominal biopsies for ovarian cancer. For which clinical manifestations indicating that the client may be experiencing a pulmonary embolus would the nurse assess the client? Select all that apply. One, some, or all responses may be correct.

Increased temperature, Decreased oxygen saturation level, Sudden onset of shortness of breath

A postpartum client receiving a continuous heparin infusion for a deep vein thrombosis has an activated partial thromboplastin time (aPTT) of 98 seconds. Which action would the nurse take in response to this situation?

Interrupt the infusion and notify the primary health care provider of the APTT result.

When discussing the therapeutic regimen of vitamin B 12 for pernicious anemia with a client, which teaching would the nurse provide?

Intramuscular injections once a month will maintain control

In which order will the nurse perform these prescribed actions for a client who is in the emergency department with sudden onset of dyspnea and possible pulmonary embolism?

The initial action for a client with dyspnea and chest pain will be obtain a baseline oxygen saturation and then start oxygen administration. Because dysrhythmias can occur because of hypoxemia secondary to pulmonary embolus, the nurse will start cardiac monitoring. Rapid administration of anticoagulants is needed, but baseline coagulation studies are needed prior to starting anticoagulation.

When a client is admitted with thrombocytopenia, which nursing actions would be included in the plan of care? Select all that apply. One, some, or all responses may be correct.

Avoid intramuscular injections, Examine the skin for ecchymotic areas

A primary health care provider examines an 11-month-old infant and suspects anemia. Which questions would the primary health care provider most likely ask the mother? Select all that apply. One, some, or all responses may be correct.

Do you use whole cow's milk? Do you use 2% cow's milk? Do you use alternative milk products?

The nurse provides discharge medication education to a client who has a prescription for warfarin. Which client statement indicates to the nurse that teaching was effective?

I will avoid taking aspirin and nonsteroidal anti-inflammatory drugs [NSAIDs].

When the nurse is caring for a client who has had a femoropopliteal bypass for peripheral arterial disease, which finding is most important to communicate to the health care provider?

Pallor of the lower leg

Which action would the nurse take first when caring for a client with a possible pulmonary embolus

Elevate the head of the bed

When the international normalized ratio (INR) for a client receiving warfarin for venous thrombosis is 4.6, which action will the nurse take?

Notify the health care provider of the laboratory results

The nurse caring for a client who has had a hysterectomy is concerned about the client's risk for postoperative thrombosis. The nurse remembers that, after pelvic surgery, the majority of pulmonary emboli begin as deep vein thromboses in which area?

Pelvis and thighs