BH7 HEME
Physiological Integrity 8. The nurse notes that a client has a higher than normal reticulocyte count. This would indicate a. polycythemia vera. b. increased erythrocyte production. c. dehydration. d. bone marrow depression.
b An increase in the reticulocyte count indicates an increase in erythrocyte production, probably because of excessive RBC destruction (hemolytic anemia) or loss (hemorrhage). DIF: Cognitive Level: Analysis REF: Text Reference: 2264 TOP: Nursing Process Step: Assessment MSC:
Physiological Integrity 27. Using Y-set with a filter, the nurse prepares to initiate a blood transfusion with the intravenous solution of a. D5W. b. normal saline. c. lactated Ringer's. d. dextran.
b To prevent hemolysis, add no solution other than normal saline to blood components. DIF: Cognitive Level: Knowledge REF: Text Reference: 2283 TOP: Nursing Process Step: Intervention MSC:
Physiological Integrity 19. The nurse schedules the time to access delayed type hypersensitivity (DTH) skin testing, which is a. 24 hours postinjection. b. 36 hours postinjection. c. 48 hours postinjection. d. 72 hours postinjection.
c A DTH should be read after 48 hours for the most reliable results. DIF: Cognitive Level: Application REF: Text Reference: 2268 TOP: Nursing Process Step: Intervention MSC:
Physiological Integrity 31. The nurse recognizes the laboratory finding that is characteristic of granulocytosis as a. elevated granulocytes. b. hypoprothrombinemia. c. profound neutropenia. d. thrombocytosis.
c The manifestations of agranulocytosis are a result of the neutropenia. DIF: Cognitive Level: Knowledge REF: Text Reference: 2301 TOP: Nursing Process Step: Assessment MSC:
Physiological Integrity 4. When teaching the client about the procedure of a bone marrow aspiration, the nurse should explain that it is used to a. identify blood abnormalities. b. determine long-term prognosis. c. assess for presence of infection. d. determine the red blood cell (RBC) indices.
a Bone marrow aspiration and biopsy are used to assess and identify most blood dyscrasias (e.g., aplastic anemia, leukemias, pernicious anemia, thrombocytopenia). DIF: Cognitive Level: Comprehension REF: Text Reference: 2265 TOP: Nursing Process Step: Intervention MSC:
Physiological Integrity Black & Hawks: Medical-Surgical Nursing: Clinical Management for Positive Outcomes, 7th Edition Chapter 77: Management of Clients with Hematologic Disorders MULTIPLE CHOICE 1. The nurse assessing a female client with a hemoglobin of 11 g/100 ml would expect the client to report a. no significant manifestations. b. shortness of breath. c. tachycardia. d. chronic fatigue.
a Clients with mild anemia (hemoglobin of 10 to 12 g/ml) are usually asymptomatic. DIF: Cognitive Level: Knowledge REF: Text Reference: 2273 TOP: Nursing Process Step: Assessment MSC:
Physiological Integrity 35. The nurse would include in the care of the client with multiple myeloma the intervention of a. forcing fluids. b. encouraging ingestion of dairy products. c. maintaining reverse isolation. d. administering frequent mouth care.
a Clients with multiple myeloma usually require about 3 L of fluid per day. The client needs sufficient fluid not only to dilute the calcium overload but also prevent protein from precipitating in the renal tubules, even after being effectively treated with chemotherapy. DIF: Cognitive Level: Application REF: Text Reference: 2303 TOP: Nursing Process Step: Intervention MSC:
Physiological Integrity 10. The nurse explains that the drug essential for a client with pernicious anemia is a. vitamin B12. b. ferrous gluconate. c. vitamin K. d. ferritin.
a Clients with pernicious anemia need both immediate care and lifelong therapy with maintenance vitamin B12. DIF: Cognitive Level: Knowledge REF: Text Reference: 2290 TOP: Nursing Process Step: Intervention MSC:
Physiological Integrity 32. The nurse recognizes a common historical finding in a client with multiple myeloma, which is a. employment in a farm industry. b. a diet that is high in fat. c. long-term smoking. d. excessive exposure to the sun.
a Etiologic factors include exposure to ionizing radiation and occupational chemical exposure. DIF: Cognitive Level: Application REF: Text Reference: 2302 TOP: Nursing Process Step: Assessment MSC:
Physiological Integrity 7. Following a client's bone marrow aspiration, the nursing intervention should be to a. apply firm pressure to the area until bleeding stops. b. provide a warm, moist compress to the site. c. encourage the client to assume a supine position. d. place an occlusive dressing on the area for 24 hours.
a Following the procedure, apply pressure until the bleeding stops. A pressure dressing or a sandbag might be necessary. DIF: Cognitive Level: Application REF: Text Reference: 2265 TOP: Nursing Process Step: Intervention MSC:
Physiological Integrity 3. A client has a hematocrit (Hct) of 30%. The nurse interprets this to mean a. the individual has fewer red blood cells than normal. b. the blood is viscous and concentrated. c. bleeding disorders are possible. d. 30% of the blood will be plasma and plasma products.
a Hematocrit measures the percent volume of red cells in whole blood. The normal value in adult women is 37% to 45%. DIF: Cognitive Level: Comprehension REF: Text Reference: 2262 TOP: Nursing Process Step: Assessment MSC:
Physiological Integrity 2. The nurse should anticipate an elevated hemoglobin level in a. a client who lives in Colorado. b. a dehydrated elderly gentleman being treated with intravenous (IV) fluids. c. a 40-year-old woman with congestive heart failure. d. a client with iron deficiency anemia.
a Hemoglobin levels are frequently elevated in people who live in high altitudes. DIF: Cognitive Level: Application REF: Text Reference: 2258 TOP: Nursing Process Step: Assessment MSC:
Health Promotion and Maintenance 26. A client who has hemophilia A and his wife, who is not a carrier of the disease, wish to start a family. In discussing the risk factors of transmitting hemophilia to his children, it is important to explain that a. none of his children are likely to have hemophilia. b. all of his children will be carriers. c. all of his sons will have hemophilia. d. 50% of his children are at risk for developing the disease.
a Hemophilia is genetically transmitted in a sex-linked (X chromosome) recessive pattern. Females usually transmit the defective gene, but males express the bleeding disorder. Males with hemophilia transmit the gene to all of their daughters but to none of their sons. DIF: Cognitive Level: Analysis REF: Text Reference: 2311, Table 77-12; TOP: Nursing Process Step: Intervention MSC:
Physiological Integrity 30. When a client experiences an adverse reaction to a blood transfusion, the nurse should initially a. discontinue the transfusion. b. notify the physician. c. administer oxygen via nasal prongs. d. raise the head of the bed.
a In all cases of transfusion reaction, stop the transfusion and keep the intravenous (IV) line open with normal saline. DIF: Cognitive Level: Application REF: Text Reference: 2284 TOP: Nursing Process Step: Intervention MSC:
Physiological Integrity 6. The manifestation the nurse would expect to find on laboratory test results on a 52-year-old who has had severe anemia for many years is a. microcytic and hypochromic red blood cells (RBCs). b. a hemoglobin level of 9.5 g/dl. c. serum iron level of 58 mg/dl. d. total iron-binding capacity reduced to less than 250 mg/dl.
a In severe cases, peripheral blood smears reveal microcytic and pale (hypochromic) RBCs. DIF: Cognitive Level: Analysis REF: Text Reference: 2286 TOP: Nursing Process Step: Assessment MSC:
Physiological Integrity 34. The nurse reassures a client newly diagnosed with multiple myeloma and is asymptomatic that he will initially be treated by a. close monitoring. b. alkalating agents. c. the VAD regimen: vincristine (Oncovin), doxorubicin (Adriamycin), and dexamethasone (Decadron). d. interferon.
a In the initial phases when clients are asymptomatic, they are often carefully monitored until the disease progresses and then are treated with chemotherapy. DIF: Cognitive Level: Comprehension REF: Text Reference: 2303 TOP: Nursing Process Step: Intervention MSC:
Physiological Integrity 15. The nursing diagnosis that would have priority in the care of a client with aplastic anemia is a. Risk for Infection due to decreased leukocyte count. b. Impaired Gas Exchange due to low RBC count. c. potential for Impaired Skin Integrity due to poor nutritional status. d. alteration in bowel elimination: Constipation due to iron overload.
a The client suffers from an increased susceptibility to infection because without leukocytes the body cannot adequately battle bacteria and other invading organisms. DIF: Cognitive Level: Analysis REF: Text Reference: 2293 TOP: Nursing Process Step: Assessment MSC:
Physiological Integrity 38. When a child with sickle cell anemia contracts gastroenteritis with vomiting and diarrhea, the nurse cautions the family about the development of the complication of a. hemoconcentration. b. gastric bleeding. c. increased need for oxygen. d. decreased nutritional intake.
a Vomiting and diarrhea can cause a fluid volume deficit that leads to hemoconcentration, a factor in the onset of sickle cell crisis. DIF: Cognitive Level: Application REF: Text Reference: 2298 TOP: Nursing Process Step: Intervention MSC:
Physiological Integrity 25. When a client with sickle cell anemia confides that she wishes to have a child, the nurse should inform her that a. pregnancy could result in vascular complications. b. her child will have sickle cell anemia. c. she has an increased chance of miscarriage. d. there is no reason not to have a child.
a Warn young women with sickle cell anemia that pregnancy carries a very high risk for them. Explain that pulmonary or renal complications, or both, may develop. DIF: Cognitive Level: Application REF: Text Reference: 2299 TOP: Nursing Process Step: Intervention MSC:
Physiological Integrity 20. The manifestation that would require immediate investigation in a client with infectious mononucleosis is a. abdominal pain. b. joint discomfort. c. sore throat. d. leukocyte count of 12,000/mm3.
a When infectious mononucleosis is severe, the client may develop splenic rupture resulting from the infiltration of the spleen by massive numbers of lymphocytes. DIF: Cognitive Level: Application REF: Text Reference: 2304 TOP: Nursing Process Step: Assessment MSC:
Physiological Integrity 21. The nursing order that would be counterproductive for a client with infectious mononucleosis is a. maintain bed rest. b. limit fluids. c. provide throat irrigations. d. use sponge baths for fever.
b Bed rest is recommended until fever is resolved. Acetaminophen, cool sponge baths, and a large fluid intake help control fever. Warm saline throat irrigations may relieve the sore throat. Aspirin is avoided because of the risk of Reye's syndrome. DIF: Cognitive Level: Application REF: Text Reference: 2304 TOP: Nursing Process Step: Intervention MSC:
Physiological Integrity 7. The food the nurse would include in the discussion relative to foods that are high in iron is a. citrus fruits. b. green leafy vegetables. c. milk products. d. grains.
b Encourage foods cooked in iron pots and ingestion of foods such as liver (the richest source), oysters, lean meats, kidney beans, whole wheat bread, kale, spinach, egg yolk, turnip tops, beet greens, carrots, apricots, and raisins. DIF: Cognitive Level: Application REF: Text Reference: 2285 TOP: Nursing Process Step: Intervention MSC:
Physiological Integrity 11. The manifestation the nurse would question the client about that is characteristically associated with anemia is a. pruritus. b. fatigue. c. rash. d. ruddy skin color.
b Fatigue is the most common manifestation of anemia. DIF: Cognitive Level: Analysis REF: Text Reference: 2255 TOP: Nursing Process Step: Assessment MSC:
Physiological Integrity 16. The nurse is monitoring the laboratory test results for a client receiving anticoagulation therapy. The nurse is aware that the International Normalized Ratio (INR) for most clinical conditions, requiring anticoagulation is a. less than 1. b. 1 to 2. c. 2 to 3.5. d. 3 to 5.5.
b For most clinical conditions that necessitate anticoagulation, the recommended INR is 2 to 3.5. DIF: Cognitive Level: Knowledge REF: Text Reference: 2265 TOP: Nursing Process Step: Assessment MSC:
Physiological Integrity 23. The nurse assessing a client with sickle cell anemia would recognize the common manifestation characteristic of the disease is a. confusion. b. leg ulcers. c. diarrhea. d. hypertension.
b Leg ulcers are found in about 75% of older children and adults with the disease. DIF: Cognitive Level: Knowledge REF: Text Reference: 2297 TOP: Nursing Process Step: Assessment MSC:
1. In evaluating a young woman, the following laboratory result the nurse recognizes as abnormal is a. hemoglobin 13 g/dl. b. platelet count 20,000/mm3. c. red blood cell count 5 million/mm3. d. white blood cell count 6000/mm3.
b Normal platelet count is 150,000/mm3. DIF: Cognitive Level: Application REF: Text Reference: 2262, Table 76-3; TOP: Nursing Process Step: Assessment MSC:
Physiological Integrity 33. When assessing the client with multiple myeloma, the nurse would expect to find the manifestation of a. shortness of breath. b. bone pain. c. ecchymosis of the skin. d. painless enlarged lymph nodes.
b Once manifestations appear, they typically involve the skeletal system, particularly the pelvis, spine, and ribs. Some clients have backache or bone pain that worsens with movement. DIF: Cognitive Level: Application REF: Text Reference: 2302 TOP: Nursing Process Step: Assessment MSC:
Physiological Integrity 36. When caring for a client with multiple myeloma, the nurse should take appropriate precautions to a. alleviate respiratory difficulty. b. prevent fractures. c. prevent seizures. d. alleviate diarrhea.
b Some clients have backache or bone pain that worsens with movement. Others suffer sudden pathologic fractures accompanied by severe pain. Because of skeletal complications, care should be taken when moving the client. Family members should institute safety measures to prevent falls. DIF: Cognitive Level: Application REF: Text Reference: 2303 TOP: Nursing Process Step: Intervention MSC:
Physiological Integrity 4. The statement about dietary iron made by a client with iron deficiency anemia that indicates understanding of the dietary concepts is a. "I know that iron from animal sources is not absorbed well." b. "I will not be able to obtain enough iron by just increasing my dietary intake." c. "I should be able to change my diet so that I can get sufficient iron." d. "I know that dairy products are the best source of iron."
b The amount of iron normally absorbed daily is sufficient for meeting the needs of women past the childbearing age and healthy men, but it does not meet the greater needs of menstruating and pregnant women, adolescents, children, and infants. DIF: Cognitive Level: Application REF: Text Reference: 2274 TOP: Nursing Process Step: Evaluation MSC:
Physiological Integrity 21. A client with polycythemia vera will have a characteristic skin color that is a. pale. b. ruddy. c. bronzed. d. jaundiced.
b The client with polycythemia vera has a ruddy complexion. DIF: Cognitive Level: Knowledge REF: Text Reference: 2259 TOP: Nursing Process Step: Assessment MSC:
Physiological Integrity 37. The nurse informs the client that the confirming finding for perncious anemia from a gastric secretion analysis is that after the administration of histamine, the gastric secretion shows a a. rebound increase in volume. b. a low volume with a high pH. c. reduction of free hydrochloric acid. d. a characteristic blue color.
b The gastric secretion analysis shows the same low volume with a high pH and high free hydrochloric acid levels even after the administration of histamine. DIF: Cognitive Level: Comprehension REF: Text Reference: 2290 TOP: Nursing Process Step: Intervention MSC:
Physiological Integrity 9. The laboratory test result that would be most helpful to the nurse in the assessment of a client with a bleeding disorder is a. RBC count. b. platelet count. c. hematocrit. d. differential count.
b The platelet count is valuable in assessing the severity of thrombocytopenia (abnormally low platelet count), which can result in spontaneous bleeding. DIF: Cognitive Level: Analysis REF: Text Reference: 2265 TOP: Nursing Process Step: Assessment MSC:
Physiological Integrity 24. The nurse explains that the definitive laboratory findng confirming the diagnosis of sickle cell anemia is a. hemoglobin of less than 9 g/dl. b. presence of hemoglobin S (Hgb S). c. increase in hemoglobin G (Hgb G). d. folate deficiency.
b The presence of Hgb S is the definitive finding that confirms the diagnosis of sickle cell anemia. DIF: Cognitive Level: Knowledge REF: Text Reference: 2295 TOP: Nursing Process Step: Intervention MSC:
Physiological Integrity 6. A client expresses concern over the discomfort expected during the bone marrow aspiration. The nurse can best address these concerns by informing the client a. "You will be asleep during the procedure." b. "There is no pain associated with bone marrow aspirations." c. "The pain during marrow aspiration is of short duration." d. "A local anesthetic will make you comfortable during the procedure."
c Because the marrow space itself cannot be anesthetized, removal of the marrow usually produces moderate to severe pain of short duration. It stops as soon as suction on the marrow space is stopped. DIF: Cognitive Level: Comprehension REF: Text Reference: 2265 TOP: Nursing Process Step: Intervention MSC:
Physiological Integrity 5. The nurse explains to a client who is to undergo a bone marrow aspiration that the most common site for withdrawal of bone marrow is a. antecubital fossa. b. long bones. c. posterior iliac crests. d. acetabulum.
c Bone marrow samples are most commonly taken from the posterior iliac crests. Other sampling sites include the sternum and the anterior iliac crests. DIF: Cognitive Level: Comprehension REF: Text Reference: 2265 TOP: Nursing Process Step: Intervention MSC:
Physiological Integrity 2. While performing an admission assessment on a moderately anemic client, the nurse would expect to find a history of a. blurred vision. b. increased appetite. c. cardiac palpitations. d. warm, flushing sensations.
c Clients with moderate anemia may suffer from dyspnea, palpitations, diaphoresis with exertion, and chronic fatigue. DIF: Cognitive Level: Knowledge REF: Text Reference: 2273 TOP: Nursing Process Step: Assessment MSC:
Physiological Integrity 12. A client presents to the ambulatory care center seeking treatment for allergies. When questioning the client about contact agents as allergic triggers, the nurse would inquire about a. pollen. b. molds and spores. c. types of clothing fibers. d. food additives.
c Contact agents as allergic triggers include dyes in clothing, fibers, and cosmetics; metal in jewelry; plant oils and secretions; topical drugs; and numerous chemicals. DIF: Cognitive Level: Analysis REF: Text Reference: 2255 TOP: Nursing Process Step: Assessment MSC:
Physiological Integrity 14. A client reports getting allergy manifestations when in the workplace. Further assessment about airborne allergens should focus on a. lighting. b. food service vendor. c. heating and cooling systems. d. water supply.
c Exposure to allergens at work may trigger reactions. Ask about the heating and cooling systems if airborne allergens are suspected. DIF: Cognitive Level: Application REF: Text Reference: 2258 TOP: Nursing Process Step: N/A MSC:
Physiological Integrity 13. The nurse should teach a client with pernicious anemia who is being treated with folic acid to report any manifestations related to the a. cardiovascular system. b. gastrointestinal system. c. neurologic system. d. respiratory system.
c Folic acid can be dangerous because it may intensify neurologic problems, and large doses of folate may obscure a vitamin B12 deficiency. DIF: Cognitive Level: Comprehension REF: Text Reference: 2290 TOP: Nursing Process Step: Intervention MSC:
Physiological Integrity 16. When obtaining a nursing history from an anemic male client, the nurse would recognize a factor significant in the development of anemia is a. smoking one pack of cigarettes daily. b. a diet high in cholesterol. c. large hemorrhoids. d. oral contraceptive intake.
c Gastrointestinal (GI) tract bleeding is a common etiologic factor in men; it may result from peptic ulcers, hiatal hernia, gastritis, cancer, hemorrhoids, diverticula, ulcerative colitis, or salicylate poisoning. DIF: Cognitive Level: Application REF: Text Reference: 2286 TOP: Nursing Process Step: Assessment MSC:
Physiological Integrity 22. The nurse counsels a client with idiopathic thrombocytopenic purpura (ITP) that if medication therapy is not effective, the surgical procedure is most likely to be used in the treatment is a. hepatic shunt. b. exploratory laparotomy. c. splenectomy. d. bone marrow transplant.
c If the client does not have a sustained remission, splenectomy may be needed. In 60% to 80% of cases, removal of the spleen results in complete and permanent remission. DIF: Cognitive Level: Knowledge REF: Text Reference: 2306 TOP: Nursing Process Step: Intervention MSC:
Health Promotion and Maintenance 8. The nurse explaining aspects of pernicious anemia to the client would include information regarding a. frequent bouts of dyspnea. b. the risks relative to dehydration. c. deficiency of intrinsic factor. d. lack of any effective treatment for this disorder.
c Pernicious anemia is a type of anemia due to failure of absorption of vitamin B12 (cobalamin). The most common cause is lack of intrinsic factor, a glucoprotein produced by the parietal cells of the gastric lining. DIF: Cognitive Level: Knowledge REF: Text Reference: 2289 TOP: Nursing Process Step: Intervention MSC:
Physiological Integrity 10. A client has severe anemia and is being treated with transfusion therapy. The nurse should be alert for a complicaton of transfusion, such as a. hearing loss. b. liver damage. c. flank pain. d. sore throat.
c Reactions to blood products include fever, chills, back or flank pain, shock, wheezing, headache, vomiting, or urticaria (hives). DIF: Cognitive Level: Application REF: Text Reference: 2257 TOP: Nursing Process Step: Assessment MSC:
Health Promotion and Maintenance 5. The nurse would instruct the client with iron deficiency anemia to avoid a. citrus fruits. b. poultry. c. tea. d. leafy green vegetables.
c Tannates (in tea and coffee), carbonates, the chelating agent ethylenediaminetetraacetic acid (EDTA), and the medicinal antacid magnesium trisilicate all hinder non-heme iron absorption. DIF: Cognitive Level: Application REF: Text Reference: 2286 TOP: Nursing Process Step: Intervention MSC:
Physiological Integrity 17. The laboratory result to which the nurse would look to confirm a diagnosis of disseminated intravascular coagulation (DIC) is a. prothrombin time. b. partial thromboplastin time. c. D-dimer. d. reticulocyte count.
c The D-dimer confirms the diagnosis of DIC. DIF: Cognitive Level: Knowledge REF: Text Reference: 2265 TOP: Nursing Process Step: Assessment MSC:
Physiological Integrity 12. The nurse is aware that the situation that would warrant administration of iron supplements to a client with pernicious anemia is a. poor appetite. b. increase in the total erythrocyte count in the peripheral circulation. c. discrepancy between hemoglobin and erythrocyte levels. d. paresthesia in the fingers.
c The client may need oral iron supplementation if the hemoglobin level fails to rise in proportion to an increased RBC count. DIF: Cognitive Level: Analysis REF: Text Reference: 2290 TOP: Nursing Process Step: Assessment MSC:
Physiological Integrity 28. The precautionary nursing intervention that is of primary importance when preparing to administer blood is a. establishing baseline vital signs. b. administration of pretransfusion antihistamines. c. asking a second health care professional to confirm blood acceptability. d. obtaining a written order for the transfusion.
c The most critical phase of transfusion is confirming product compatibility and verifying client identity. DIF: Cognitive Level: Application REF: Text Reference: 2283 TOP: Nursing Process Step: Intervention MSC:
Physiological Integrity 20. A client with thrombocytopenia complains of a visual disturbance. The nurse is aware this visual problem may be due to a. occlusive emboli in the visual center of the brain. b. severe anemia causing altered perfusion to the brain. c. minute retinal hemorrhages. d. bile pigment accumulation in the eye.
c The reduced number of platelets make the thrombocytopenic clients at risk for hemorrhages. DIF: Cognitive Level: Application REF: Text Reference: 2259 TOP: Nursing Process Step: Assessment MSC:
Physiological Integrity 13. The nurse assesses the client who underwent partial removal of the stomach a year ago for the manifestations of a. shortened bleeding times. b. high white blood cell count. c. low platelet count. d. anemia.
d Anemia may also occur following partial or total gastrectomy or removal of the terminal portion of the ileum because of the consequent reduction in absorption of vitamin B12. DIF: Cognitive Level: Analysis REF: Text Reference: 2256 TOP: Nursing Process Step: Assessment MSC:
Health Promotion and Maintenance 15. The nurse reads that an assigned client has an immunodeficiency. The nurse reads further in the medical record, anticipating that the client also most likely has a history of a. skin eruptions. b. conjunctivitis. c. severe headaches. d. unexplained weight loss.
d Clients with immunodeficiencies have a history of recurrent infections, especially of mucous membranes (e.g., oral cavity, anorectal area, genitourinary [GU] tract, respiratory tract); poor wound healing; diarrhea; and manifestations of systemic activation of the immune response. DIF: Cognitive Level: Analysis REF: Text Reference: 2258 TOP: Nursing Process Step: Assessment MSC:
Physiological Integrity 17. The nurse outlines methods to increase iron in diets that include a. including tea or coffee at mealtime. b. cooking food quickly with high heat setting. c. boiling foods in at least 3 cups of water. d. cooking in iron cookware.
d Cooking in iron cookware, cooking foods at a moderate heat in a minimum of water, and excluding caffeine will improve the iron intake. DIF: Cognitive Level: Comprehension REF: Text Reference: 2285 TOP: Nursing Process Step: Intervention MSC:
Health Promotion and Maintenance 18. The nurse recognizes that the laboratory finding indicative of polycythemia vera is a. erythrocyte count of 5 million/mm3. b. leukocyte count of 6000/mm3. c. platelets of 50,000/mm3. d. hemoglobin level of 22 g/100 ml.
d Diagnostic findings include RBC count as high as 8 to 12 million/mm3, hemoglobin level of 18 to 25 g/dl, and a hematocrit level greater than 54% in men and 49% in women. DIF: Cognitive Level: Application REF: Text Reference: 2300 TOP: Nursing Process Step: Assessment MSC:
Physiological Integrity 29. The nurse can decrease the danger of transfusion reactions in a client by a. forcing fluids. b. adding sterile saline to the blood transfusion. c. monitoring the urine output. d. infusing the blood slowly during the first 15 minutes.
d It is recommended that the transfusion begin slowly and that the client be closely monitored. If no evidence of a reaction is noted within the first 15 minutes, flow can then be increased to the prescribed rate. DIF: Cognitive Level: Application REF: Text Reference: 2284 TOP: Nursing Process Step: Intervention MSC:
Physiological Integrity 9. To determine if the client has a risk factor related to iron deficiency anemia, the nurse could ask a. "Have you ever had a cardiac catheterization?" b. "Have you had a pregnancy terminated within the past 6 months?" c. "Have you had a blood transfusion recently?" d. "Have you ever had any surgery involving your stomach?"
d Malabsorption of iron may result from alterations in the mucosa of the duodenum and proximal jejunum, gastrectomy, or removal of the proximal small bowel, resulting in iron deficiency anemia. DIF: Cognitive Level: Application REF: Text Reference: 2286 TOP: Nursing Process Step: Assessment MSC:
Physiological Integrity 19. The nurse caring for a client with polycythemia vera explains the objective of phlebotomies is to decrease the hematocrit to a. 15%. b. 25%. c. 35%. d. 45%.
d Phlebotomies can be used to normalize red cell mass until the hematocrit reaches 45%. DIF: Cognitive Level: Application REF: Text Reference: 2300 TOP: Nursing Process Step: Intervention MSC:
Physiological Integrity 11. The nurse informs a client suspected of pernicious anemia that the lab study that will be helpful in the diagnosis is a. clotting studies. b. hemoglobin levels. c. endoscopy. d. Schilling test.
d The Schilling test measures the absorption of orally administered radioactive vitamin B12 (tagged with cobalt 60) before and after parenteral administration of intrinsic factor. This procedure detects lack of intrinsic factor and is the definitive test for pernicious anemia. DIF: Cognitive Level: Knowledge REF: Text Reference: 2290 TOP: Nursing Process Step: Intervention MSC:
Physiological Integrity 18. The nurse discovers a client is taking the herb St. John's wort. The nurse cautions that this herb reduces the effectiveness of a. prednisone. b. theophylline. c. lanoxin. d. warfarin.
d The anticoagulation properties of warfarin are diminished if taken in conjunction with St. John's wort. DIF: Cognitive Level: Application REF: Text Reference: 2257 TOP: Nursing Process Step: Intervention MSC:
Physiological Integrity 3. The nurse points out that nursing management of all individuals with anemia is primarily directed toward a. genetic counseling. b. identifying complications. c. rehabilitative measures. d. managing manifestations.
d The goals of care for clients with anemia include (1) alleviating or controlling the causes, (2) relieving the manifestations, and (3) preventing complications. DIF: Cognitive Level: Comprehension REF: Text Reference: 2273 TOP: Nursing Process Step: Intervention MSC:
Physiological Integrity 14. The statement made by a client with pernicious anemia that would indicate to the nurse a need for further teaching is a. "I promise to have a checkup every 6 months." b. "I'm glad my nervous problems will not get worse." c. "Monthly injections are not so bad." d. "I need physical therapy to get rid of my palpitations."
d The response to injections is quick and dramatic. By the end of the first week the total RBC count rises significantly. Cardiovascular involvement usually lessens with improved erythropoiesis. Peripheral nerve function may improve with treatment. DIF: Cognitive Level: Analysis REF: Text Reference: 2290 TOP: Nursing Process Step: Evaluation MSC:
