Blood Test

The nurse is obtaining the health history of a client who has iron deficiency anemia. Which factor in this client's history does the nurse correlate with this diagnosis? a. Eating a meat-free diet b. Family history of sickle cell disease c. History of leukemia d. History of bleeding ulcer

A A diet high in protein and iron helps keep the client's levels of iron within normal limits. Meat is a good source of protein and iron. A bleeding ulcer could cause anemia but would not cause iron deficiency. Sickle cell disease causes sickle cell anemia. Leukemia causes a decrease in white blood cells. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Analysis)

The nurse is administering a prescribed fibrinolytic to a client who is having a myocardial infarction (MI). Which adverse effect does the nurse monitor for? a. Bleeding b. Orthostatic hypotension c. Deep vein thrombosis d. Nausea and vomiting

A A fibrinolytic lyses any clots in the body, thus causing an increased risk for bleeding. Fibrinolytic therapy does not place the client at risk for hypotension, thrombosis, or nausea and vomiting. DIF: Cognitive Level: Comprehension/Understanding REF: p. 861 TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse Effects/Contraindications/Side Effects/Interactions) MSC: Integrated Process: Nursing Process (Assessment)

A young child with leukemia has anorexia and severe stomatitis. The nurse should suggest that the parents try which intervention? a. Relax any eating pressures. b. Firmly insist that child eat normally. c. Begin gavage feedings to supplement diet. d. Serve foods that are either hot or cold.

A A multifaceted approach is necessary for children with severe stomatitis and anorexia. First, the parents should relax eating pressures rather than insisting the child eat normally. The nurse should suggest that the parents try soft, bland foods rather than hot or cold foods; normal saline or bicarbonate mouthwashes; and local anesthetics. The stomatitis is a temporary condition; gavage feedings are not necessary. The child can resume good food habits as soon as the condition resolves. PTS: 1 DIF: Cognitive Level: Application REF: 1383 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

The nurse is caring for a client who had a bone marrow aspiration. The client begins to bleed from the aspiration site. Which action does the nurse perform? a. Apply external pressure to the site. b. Elevate the extremities. c. Cover the site with a dressing. d. Immobilize the leg.

A All these options could be done after a bone marrow aspiration and biopsy. However, the most important action when bleeding occurs is to apply external pressure to the site until hemostasis is ensured. The other measures could then be carried out. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Diagnostic Tests/Treatments/Procedures) MSC: Integrated Process: Nursing Process (Implementation)

The nurse is assessing a client with anemia. Which clinical manifestation does the nurse expect to see in this client? a. Dyspnea with activity b. Hypertension c. Bradycardia d. Warm, flushed skin

A Anemia is a reduction in the number of red blood cells (RBCs), the amount of hemoglobin, or the hematocrit level. Tissue oxygenation depends on RBCs. Typical symptoms of anemic clients include dyspnea, increased somnolence, tachycardia, and pallor. A client who is anemic tends to have lower blood pressure, increased heart rate, and skin that is pale and cool to touch. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Nursing Process (Assessment)

In which condition are all the formed elements of the blood simultaneously depressed? a. Aplastic anemia c. Thalassemia major b. Sickle cell anemia d. Iron deficiency anemia

A Aplastic anemia refers to a bone marrow-failure condition in which the formed elements of the blood are simultaneously depressed. Sickle cell anemia is a hemoglobinopathy in which normal adult hemoglobin is partly or completely replaced by abnormal sickle hemoglobin. Thalassemia major is a group of blood disorders characterized by deficiency in the production rate of specific hemoglobin globin chains. Iron deficiency anemia results in a decreased amount of circulating red cells. PTS: 1 DIF: Cognitive Level: Comprehension REF: 1374 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

The nurse is planning care for an adolescent with acquired immunodeficiency syndrome. The priority nursing goal is to: a. Prevent infection. c. Restore immunologic defenses. b. Prevent secondary cancers. d. Identify source of infection.

A As a result of the immunocompromise that is associated with human immunodeficiency virus infection, the prevention of infection is paramount. Although certain precautions are justified in limiting exposure to infection, these must be balanced with the concern for the child's normal developmental needs. Restoring immunologic defenses is not currently possible. Current drug therapy is affecting the disease progression; although not a cure, these drugs can suppress viral replication, preventing further deterioration. Case finding is not a priority nursing goal. PTS: 1 DIF: Cognitive Level: Application REF: 1387 OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

Which statement best explains why iron deficiency anemia is common during toddlerhood? a. Milk is a poor source of iron. b. Iron cannot be stored during fetal development. c. Fetal iron stores are depleted by age 1 month. d. Dietary iron cannot be started until age 12 months.

A Children between the ages of 12 and 36 months are at risk for anemia because cow's milk is a major component of their diet, and it is a poor source of iron. Iron is stored during fetal development, but the amount stored depends on maternal iron stores. Fetal iron stores are usually depleted by age 5 to 6 months. Dietary iron can be introduced by breastfeeding, iron-fortified formula, and cereals during the first 12 months of life. PTS: 1 DIF: Cognitive Level: Analysis REF: 1365 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

The nurse is planning discharge teaching for a client who has acute myelogenous leukemia (AML). Which instruction does the nurse include in this client's discharge plan? a. Avoid contact sports. b. Refrain from intercourse. c. Apply heat to any bruised areas. d. Use aspirin for headaches.

A Clients with AML have a low platelet count and are at risk for bleeding. Contact sports can cause bleeding and should be avoided by those with a low platelet count. Anal intercourse should be avoided, but it is not necessary to refrain from all types of intercourse. Ice should be placed on bruised areas instead of heat, and aspirin should not be used by those with a low platelet count. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care) MSC: Integrated Process: Teaching/Learning

The nurse is caring for a client who has a decreased serum iron level. Which intervention does the nurse prioritize for this client? a. Dietary consult b. Family assessment c. Cardiac assessment d. Administration of vitamin K

A Diets can alter cell quality and affect blood clotting. Diets low in iron can cause anemia and decrease the function of all red blood cells. The question does not say that the hemoglobin is low enough to affect the cardiac function. Family assessment may be important in finding out any genetic or family lifestyle causes of the low serum iron level. However, the first intervention that the nurse can provide is to have the client's dietary habits evaluated and changed so that iron levels can increase. Vitamin K is involved with clotting, not with iron stores. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Basic Care and Comfort—Nutrition and Oral Hydration) MSC: Integrated Process: Nursing Process (Implementation)

A possible cause of acquired aplastic anemia in children is: a. Drugs. c. Deficient diet. b. Injury. d. Congenital defect.

A Drugs such as chemotherapeutic agents and several antibiotics such as chloramphenicol can cause aplastic anemia. Fanconi syndrome is a primary form of the disorder, which is congenital/present-at-birth and not acquired after birth. Injury, deficient diet, and congenital defect are not causative agents in acquired aplastic anemia. PTS: 1 DIF: Cognitive Level: Comprehension REF: 1374 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

The nurse is assessing a client who has a factor VIII deficiency. Which clinical manifestation does the nurse expect to assess in this client? a. Excessive bleeding from a cut b. Chronic lower back pain c. Nausea and vomiting d. Temperature of 101° F

A Factor VIII deficiency is also known as hemophilia A. With hemophilia, a client has a prolonged partial thromboplastin time (PTT) and is at risk for excessive bleeding from minor cuts. The other three distractors are not associated with a factor VIII deficiency. DIF: Cognitive Level: Comprehension/Understanding REF: p. 896 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Nursing Process (Assessment)

The nurse is assessing a 75-year-old male client. Which blood value indicates that the client is experiencing normal changes associated with aging? a. Hemoglobin, 13.0 g/dL b. Platelet count, 100,000/mm3 c. Prothrombin time (PT), 14 seconds d. White blood cell (WBC) count, 5000/mm3

A Hemoglobin levels in men and women fall after middle age. Therefore, this client's hemoglobin value would be considered part of the aging process. Platelet counts and blood-clotting times are not age related; the client's platelet count and PT are elevated for some other reason. The WBC count shown is normal. DIF: Cognitive Level: Comprehension/Understanding REF: p. 860 TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Laboratory Values) MSC: Integrated Process: Nursing Process (Assessment)

The nurse is administering an intravenous chemotherapeutic agent to a child with leukemia. The child suddenly begins to wheeze and have severe urticaria. Which is the most appropriate nursing action? a. Stop drug infusion immediately. b. Recheck rate of drug infusion. c. Observe child closely for next 10 minutes. d. Explain to child that this is an expected side effect.

A If an allergic reaction is suspected, the drug should be immediately discontinued. Any drug in the line should be withdrawn, and a normal saline infusion begun to keep the line open. Rechecking the rate of drug infusion, observing the child closely for next 10 minutes, and explaining to the child that this is an expected side effect can all be done after the drug infusion is stopped and the child is evaluated. PTS: 1 DIF: Cognitive Level: Application REF: 1382 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

What is the priority nursing intervention for a child hospitalized with hemarthrosis resulting from hemophilia? a. Immobilization and elevation of the affected joint b. Administration of acetaminophen for pain relief c. Assessment of the child's response to hospitalization d. Assessment of the impact of hospitalization on the family system

A Immobilization and elevation of the joint will prevent further injury until bleeding is resolved. Although acetaminophen may help with pain associated with the treatment of hemarthrosis, it is not the priority nursing intervention. Assessment of a child's response to hospitalization is relevant to all hospitalized children; however, in this situation, psychosocial concerns are secondary to physiologic concerns. A priority nursing concern for this child is the management of hemarthrosis. Assessing the impact of hospitalization on the family system is relevant to all hospitalized children; however, it is not the priority in this situation. PTS: 1 DIF: Cognitive Level: Application REF: 1375 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

What is the most common mode of transmission of human immunodeficiency virus (HIV) in the pediatric population? a. Perinatal transmission c. Blood transfusions b. Sexual abuse d. Poor hand washing

A Perinatal transmission accounts for the highest percentage (91%) of HIV infections in children. Infected women can transmit the virus to their infants across the placenta during pregnancy, at delivery, and through breastfeeding. Cases of HIV infection from sexual abuse have been reported; however, perinatal transmission accounts for most pediatric HIV infections. In the past some children became infected with HIV through blood transfusions; however, improved laboratory screening has significantly reduced the probability of contracting HIV from blood products. Poor hand washing is not an etiology of HIV infection. PTS: 1 DIF: Cognitive Level: Application REF: 1385 OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

The nurse is assessing a client with numerous areas of bruising. Which question does the nurse ask to determine the cause of this finding? a. "Do you take aspirin?" b. "How often do you exercise?" c. "Are you a vegetarian?" d. "How often do you take Tylenol?"

A Platelet aggregation is essential for blood clotting. An inability to clot blood when an injury occurs can result in bleeding, which would cause bruising. Aspirin is a drug that interferes with platelet aggregation and has the ability to "plug" an extrinsic event, such as trauma. Vitamin K found in green vegetables enhances clotting factors, which would improve the ability to stop bleeding associated with an extrinsic event. Acetaminophen (Tylenol) and exercise do not inhibit clotting factors. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening) MSC: Integrated Process: Nursing Process (Assessment)

An inherited immunodeficiency disorder characterized by absence of both humoral and cell-mediated immunity is: a. Severe combined immunodeficiency syndrome (SCIDS). b. Acquired immunodeficiency syndrome. c. Wiskott-Aldrich syndrome. d. Fanconi syndrome.

A Severe SCIDS is a genetic disorder that results in deficits of both humoral and cellular immunity. Acquired immunodeficiency syndrome is not inherited. Wiskott-Aldrich syndrome is an X-linked recessive disorder with selected deficiencies of T and B lymphocytes. Fanconi syndrome is a hereditary disorder of red cell production. PTS: 1 DIF: Cognitive Level: Comprehension REF: 1388 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

The most appropriate nursing diagnosis for a child with anemia is: a. Activity Intolerance related to generalized weakness. b. Decreased Cardiac Output related to abnormal hemoglobin. c. Risk for Injury related to depressed sensorium. d. Risk for Injury related to dehydration and abnormal hemoglobin.

A The basic pathology in anemia is the decreased oxygen-carrying capacity of the blood. The nurse must assess the child's activity level (response to the physiologic state). The nursing diagnosis would reflect the activity intolerance. In generalized anemia no abnormal hemoglobin may be present. Only at a level of very severe anemia does cardiac output become altered. No decreased sensorium exists until profound anemia occurs. Dehydration and abnormal hemoglobin are not usually part of anemia. PTS: 1 DIF: Cognitive Level: Analysis REF: 1365 OBJ: Nursing Process: Diagnosis MSC: Client Needs: Physiologic Integrity

The nurse is preparing a client for surgery. The client states, "I am concerned I might be given blood products during surgery and this would be against my religious beliefs." How does the nurse respond? a. "We can use other means to replace blood loss besides blood products." b. "Your chance of needing a blood transfusion is small." c. "The operating team will do what is necessary to save your life." d. "You could have family members donate blood for you."

A The client's rights and wishes should be respected while accurate information is provided for reassurance. Directed donations from family members neither ensure safe blood products nor may be sanctioned by the client's religion. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Psychosocial Integrity (Religious and Spiritual Influences on Health) MSC: Integrated Process: Nursing Process (Implementation)

The nurse is planning discharge teaching for a client who has a splenectomy. Which statement does the nurse include in this client's teaching plan? a. "Avoid crowds and people who are sick." b. "Do not eat raw fruits or vegetables." c. "Avoid environmental allergens." d. "Do not play contact sports."

A The spleen is the major site of B-lymphocyte maturation and antibody production. Those who undergo splenectomies for any reason have a decreased antibody-mediated immune response and are particularly susceptible to viral infections. Eating raw fruits and vegetables places the client at risk for bacterial infections. The body responds to environmental allergens with an unspecific inflammatory process. The client is not at risk for bleeding or injury due to contact sports. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Teaching/Learning

The school nurse is informed that a child with human immunodeficiency virus (HIV) will be attending school soon. Which is an important nursing intervention? a. Carefully follow universal precautions. b. Determine how the child became infected. c. Inform the parents of the other children. d. Reassure other children that they will not become infected.

A Universal precautions are necessary to prevent further transmission of the disease. It is not the role of the nurse to determine how the child became infected. Informing the parents of other children and reassuring other children that they will not become infected is a violation of the child's right to privacy. PTS: 1 DIF: Cognitive Level: Application REF: 1387 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

The nurse is assessing a client whose warfarin (Coumadin) therapy was discontinued 3 weeks ago. Which laboratory test result indicates that the client's warfarin therapy is no longer therapeutic? a. International normalized ratio (INR), 0.9 b. Reticulocyte count, 1% c. Serum ferritin level, 350 ng/mL d. Total white blood cell (WBC) count, 9000/mm3

A Warfarin therapy increases the INR. Normal INR ranges between 0.7 and 1.8. Therapeutic warfarin levels, depending on the indication of the disorder, should maintain the INR between 1.5 and 3.0. When the effects of warfarin are no longer present, the INR returns to normal levels. Warfarin therapy does not affect white blood cell count, serum ferritin level, or reticulocyte count. DIF: Cognitive Level: Comprehension/Understanding REF: p. 866 TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Laboratory Values) MSC: Integrated Process: Nursing Process (Evaluation)

The nurse is caring for a client who has autoimmune thrombocytopenic purpura. Which intervention does the nurse implement for this client? a. Avoid intramuscular injections. b. Administer prescribed anticoagulants. c. Infuse intravenous normal saline. d. Monitor for an increase in temperature.

A With autoimmune thrombocytopenic purpura, the total number of circulating platelets is greatly reduced. As a result of the decreased platelet count, the client is at great risk for bleeding, and intramuscular injections should be avoided. Anticoagulants should not be given. A low platelet count is not treated with saline, and thrombocytopenia will not cause a change in body temperature. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Implementation)

B PTS: 1 DIF: Cognitive Level: Application REF: 1372 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity NOT: If a blood transfusion reaction of any type is suspected, stop the transfusion, take vital signs, maintain a patent IV line with normal saline and new tubing, notify the practitioner, and do not restart the transfusion until the childÆs condition has been medically evaluated. 53.

A PTS: 1 DIF: Cognitive Level: Application REF: 1372 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity NOT: If a blood transfusion reaction of any type is suspected, stop the transfusion, take vital signs, maintain a patent IV line with normal saline and new tubing, notify the practitioner, and do not restart the transfusion until the childÆs condition has been medically evaluated. 54.

The nurse is teaching a client who is receiving sodium warfarin (Coumadin). Which topics does the nurse include in the teaching plan? (Select all that apply.) a. Foods high in vitamin K b. Using acetaminophen (Tylenol) for minor pain c. Daily exercise and weight management d. Use of a safety razor and soft toothbrush e. Blood testing regimen

A, B, D, E The client on warfarin will need to know which foods are high in vitamin K because vitamin K intake must be consistent to avoid interfering with the anticoagulant properties of warfarin. Clients should not take aspirin or NSAIDs for minor pain owing to their anticoagulant properties. Clients must use safety razors and soft toothbrushes to avoid bleeding episodes. The client on warfarin needs regular blood tests for prothrombin time (PT) and international normalized ratio (INR). Daily exercise and weight management are not specifically important to this client. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse Effects/Contraindications/Side Effects/Interactions) MSC: Integrated Process: Teaching/Learning

The nurse is preparing to give oral care to a school-age child with mucositis secondary to chemotherapy administered to treat leukemia. Which preparations should the nurse use for oral care on this child (Select all that apply)? a. Chlorhexidine gluconate (Peridex) b. Lemon glycerin swabs c. Antifungal troches (lozenges) d. Lip balm (Aquaphor) e. Hydrogen peroxide

A, C, D Preparations that may be used to prevent or treat mucositis include chlorhexidine gluconate (Peridex) because of its dual effectiveness against candidal and bacterial infections, antifungal troches (lozenges) or mouthwash, and lip balm (e.g., Aquaphor) to keep the lips moist. Agents that should not be used include lemon glycerin swabs (irritate eroded tissue and can decay teeth), hydrogen peroxide (delays healing by breaking down protein), and milk of magnesia (dries mucosa). PTS: 1 DIF: Cognitive Level: Application REF: 1383 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation COMPLETION

The nurse is monitoring a client with liver failure. Which assessments does the nurse perform when monitoring for bleeding in this client? (Select all that apply.) a. Gums b. Lung sounds c. Urine d. Stool e. Hair

A, C, D The liver is the site for production of clotting factors. Without these factors, the client is at risk for bleeding. Common areas of bleeding include the gums and mucous membranes, bladder, and gastrointestinal tract. Lung sounds and hair are part of the assessment but are not essential in the presence of liver failure and hematologic abnormalities. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Nursing Process (Assessment)

Which home care instructions should the nurse provide to the parents of a child with acquired immunodeficiency syndrome (AIDS) (Select all that apply)? a. Give supplemental vitamins as prescribed. b. Yearly influenza vaccination should be avoided. c. Administer trimethoprim-sulfamethoxazole (Bactrim) as prescribed. d. Notify the physician if the child develops a cough or congestion. e. Missed doses of antiretroviral medication do not need to be recorded.

A, C, D The parents should be taught that supplemental vitamins will be prescribed to aid in nutritional status. Bactrim is administered to prevent the opportunistic infection of Pneumocystis jiroveci pneumonia. The physician should be notified if the child with AIDS develops a cough and congestion. The yearly influenza vaccination is recommended, and any missed doses of antiretroviral medication need to be recorded and reported. PTS: 1 DIF: Cognitive Level: Application REF: 1387 OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

A toddler with leukemia is on intravenous chemotherapy treatments. The toddler's lab results are white blood cell count (WBC): 1000; neutrophils: 7%; nonsegmented neutrophils (bands): 7%. What is this child's absolute neutrophil count (ANC)? _____ Record your answer as a whole number.

ANS: 140 To calculate an ANC for a WBC = 1000, neutrophils = 7%, and nonsegmented neutrophils (bands) = 7%, the steps are: Step 1: 7% + 7% = 14%. Step 2: 0.14 ´ 1000 = 140 ANC. PTS: 1 DIF: Cognitive Level: Analysis REF: 1381 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

A young boy will receive a bone marrow transplant (BMT). This is possible because one of his older siblings is a histocompatible donor. This type of BMT is termed: a. Syngeneic. c. Monoclonal. b. Allogeneic. d. Autologous.

B Allogeneic transplants are from another individual. Because he and his sibling are histocompatible, the bone marrow transplantation can be done. Syngeneic marrow is from an identical twin. There is no such thing as a monoclonal bone marrow transplant. Autologous refers to the individual's own marrow. PTS: 1 DIF: Cognitive Level: Analysis REF: 1389 OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

A young child with human immunodeficiency virus is receiving several antiretroviral drugs. The purpose of these drugs is to: a. Cure the disease. b. Delay disease progression. c. Prevent spread of disease. d. Treat Pneumocystis jiroveci pneumonia.

B Although not a cure, these antiviral drugs can suppress viral replication, preventing further deterioration of the immune system, and delay disease progression. At this time cure is not possible. These drugs do not prevent the spread of the disease. Pneumocystis jiroveci prophylaxis is accomplished with antibiotics. PTS: 1 DIF: Cognitive Level: Comprehension REF: 1386 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

The nurse is completing the preoperative checklist on a client. The client states, "I take an aspirin every day for my heart." How does the nurse respond? a. "I will call your doctor and request a prescription for pain medication." b. "I need to call the surgeon and reschedule your surgery." c. "I'll give you the prescribed Tylenol to minimize any headache before surgery." d. "I need to administer vitamin K to prevent bleeding during the procedure."

B Aspirin and other salicylates interfere with platelet aggregation—the first step in the blood-clotting cascade—and decrease the ability of the blood to form a platelet plug. These effects last for longer than 1 week after just one dose of aspirin. The client may need to have the surgery rescheduled. Vitamin K, prescribed pain medication, and Tylenol cannot reduce the anticlotting effects of aspirin. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse Effects/Contraindications/Interactions/Side Effects) MSC: Integrated Process: Nursing Process (Implementation)

Which risk factor does the nurse assess for to determine a client's cause of anemia? a. Antacid therapy b. Chronic alcoholism c. Congestive heart failure d. Type 2 diabetes

B Chronic alcohol abuse is strongly associated with malnutrition of many dietary essentials, including iron, folic acid, and vitamin B12. Antacids, heart failure, and diabetes affect nutrition at varying levels, but anemia is most closely related to the malnutrition seen with chronic alcohol abuse. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Nursing Process (Assessment)

The nurse is providing health promotion education to a client who has a family history of leukemia. Which factor does the nurse teach this client to avoid? a. Alcohol consumption b. Exposure to ionizing radiation c. High-cholesterol diet d. Smoking cigarettes

B Many genetic and environmental factors are involved in the development of leukemia. Exposure to radiation increases the risk for development of leukemia, particularly acute myelogenous leukemia (AML). Although alcohol consumption, high-cholesterol diet, and smoking are not healthy behaviors, they do not increase the risk for leukemia. DIF: Cognitive Level: Comprehension/Understanding REF: p. 880 TOP: Client Needs Category: Health Promotion and Maintenance (Health Promotion/Disease Prevention) MSC: Integrated Process: Teaching/Learning

The nurse is teaching a client who is being discharged to home after bone marrow transplantation. The client asks, "Why is it so important to protect myself from injury?" How does the nurse respond? a. "Injuries put you at high risk for infection." b. "Platelet recovery is slow, which makes you at risk for bleeding." c. "Severe trauma could result in rejection of the transplant." d. "The medications you are taking will make you bruise easily."

B Platelets recover more slowly than other blood cells after bone marrow transplantation. Thus the client is still thrombocytopenic at home and remains at risk for excessive bleeding after any trauma or injury. Injured tissue makes a client at risk for infection, and trauma could result in injury to the transplant (but not rejection). However, these are not the best responses to give the client. A steroid regimen may make a client more at risk for bruising, but the most accurate response pertains to platelet recovery. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Principles of Teaching/Learning) MSC: Integrated Process: Teaching/Learning

A condition in which the normal adult hemoglobin is partly or completely replaced by abnormal hemoglobin is: a. Aplastic anemia. c. Thalassemia major. b. Sickle cell anemia. d. Iron deficiency anemia.

B Sickle cell anemia is one of a group of diseases collectively called hemoglobinopathies, in which normal adult hemoglobin is replaced by abnormal hemoglobin. Aplastic anemia is a lack of cellular elements being produced. Hemophilia refers to a group of bleeding disorders in which there is deficiency of one of the factors necessary for coagulation. Iron deficiency anemia affects size and depth of color of hemoglobin and does not involve abnormal hemoglobin. PTS: 1 DIF: Cognitive Level: Comprehension REF: 1367 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

The nurse is caring for a client who is receiving heparin therapy. How does the nurse evaluate the therapeutic effect of the therapy? a. Evaluate platelets. b. Monitor the partial thromboplastin time (PTT). c. Assess bleeding time. d. Monitor fibrin degradation products.

B The PTT assesses the intrinsic clotting cascade. Heparin therapy is monitored by the PTT. Platelets are monitored by the platelet count laboratory value, bleeding time evaluates vascular and platelet activity during hemostasis, and fibrin degradation products help assess for fibrinolysis. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Laboratory Values) MSC: Integrated Process: Nursing Process (Evaluation)

Which immunization should be given with caution to children infected with human immunodeficiency virus? a. Influenza c. Pneumococcus b. Varicella d. Inactivated poliovirus

B The children should be carefully evaluated before giving live viral vaccines such as varicella, measles, mumps, and rubella. The child must be immunocompetent and not have contact with other severely immunocompromised individuals. Influenza, pneumococcus, and inactivated poliovirus are not live vaccines. PTS: 1 DIF: Cognitive Level: Application REF: 1387 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

A boy with leukemia screams whenever he needs to be turned or moved. The most probable cause of this pain is: a. Edema. c. Petechial hemorrhages. b. Bone involvement. d. Changes within the muscles.

B The invasion of the bone marrow with leukemic cells gradually causes a weakening of the bone and a tendency toward fractures. As leukemic cells invade the periosteum, increasing pressure causes severe pain. Edema, petechial hemorrhages, and muscular changes would not cause severe pain. PTS: 1 DIF: Cognitive Level: Analysis REF: 1380 OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

A school-age child is admitted in vaso-occlusive sickle cell crisis. The child's care should include: a. Correction of acidosis. b. Adequate hydration and pain management. c. Pain management and administration of heparin. d. Adequate oxygenation and replacement of factor VIII.

B The management of crises includes adequate hydration, minimizing energy expenditures, pain management, electrolyte replacement, and blood component therapy if indicated. The acidosis will be corrected as the crisis is treated. Heparin and factor VIII are not indicated in the treatment of vaso-occlusive sickle cell crisis. Oxygen may prevent further sickling, but it is not effective in reversing sickling because it cannot reach the clogged blood vessels. PTS: 1 DIF: Cognitive Level: Analysis REF: 1369 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

The nurse is teaching a client who has undergone a bone marrow biopsy. Which instruction does the nurse give the client? a. "Wear protective gear when playing contact sports." b. "Monitor the biopsy site for bruising." c. "Remain in bed for at least 12 hours." d. "Use a heating pad for pain at the biopsy site."

B The most important instruction is to have the client monitor the area for external or internal bleeding. Activities such as contact sports should be avoided, and an ice pack can be used to limit bruising. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Diagnostic Tests/Treatments/Procedures) MSC: Integrated Process: Teaching/Learning

The nurse is planning care for a client who has a platelet count of 30,000/mm3. Which intervention does the nurse include in this client's plan of care? a. Oxygen by nasal cannula b. Bleeding Precautions c. Isolation Precautions d. Vital signs every 4 hours

B The normal platelet count ranges between 150,000 and 400,000/mm3. This client is at extreme risk for bleeding. Although it is necessary to notify the provider, the nurse would first protect the client by instituting Bleeding Precautions. The other interventions are not related to the low platelet count. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Laboratory Values) MSC: Integrated Process: Nursing Process (Analysis)

The parents of a child hospitalized with sickle cell anemia tell the nurse that they are concerned about narcotic analgesics causing addiction. The nurse should explain that narcotic analgesics: a. Are often ordered but not usually needed. b. Rarely cause addiction because they are medically indicated. c. Are given as a last resort because of the threat of addiction. d. Are used only if other measures such as ice packs are ineffective.

B The pain of sickle cell anemia is best treated by a multidisciplinary approach. Mild-to-moderate pain can be controlled by ibuprofen and acetaminophen. When narcotics are indicated, they are titrated to effect and given around the clock. Patient-controlled analgesia reinforces the patient's role and responsibility in managing the pain and provides flexibility in dealing with pain. Few if any patients who receive opioids for severe pain become behaviorally addicted to the drug. Narcotics are often used because of the severe nature of the pain of vaso-occlusive crisis. Ice is contraindicated because of its vasoconstrictive effects. PTS: 1 DIF: Cognitive Level: Application REF: 1371 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

The nurse helps to ambulate a client who has anemia. Which clinical manifestation indicates that the client is not tolerating the activity? a. Blood pressure of 120/90 mm Hg b. Heart rate of 110 beats/min c. Pulse oximetry reading of 95% d. Respiratory rate of 20 breaths/min

B The red blood cells contain thousands of hemoglobin molecules. The most important feature of hemoglobin is its ability to combine loosely with oxygen. A low hemoglobin level can cause decreased oxygenation to the tissues, thus causing a compensatory increase in heart rate. The other options are close to normal range and are not indicative of not tolerating this activity. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Nursing Process (Analysis)

The nurse is planning care for a client who has leukemia. Which intervention does the nurse include in the plan of care to prevent fatigue? a. Arrange for a family member to stay with the client. b. Plan care for times when the client has the most energy. c. Schedule for daily physicals and occupational therapy. d. Plan all activities to occur in the morning to allow for afternoon naps.

B With leukemia, energy management is needed to help conserve the client's energy. Care should be scheduled when the client has the most energy. This client may not have the most energy in the morning. If the benefit of an activity such as physical or occupational therapy is less than its worsening of fatigue, it may be postponed. The nurse should limit the number of visitors and interruptions by visitors, as appropriate. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Basic Care and Comfort—Rest and Sleep) MSC: Integrated Process: Nursing Process (Implementation)

The nurse is planning care for a school-age child admitted to the hospital with hemophilia. Which interventions should the nurse plan to implement for this child (Select all that apply)? a. Fingersticks for blood work instead of venipunctures b. Avoidance of intramuscular (IM) injections c. Acetaminophen (Tylenol) for mild pain control d. Soft toothbrush for dental hygiene e. Administration of packed red blood cells

B, C, D Nurses should take special precautions when caring for a child with hemophilia to prevent the use of procedures that may cause bleeding, such as IM injections. The subcutaneous route is substituted for IM injections whenever possible. Venipunctures for blood samples are usually preferred for these children. There is usually less bleeding after the venipuncture than after finger or heel punctures. Neither aspirin nor any aspirin-containing compound should be used. Acetaminophen is a suitable aspirin substitute, especially for controlling mild pain. A soft toothbrush is recommended for dental hygiene to prevent bleeding from the gums. Packed red blood cells are not administered. The primary therapy for hemophilia is replacement of the missing clotting factor. The products available are factor VIII concentrates. PTS: 1 DIF: Cognitive Level: Application REF: 1377 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

The nurse is caring for a child with aplastic anemia. Which nursing diagnoses are appropriate (Select all that apply)? a. Acute Pain related to vaso-occlusion b. Risk for Infection related to inadequate secondary defenses or immunosuppression c. Ineffective Protection related to thrombocytopenia d. Ineffective Tissue Perfusion related to anemia e. Ineffective Protection related to abnormal clotting

B, C, D These are appropriate nursing diagnosis for the nurse planning care for a child with aplastic anemia. Aplastic anemia is a condition in which the bone marrow ceases production of the cells it normally manufactures, resulting in pancytopenia. The child will have varying degrees of the disease depending on how low the values are for absolute neutrophil count (affecting the body's response to infection), platelet count (putting the child at risk for bleeding), and absolute reticulocyte count (causing the child to have anemia). Acute Pain related to vaso-occlusion is an appropriate nursing diagnosis for sickle cell anemia for the child in vaso-occlusive crisis, but it is not applicable to a child with aplastic anemia. Ineffective Protection related to abnormal clotting is an appropriate diagnosis for a child with hemophilia. PTS: 1 DIF: Cognitive Level: Application REF: 1374 OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

Which should the nurse teach about prevention of sickle cell crises to parents of a preschool child with sickle cell disease (Select all that apply)? a. Limit fluids at bedtime. b. Notify the health care provider if a fever of 38.5° C (101.3° F) or greater occurs. c. Give penicillin as prescribed. d. Use ice packs to decrease the discomfort of vaso-occlusive pain in the legs. e. Notify the health care provider if your child begins to develop symptoms of a cold.

B, C, E The most important issues to teach the family of a child with sickle cell anemia are to (1) seek early intervention for problems, such as a fever of 38.5° C (101.3° F) or greater; (2) give penicillin as ordered; (3) recognize signs and symptoms of splenic sequestration, as well as respiratory problems that can lead to hypoxia; and (4) treat the child normally. The nurse emphasizes the importance of adequate hydration to prevent sickling and to delay the adhesion-stasis-thrombosis-ischemia cycle. It is not sufficient to advise parents to "force fluids" or "encourage drinking." They need specific instructions on how many daily glasses or bottles of fluid are required. Many foods are also a source of fluid, particularly soups, flavored ice pops, ice cream, sherbet, gelatin, and puddings. Increased fluids combined with impaired kidney function result in the problem of enuresis. Parents who are unaware of this fact frequently use the usual measures to discourage bedwetting, such as limiting fluids at night. Enuresis is treated as a complication of the disease, such as joint pain or some other symptom, to alleviate parental pressure on the child. Ice should not be used during a vaso-occlusive pain crisis because it vasoconstricts and impairs circulation even more. PTS: 1 DIF: Cognitive Level: Application REF: 1371 OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

Parents of a school-age child with hemophilia ask the nurse, "Which sports are recommended for children with hemophilia?" Which sports should the nurse recommend (Select all that apply)? a. Soccer b. Swimming c. Basketball d. Golf e. Bowling

B, D, E Because almost all persons with hemophilia are boys, the physical limitations in regard to active sports may be a difficult adjustment, and activity restrictions must be tempered with sensitivity to the child's emotional and physical needs. Use of protective equipment, such as padding and helmets, is particularly important, and noncontact sports, especially swimming, walking, jogging, tennis, golf, fishing, and bowling, are encouraged. Contact sports such as soccer and basketball are not recommended. PTS: 1 DIF: Cognitive Level: Application REF: 1377 OBJ: Nursing Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance

The nurse is preparing a client for a bone biopsy and aspiration. The client asks, "Will this be painful?" How does the nurse respond? a. "The procedure is always done under general anesthesia." b. "The biopsy lasts for only 2 minutes." c. "There is a chance that you may have pain." d. "You can relieve pain with guided imagery."

C Clients may have pain during this procedure. The type and amount of anesthesia or sedation depend on the physician's preference, the client's preference, and previous experience with bone marrow aspiration. The procedure takes from 5 to 15 minutes. Guided imagery can relieve pain but works well only with some clients. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Diagnostic Tests/Treatments/Procedures) MSC: Integrated Process: Nursing Process (Implementation)

The nurse is transfusing red blood cells to a client who has sickle cell disease. Which laboratory result indicates that the nurse should discontinue the transfusion? a. Hematocrit level (Hct), 32% b. Hemoglobin S, 88% c. Serum iron level, 300 mcg/dL d. Total white blood cell count, 12,000/mm3

C Clients with sickle cell disease are anemic but are not iron deficient. Transfusions are prescribed cautiously to prevent iron overload with repeated transfusions. Iron overload damages the heart, liver, and endocrine organs. Monitor the client's serum ferritin, serum iron (Fe), and total iron-binding capacity (TIBC) during transfusion therapy. The other laboratory values should not result in discontinuation of the transfusion by the nurse. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Blood and Blood Products) MSC: Integrated Process: Nursing Process (Evaluation)

The nurse is assessing a client's susceptibility to rejecting a transplanted kidney. Which result does the nurse recognize as increasing the client's chances of rejection? a. Decreased T-lymphocyte helper b. Decreased white blood cell count c. Increased cytotoxic-cytolytic T cell d. Increased neutrophil count

C Cytotoxic-cytolytic T cells function to attack and destroy non-self-cells, specifically virally infected cells and cells from transplanted grafts and organs. A high level of these cells would increase the chances of rejection. Decreased white blood cells would indicate immune suppression. Neutrophils are increased during an infection. DIF: Cognitive Level: Knowledge/Remembering REF: Table 41-1, p. 857 TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Laboratory Values) MSC: Integrated Process: Nursing Process (Analysis)

Children receiving long-term systemic corticosteroid therapy are most at risk for: a. Hypotension. b. Dilation of blood vessels in the cheeks. c. Growth delays. d. Decreased appetite and weight loss.

C Growth delay is associated with long-term steroid use. Hypertension is a clinical manifestation of long-term systemic steroid administration. Dilation of blood vessels in the cheeks is associated with an excess of topically administered steroids. Increased appetite and weight gain are clinical manifestations of excess systemic corticosteroid therapy. PTS: 1 DIF: Cognitive Level: Comprehension REF: 1375 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

Which statement best describes b-thalassemia major (Cooley's anemia)? a. All formed elements of the blood are depressed. b. Inadequate numbers of red blood cells are present. c. Increased incidence occurs in families of Mediterranean extraction. d. Increased incidence occurs in persons of West African descent.

C Individuals who live near the Mediterranean Sea and their descendants have the highest incidence of thalassemia. An overproduction of red cells occurs. Although numerous, the red cells are relatively unstable. Sickle cell disease is common in blacks of West African descent. PTS: 1 DIF: Cognitive Level: Comprehension REF: 1373 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

Iron dextran is ordered for a young child with severe iron deficiency anemia. Nursing considerations include: a. Administering with meals. b. Administering between meals. c. Injecting deeply into a large muscle. d. Massaging injection site for 5 minutes after administration of drug.

C Iron dextran is a parenteral form of iron. When administered intramuscularly, it must be injected into a large muscle using the Z-track method. Iron dextran is for intramuscular or intravenous administration; it is not taken orally. The site should not be massaged to prevent leakage, potential irritation, and staining of the skin. PTS: 1 DIF: Cognitive Level: Comprehension REF: 1366 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

A female client is admitted with the medical diagnosis of anemia. The nurse assesses for which potential cause? a. Diet high in meat and fat b. Daily intake of aspirin c. Heavy menses d. Smoking history

C Iron levels can be low because intake of iron is too low, or because loss of iron through bleeding is excessive. A premenopausal woman may be having unusually heavy menses sufficient to cause excessive loss of blood and iron. Smoking and aspirin do not cause iron deficiency. A diet high in meat provides iron. DIF: Cognitive Level: Comprehension/Understanding REF: p. 861 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Nursing Process (Assessment)

The nurse observes yellow-tinged sclera in a client with dark skin. Based on this assessment finding, what does the nurse do next? a. Assess the client's pulses. b. Examine the soles of the client's feet. c. Inspect the client's hard palate. d. Auscultate the client's lung sounds.

C Jaundice can best be observed in clients with dark skin by inspecting the oral mucosa, especially the hard palate, for yellow discoloration. Because sclera may have subconjunctival fat deposits that show a yellow hue, and because foot calluses may appear yellow, neither of these areas should be used to assess for jaundice. The client's pulse and lung sounds have no correlation with an assessment of jaundice. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening) MSC: Integrated Process: Nursing Process (Assessment)

The nurse is caring for a client during a sickle cell crisis. Which intervention does the nurse implement for the client? a. Administer acetaminophen (Tylenol) as needed. b. Administer intravenous fluids to keep the vein open. c. Keep the room temperature at 80° F. d. Transfuse red blood cells (RBCs).

C Keeping the room warm can be used as a complementary therapy to relieve the pain of a sickle cell crisis. Cold can act as a factor in causing a crisis. Analgesia is an important part of relieving pain. The analgesia routine should be followed on an around-the-clock basis and should consist of IV opioids for severe pain, followed by treatment with oral doses of opioids or NSAIDs. High-volume intravenous fluids should be administered to minimize pain during a sickle cell crisis. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC: Integrated Process: Nursing Process (Planning)

What is most descriptive of the pathophysiology of leukemia? a. Increased blood viscosity occurs. b. Thrombocytopenia (excessive destruction of platelets) occurs. c. Unrestricted proliferation of immature white blood cells (WBCs) occurs. d. The first stage of the coagulation process is abnormally stimulated.

C Leukemia is a group of malignant disorders of the bone marrow and the lymphatic system. It is defined as an unrestricted proliferation of immature WBCs in the blood-forming tissues of the body. Increased blood viscosity may occur secondary to the increased number of WBCs. Thrombocytopenia may occur secondary to the overproduction of WBCs in the bone marrow. The coagulation process is unaffected by leukemia. PTS: 1 DIF: Cognitive Level: Comprehension REF: 1380 OBJ: Nursing Process: Diagnosis MSC: Client Needs: Physiologic Integrity

The nurse is teaching a client with vitamin B12 deficiency anemia to eat a diet high in this vitamin. Which meal selected by the client indicates that the client correctly understands the prescribed diet? a. Baked chicken breast, mashed potatoes, glass of milk b. Eggplant parmesan, cottage cheese, iced tea c. Fried liver and onions, orange juice, spinach salad d. Fettuccine alfredo, green salad, glass of red wine

C Organ meats and leafy green vegetables have the highest content of vitamin B12. The other selections do not indicate understanding of the teaching on diet. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care) MSC: Integrated Process: Nursing Process (Evaluation)

Several blood tests are ordered for a preschool child with severe anemia. She is crying and upset because she remembers the venipuncture done at the clinic 2 days ago. The nurse should explain that: a. Venipuncture discomfort is very brief. b. Only one venipuncture will be needed. c. Topical application of local anesthetic can eliminate venipuncture pain. d. Most blood tests on children require only a finger puncture because a small amount of blood is needed.

C Preschool children are very concerned about both pain and the loss of blood. When preparing the child for venipuncture, a topical anesthetic will be used to eliminate any pain. This is a very traumatic experience for preschool children. They are concerned about their bodily integrity. A local anesthetic should be used, and a bandage should be applied to maintain bodily integrity. A promise that only one venipuncture will be needed should not be made in case multiple attempts are required. Both finger punctures and venipunctures are traumatic for children. Both require preparation. PTS: 1 DIF: Cognitive Level: Application REF: 1365 OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

The nurse is teaching a client who is being discharged after stem cell transplantation. Which instruction does the nurse include in this client's discharge teaching? a. Eat a diet high in fruits and vegetables. b. Ask your provider to administer a rubella vaccination. c. Wash your hands frequently. d. Participate in physical therapy every day.

C Protecting the client from infection at home is just as important as it was during hospitalization for a client who has had stem cell transplantation. Hand hygiene is the best protection against infection. Salads, raw fruits, and live vaccinations (such as rubella) are contraindicated in a client who has a risk for infection. Energy management is important; therefore activities such as physical therapy may need to be postponed. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Health Promotion/Disease Prevention) MSC: Integrated Process: Teaching/Learning

The nurse is caring for a client who is receiving chemotherapy for cancer. Which intervention does the nurse implement for this client? a. Assess the client's fibrinogen level. b. Administer the prescribed iron. c. Maintain strict Standard Precautions. d. Monitor the client's pulse oximetry.

C The client who is receiving chemotherapy drugs that suppress the bone marrow will be at risk for a decreased white blood cell (WBC) count and infection. The nurse will be most therapeutic by adhering to Standard Precautions to prevent infection, such as handwashing. The nurse will not expect the fibrinogen level to be affected by this therapy. Iron is not typically administered with chemotherapy because this is bone marrow suppression, so the administration of epoetin (Epogen) or filgrastim (Neupogen) is most effective. Monitoring the pulse oximetry is part of routine care and probably would not need to be done continuously. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Diagnostic Tests/Treatments/Procedures) MSC: Integrated Process: Nursing Process (Implementation)

Which statement most accurately describes the pathologic changes of sickle cell anemia? a. Sickle-shaped cells carry excess oxygen. b. Sickle-shaped cells decrease blood viscosity. c. Increased red blood cell destruction occurs. d. Decreased red blood cell destruction occurs.

C The clinical features of sickle cell anemia are primarily the result of increased red blood cell destruction and obstruction caused by the sickle-shaped red blood cells. Sickled red cells have decreased oxygen-carrying capacity and transform into the sickle shape in conditions of low oxygen tension. When the sickle cells change shape, they increase the viscosity in the area where they are involved in the microcirculation. PTS: 1 DIF: Cognitive Level: Application REF: 1364 OBJ: Nursing Process: Diagnosis MSC: Client Needs: Physiologic Integrity

As related to inherited disorders, which statement is descriptive of most cases of hemophilia? a. Autosomal dominant disorder causing deficiency in a factor involved in the blood-clotting reaction b. X-linked recessive inherited disorder causing deficiency of platelets and prolonged bleeding c. X-linked recessive inherited disorder in which a blood-clotting factor is deficient d. Y-linked recessive inherited disorder in which the red blood cells become moon shaped

C The inheritance pattern in 80% of all of the cases of hemophilia is X-linked recessive. The two most common forms of the disorder are factor VIII deficiency (hemophilia A or classic hemophilia), and factor IX deficiency (hemophilia B or Christmas disease). The disorder involves coagulation factors, not platelets. The disorder does not involve red cells or the Y chromosome. PTS: 1 DIF: Cognitive Level: Comprehension REF: 1375 OBJ: Nursing Process: Diagnosis MSC: Client Needs: Physiologic Integrity

The nurse is caring for four clients with hematologic-type problems. Which client does the nurse prioritize to see first? a. 18-year-old female with decreased protein levels b. 36-year-old male with increased lymphocytes c. 60-year-old female with decreased erythropoietin d. 82-year-old male with an increased thromboxane level

C The kidney releases more erythropoietin when tissue oxygenation levels are low. This growth factor then stimulates the bone marrow to increase red blood cell (RBC) production, which improves tissue oxygenation and prevents hypoxia. Hypoxia causes the body to increase its respiratory rate to overcome decreased oxygenation of the tissues. All these clients are important, but the woman with decreased erythropoietin takes priority because of her risk for hypoxia. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Analysis)

The nurse is performing an admission assessment on a 46-year-old client, who states, "I have been drinking a 12-pack of beer every day for the past 20 years." Which laboratory abnormality does the nurse correlate with this history? a. Decreased white blood cell (WBC) count b. Decreased bleeding time c. Elevated prothrombin time (PT) d. Elevated red blood cell (RBC) count

C The liver is the site for production of prothrombin and most of the blood-clotting factors. If the liver is damaged because of chronic alcoholism, it is unable to produce these clotting factors. Therefore, the PT could become elevated, which would reflect deficiency of some clotting factors. The WBC would not be elevated in this situation because no infection is present. Bleeding time would likely increase. The client's RBC count most likely would not be affected unless the client was bleeding, in which case it would decrease. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Analysis)

A school-age child with leukemia experienced severe nausea and vomiting when receiving chemotherapy for the first time. The most appropriate nursing action to prevent or minimize these reactions with subsequent treatments is to: a. Encourage drinking large amounts of favorite fluids. b. Encourage child to take nothing by mouth (remain NPO) until nausea and vomiting subside. c. Administer an antiemetic before chemotherapy begins. d. Administer an antiemetic as soon as child has nausea.

C The most beneficial regimen to minimize nausea and vomiting associated with chemotherapy is to administer the antiemetic before the chemotherapy is begun. The goal is to prevent anticipatory symptoms. Drinking fluids will add to the discomfort of the nausea and vomiting. Encouraging the child to remain NPO will help with this episode, but the child will have the discomfort and be at risk for dehydration. Administering an antiemetic after the child has nausea does not avoid anticipatory nausea. PTS: 1 DIF: Cognitive Level: Application REF: 1382 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

The parents of a child with cancer tell the nurse that a bone marrow transplant (BMT) may be necessary. What should the nurse recognize as important when discussing this with the family? a. BMT should be done at time of diagnosis. b. Parents and siblings of child have a 25% chance of being a suitable donor. c. Finding a suitable donor involves matching antigens from the human leukocyte antigen (HLA) system. d. If BMT fails, chemotherapy or radiotherapy must be continued.

C The most successful BMTs come from suitable HLA-matched donors. The timing of a BMT depends on the disease process involved. It usually follows intensive high-dose chemotherapy and/or radiation therapy. Usually parents only share approximately 50% of the genetic material with their children. A one-in-four chance exists that two siblings will have two identical haplotypes and will be identically matched at the HLA loci. Discussing the continuation of chemotherapy or radiotherapy is not appropriate when planning the BMT. That decision will be made later. PTS: 1 DIF: Cognitive Level: Analysis REF: 1374 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

When teaching the mother of a 9-month-old infant about administering liquid iron preparations, the nurse should include that: a. They should be given with meals. b. They should be stopped immediately if nausea and vomiting occur. c. Adequate dosage will turn the stools a tarry green color. d. Preparation should be allowed to mix with saliva and bathe the teeth before swallowing.

C The nurse should prepare the mother for the anticipated change in the child's stools. If the iron dose is adequate, the stools will become a tarry green color. The lack of the color change may indicate insufficient iron. The iron should be given in two divided doses between meals, when the presence of free hydrochloric acid is greatest. Iron is absorbed best in an acidic environment. Vomiting and diarrhea may occur with iron administration. If these occur, the iron should be given with meals, and the dosage reduced and gradually increased as the child develops tolerance. Liquid preparations of iron stain the teeth. They should be administered through a straw, and the mouth rinsed after administration. PTS: 1 DIF: Cognitive Level: Analysis REF: 1366 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

The nurse prepares to administer a blood transfusion to a client. Which means of identification does the nurse use to ensure that the blood is administered to the correct client? a. Ask the client whether his or her name is the one on the blood product tag. b. Ask the client's spouse if the client is supposed to have a transfusion. c. Compare the name and ID number on the blood product tag with the name and ID number on the client's ID band. d. Compare the unit and room number of the client with the unit and room number listed on the blood product tag.

C The safest way to determine whether the blood product is to be given to the correct client is to check the client's hospital ID band and compare the information on it with that on the blood product tag. The room and unit numbers are never considered as means of positive identification. Asking the client who he or she is might result in an error if the client is confused. Similarly, a visitor cannot be assumed to know whether this is the client to have the blood transfusion. DIF: Cognitive Level: Comprehension/Understanding REF: p. 898 TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Error Prevention) MSC: Integrated Process: Nursing Process (Implementation)

A client who has a chronic vitamin B12 deficiency is admitted to the hospital. When obtaining the client's health history, which priority question does the nurse ask this client? a. "Are you having any pain?" b. "Are you having blood in your stools?" c. "Do you notice any changes in your memory?" d. "Do you bruise easily?"

C Vitamin B12 deficiency impairs cerebral, olfactory, spinal cord, and peripheral nerve function. Severe chronic deficiency may cause permanent neurologic degeneration. The other options are not symptoms of vitamin B12deficiency. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening) MSC: Integrated Process: Nursing Process (Assessment)

D PTS: 1 DIF: Cognitive Level: Application REF: 1372 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity NOT: If a blood transfusion reaction of any type is suspected, stop the transfusion, take vital signs, maintain a patent IV line with normal saline and new tubing, notify the practitioner, and do not restart the transfusion until the childÆs condition has been medically evaluated. 55.

C PTS: 1 DIF: Cognitive Level: Application REF: 1372 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity NOT: If a blood transfusion reaction of any type is suspected, stop the transfusion, take vital signs, maintain a patent IV line with normal saline and new tubing, notify the practitioner, and do not restart the transfusion until the childÆs condition has been medically evaluated.

The nurse is teaching a client who has sickle cell disease and was admitted for splenomegaly and abdominal pain. Which instruction does the nurse include in the client's discharge teaching? a. "Avoid drinking large amounts of fluids." b. "Eat six small meals daily instead of large meals." c. "Engage in aerobic exercise 3 days a week." d. "Receive a yearly influenza vaccination."

D Abdominal pain and a palpable spleen could indicate blood trapping in the spleen. Over time, the spleen may become nonfunctional, which makes the client at risk for infection. An annual influenza vaccination helps prevent infection. A client with sickle cell disease should not become dehydrated or engage in strenuous physical activity because this could precipitate a crisis. Eating smaller meals has no impact on sickle cell disease or infection. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Health Promotion/Disease Prevention) MSC: Integrated Process: Teaching/Learning

The nurse is assessing a client with liver failure. Which assessment is the highest priority for this client? a. Auscultation for bowel sounds b. Assessing for deep vein thrombosis c. Monitoring of blood pressure hourly d. Assessing for signs of bleeding

D All these options are important in assessment of the client, but the most important action is assessment for signs of bleeding. The liver is the site of production of prothrombin and most of the blood-clotting factors. Clients with liver failure run a high risk of having problems with bleeding. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Assessment)

The nurse is preparing a child for possible alopecia from chemotherapy. Which suggestion should be included in the teaching? a. Explaining to the child that hair usually regrows in 1 year. b. Advising the child to expose the head to sunlight to minimize alopecia. c. Explaining to the child that wearing a hat or scarf is preferable to wearing a wig. d. Explaining to the child that, when hair regrows, it may have a slightly different color or texture.

D Alopecia is a side effect of certain chemotherapeutic agents. When the hair regrows, it may be of different color or texture. The hair usually grows back within 3 to 6 months after the cessation of treatment. The head should be protected from sunlight to avoid sunburn. Children should choose the head covering that they prefer. PTS: 1 DIF: Cognitive Level: Application REF: 1383 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

An accurate description of anemia is: a. Increased blood viscosity. b. Depressed hematopoietic system. c. Presence of abnormal hemoglobin. d. Decreased oxygen-carrying capacity of blood.

D Anemia is a condition in which the number of red blood cells or hemoglobin concentration is reduced below the normal values for age. This results in a decreased oxygen-carrying capacity of blood. Increased blood viscosity is usually a function of too many cells or of dehydration, not of anemia. A depressed hematopoietic system or abnormal hemoglobin can contribute to anemia, but the definition depends on the deceased oxygen-carrying capacity of the blood. PTS: 1 DIF: Cognitive Level: Comprehension REF: 1362 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

A common clinical manifestation of Hodgkin's disease is: a. Petechiae. b. Bone and joint pain. c. Painful, enlarged lymph nodes. d. Enlarged, firm, nontender lymph nodes.

D Asymptomatic, enlarged, cervical or supraclavicular lymphadenopathy is the most common presentation of Hodgkin's disease. Petechiae are usually associated with leukemia. Bone and joint pain are not likely in Hodgkin's disease. The enlarged nodes are rarely painful. PTS: 1 DIF: Cognitive Level: Comprehension REF: 1385 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

The nurse is recommending how to prevent iron deficiency anemia in a healthy, term, breastfed infant. What should she or he suggest? a. Iron (ferrous sulfate) drops after age 1 month. b. Iron-fortified commercial formula can be used by ages 4 to 6 months. c. Iron-fortified infant cereal can be introduced at age 2 months. d. Iron-fortified infant cereal can be introduced at approximately 6 months of age.

D Breast milk supplies inadequate iron for growth and development after age 5 months. Supplementation is necessary at this time. Iron supplementation or the introduction of solid foods in a breastfed baby is not indicated. Introducing iron-fortified infant cereal at 2 months should be done only if the mother is choosing to discontinue breastfeeding. PTS: 1 DIF: Cognitive Level: Application REF: 1366 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

A child with leukemia is receiving triple intrathecal chemotherapy consisting of methotrexate, cytarabine, and hydrocortisone. The purpose of this is to prevent: a. Infection. b. Brain tumor. c. Drug side effects. d. Central nervous system (CNS) disease.

D For certain children, CNS prophylactic therapy is indicated. This drug regimen is used to prevent CNS leukemia. This regimen does not prevent infection or drug side effects. If the child has a brain tumor in addition to leukemia, additional therapy would be indicated. PTS: 1 DIF: Cognitive Level: Application REF: 1381 OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

An acquired hemorrhagic disorder that is characterized by excessive destruction of platelets is: a. Aplastic anemia. b. Thalassemia major. c. Disseminated intravascular coagulation. d. Idiopathic thrombocytopenic purpura.

D Idiopathic thrombocytopenic purpura is an acquired hemorrhagic disorder characterized by an excessive destruction of platelets, discolorations caused by petechiae beneath the skin, and a normal bone marrow. Aplastic anemia refers to a bone marrow failure condition in which the formed elements of the blood are simultaneously depressed. Thalassemia major is a group of blood disorders characterized by deficiency in the production rate of specific hemoglobin globin chains. Disseminated intravascular coagulation is characterized by diffuse fibrin deposition in the microvasculature, consumption of coagulation factors, and endogenous generation of thrombin and plasma. PTS: 1 DIF: Cognitive Level: Comprehension REF: 1379 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

The nurse is caring for a 20-year-old man who has Hodgkin's lymphoma in the abdominal and pelvic regions. The client is scheduled for radiation therapy and states, "I want to have children someday, and this procedure will destroy my chances." How does the nurse respond? a. "Adoption is always an option." b. "Infertility is not seen with this type of radiation therapy." c. "Sperm production will be permanently disrupted." d. "You have the option to store sperm in a sperm bank."

D Permanent sterility can occur in male clients receiving radiation in the abdominal and pelvic regions. The client should be informed of this side effect and given the option to store sperm in a sperm bank before treatment. The other options do not appropriately address the client's concerns. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communication) MSC: Integrated Process: Nursing Process (Implementation)

The nurse is preparing a client with leukemia for a peripheral stem cell transfusion. Which information does the nurse provide the client? a. "Nausea and vomiting are common after the transfusion." b. "The transfusion will take about 6 hours." c. "You may have numbness in your fingers and toes." d. "Your urine may be red for a short time."

D Red urine can occur as a result of red blood cell breakage within infused stem cells. The cells are transfused during the time frame of an ordinary blood transfusion, numbness and tingling may have been seen during pheresis (not transfusion), and nausea and vomiting may occur during administration of chemotherapy before the stem cell transfusion. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction in Risk Potential—Potential for Alterations in Body Systems) MSC: Integrated Process: Teaching/Learning

Several complications can occur when a child receives a blood transfusion. An immediate sign or symptom of an air embolus is: a. Chills and shaking. c. Irregular heart rate. b. Nausea and vomiting. d. Sudden difficulty in breathing.

D Signs of air embolism are sudden difficulty breathing, sharp pain in the chest, and apprehension. Air emboli should be avoided by carefully flushing all tubing of air before connecting to the patient. Chills, shaking, nausea, and vomiting are associated with hemolytic reactions. Irregular heart rate is associated with electrolyte disturbances and hypothermia. PTS: 1 DIF: Cognitive Level: Application REF: 1372 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

Myelosuppression associated with chemotherapeutic agents or some malignancies such as leukemia can cause bleeding tendencies because of a/an: a. Decrease in leukocytes. c. Vitamin C deficiency. b. Increase in lymphocytes. d. Decrease in blood platelets.

D The decrease in blood platelets secondary to the myelosuppression of chemotherapy can cause an increase in bleeding. The child and family should be alerted to avoid risk of injury. Decrease in leukocytes, increase in lymphocytes, and vitamin C deficiency would not affect bleeding tendencies. PTS: 1 DIF: Cognitive Level: Application REF: 1381 OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

An 8-year-old girl is receiving a blood transfusion when the nurse notes that she has developed precordial pain, dyspnea, distended neck veins, slight cyanosis, and a dry cough. These manifestations are most suggestive of: a. Air embolism. c. Hemolytic reaction. b. Allergic reaction. d. Circulatory overload.

D The signs of circulatory overload include distended neck veins, hypertension, crackles, dry cough, cyanosis, and precordial pain. Signs of air embolism are sudden difficulty breathing, sharp pain in the chest, and apprehension. Allergic reactions are manifested by urticaria, pruritus, flushing, asthmatic wheezing, and laryngeal edema. Hemolytic reactions are characterized by chills, shaking, fever, pain at infusion site, nausea, vomiting, tightness in chest, flank pain, red or black urine, and progressive signs of shock and renal failure. PTS: 1 DIF: Cognitive Level: Application REF: 1389 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

Which immunization should not be given to a child receiving chemotherapy for cancer? a. Tetanus vaccine c. Diphtheria, pertussis, tetanus (DPT) b. Inactivated poliovirus vaccine d. Measles, rubella, mumps

D The vaccine used for measles, mumps, and rubella is a live virus and can result in an overwhelming infection. Tetanus vaccine, inactivated poliovirus vaccine, and DPT are not live virus vaccines. PTS: 1 DIF: Cognitive Level: Application REF: 1381 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

Chelation therapy is begun on a child with b-thalassemia major. The purpose of this therapy is to: a. Treat the disease. c. Decrease the risk of hypoxia. b. Eliminate excess iron. d. Manage nausea and vomiting.

B A complication of the frequent blood transfusions in thalassemia is iron overload. Chelation therapy with deferoxamine (an iron-chelating agent) is given with oral supplements of vitamin C to increase iron excretion. Chelation therapy treats the side effects of disease management. Decreasing the risk of hypoxia and managing nausea and vomiting are not the purposes of chelation therapy. PTS: 1 DIF: Cognitive Level: Comprehension REF: 1374 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

Which condition is caused by a virus that primarily infects a specific subset of T lymphocytes, the CD4+ T-cells? a. Wiskott-Aldrich syndrome b. Idiopathic thrombocytopenic purpura (ITP) c. Acquired immunodeficiency syndrome (AIDS) d. Severe combined immunodeficiency disease

C AIDS is caused by the human immunodeficiency virus, which primarily attacks the CD4+ T-cells. Wiskott-Aldrich syndrome, ITP, and severe combined immunodeficiency disease are not viral illnesses. PTS: 1 DIF: Cognitive Level: Application REF: 1386 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

Which child should the nurse document as being anemic? a. 7-year-old child with a hemoglobin of 11.5 g/dL b. 3-year-old child with a hemoglobin of 12 g/dL c. 14-year-old child with a hemoglobin of 10 g/dL d. 1-year-old child with a hemoglobin of 13 g/dL

C Anemia is a condition in which the number of red blood cells, or hemoglobin concentration, is reduced below the normal values for age. Anemia is defined as a hemoglobin level below 10 or 11 g/dL. The child with a hemoglobin of 10 g/dL would be considered anemic. The normal hemoglobin for a child after 2 years of age is 11.5 to 15.5 g/dL. PTS: 1 DIF: Cognitive Level: Comprehension REF: 1362 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

The nurse is planning activity for a 4-year-old child with anemia. Which activity should the nurse plan for this child? a. Game of "hide and seek" in the children's outdoor play area b. Participation in dance activities in the playroom c. Puppet play in the child's room d. A walk down to the hospital lobby

C Because the basic pathologic process in anemia is a decrease in oxygen-carrying capacity, an important nursing responsibility is to assess the child's energy level and minimize excess demands. The child's level of tolerance for activities of daily living and play is assessed, and adjustments are made to allow as much self-care as possible without undue exertion. Puppet play in the child's room would not be overly tiring. Hide and seek, dancing, and walking to the lobby would not conserve the anemic child's energy. PTS: 1 DIF: Cognitive Level: Application REF: 1365 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

An adolescent will receive a bone marrow transplant (BMT). The nurse should explain that the bone marrow will be administered by which route? a. Bone grafting c. Intravenous infusion b. Bone marrow injection d. Intraabdominal infusion

C Bone marrow from a donor is infused intravenously, not intraabdominally, and the transfused stem cells will repopulate the marrow. Because the stem cells migrate to the recipient's marrow when given intravenously, this method of administration is used rather than bone grafting or bone marrow injection. PTS: 1 DIF: Cognitive Level: Application REF: 1365 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity MULTIPLE RESPONSE

The registered nurse is assigning a practical nurse to care for a client who has leukemia. Which instruction does the registered nurse provide to the practical nurse when delegating this client's care? a. Evaluate the amount of protein the client eats. b. Assess the client's roommate for symptoms of infection. c. Perform effective hand hygiene frequently. d. Wear a mask when entering the room.

C A major objective in caring for the client with leukemia is protection from infection. Frequent handwashing is of the utmost importance. If at all possible, the client should be in a private room. Masks are worn by anyone who has an upper respiratory tract infection. The client may be on a "minimal bacteria diet." Protein is not a factor in this diet. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Standard Precautions/Transmission-Based Precautions/Surgical Asepsis) MSC: Integrated Process: Communication and Documentation

The nurse assesses that a client has a smooth, beefy red tongue. Which intervention does the nurse implement for this client? a. Administer prescribed oral iron supplements. b. Monitor the daily white blood cell count. c. Provide a diet high in green leafy vegetables. d. Perform more frequent mouth care.

C A smooth, beefy red tongue could signify glossitis, which is seen with vitamin B12 deficiency. Green leafy vegetables are high in vitamin B12. Iron supplements would be used with iron deficiency anemia. The red blood cell count is what is affected by vitamin B12 deficiency—not the white blood cell count. The beefy red tongue is caused by the vitamin deficiency, not by poor mouth care. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC: Integrated Process: Nursing Process (Implementation)

The nurse is teaching a client who has iron deficiency anemia. Which food choice indicates that the client correctly understands the teaching? a. Chicken b. Oranges c. Steak d. Tomatoes

C Treatment for iron deficiency anemia involves increasing oral intake of iron from food sources. Foods high in iron include red meat, organ meat, kidney beans, leafy green vegetables, and raisins. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care) MSC: Integrated Process: Nursing Process (Evaluation)

The nurse is assessing the following laboratory results of a client before discharge. Which instruction does the nurse include in this client's discharge teaching plan? Test Result Hemoglobin 15 g/dL Hematocrit 45% White blood cell (WBC) count 2000/mm3 Platelet count 250,000/mm3 a. "Avoid contact sports." b. "Do not take any aspirin." c. "Eat a diet high in iron." d. "Perform good hand hygiene."

D A normal WBC count is 5000 to 10,000/mm3. A white blood cell count of 2000/mm3 is low and makes this client at risk for infection. Good handwashing technique is the best way to prevent the transmission of infection. The other laboratory results are all within normal limits. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care) MSC: Integrated Process: Teaching/Learning MULTIPLE RESPONSE

Which clinical manifestation should the nurse expect when a child with sickle cell anemia experiences an acute vaso-occlusive crisis? a. Circulatory collapse b. Cardiomegaly, systolic murmurs c. Hepatomegaly, intrahepatic cholestasis d. Painful swelling of hands and feet, painful joints

D A vaso-occlusive crisis is characterized by severe pain in the area of involvement. If in the extremities, painful swelling of the hands and feet is seen; if in the abdomen, severe pain resembles that of acute surgical abdomen; and if in the head, stroke and visual disturbances occur. Circulatory collapse results from sequestration crises. Cardiomegaly, systolic murmurs, hepatomegaly, and intrahepatic cholestasis result from chronic vaso-occlusive phenomena. PTS: 1 DIF: Cognitive Level: Comprehension REF: 1369 OBJ: Nursing Process: Diagnosis MSC: Client Needs: Physiologic Integrity

The nurse is caring for a client who has an elevated white blood cell count. Which intervention does the nurse implement for this client? a. Administer the prescribed Tylenol. b. Hold the client's prescribed steroids. c. Assess the client's respiratory rate. d. Obtain the client's temperature.

D White blood cells provide immunity and protect against invasion and infection. An elevated white blood cell count could indicate an infectious process, which could cause an elevation in body temperature. Tylenol would treat a fever but not the elevated white blood cell count. Steroids place the client at higher risk for infection but should not be stopped suddenly. The respiratory rate does not need to be assessed in this client. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Laboratory Values) MSC: Integrated Process: Nursing Process (Implementation)

MATCHING The nurse has initiated a blood transfusion on a preschool child. The child begins to exhibit signs of a transfusion reaction. Place in order the interventions the nurse should implement, sequencing from the highest priority to the lowest. a. Take the vital signs. b. Stop the transfusion. c. Notify the practitioner. d. Maintain a patent intravenous (IV) line with normal saline.

First priority Second priority Third priority Fourth priority 52.