Chapter 29
A client with megaloblastic anemia reports mouth and tongue soreness. What instruction will the nurse give the client regarding eating while managing the client's symptoms? "Eat low-fiber blended foods only." "Eat small amounts of bland, soft foods frequently." "Eat cold, bland foods with a large amount of water." "Eat larger amounts of bland, soft foods less frequently."
"Eat small amounts of bland, soft foods frequently." -Because the client with megaloblastic anemia often reports mouth and tongue soreness, the nurse should instruct the client to eat small amounts of bland, soft foods frequently. The other answer choices do not factor in the client's mouth soreness or need for nutrition.
A client with pernicious anemia is receiving parenteral vitamin B12 therapy. Which client statement indicates effective teaching about this therapy? "I will receive parenteral vitamin B12 therapy until my vitamin B12 level returns to normal." "I will receive parenteral vitamin B12 therapy for the rest of my life." "I will receive parenteral vitamin B12 therapy until my signs and symptoms disappear." "I will receive parenteral vitamin B12 therapy monthly for 6 months to a year."
"I will receive parenteral vitamin B12 therapy for the rest of my life." -Because a client with pernicious anemia lacks intrinsic factor, oral vitamin B12 can't be absorbed. Therefore, parenteral vitamin B12 therapy is recommended and required for life.
A home care nurse visits a client diagnosed with atrial fibrillation who is ordered warfarin. The nurse teaches the client about warfarin therapy. Which statement by the client indicates the need for further teaching? "I'll use an electric razor to shave." "I'll watch my gums for bleeding when I brush my teeth." "I'll eat four servings of fresh, dark green vegetables every day." "I'll report unexplained or severe bruising to my doctor right away."
"I'll eat four servings of fresh, dark green vegetables every day." -The client requires additional teaching if he states that he'll eat four servings of dark green vegetables every day. Dark, green vegetables contain vitamin K, which reverses the effects of warfarin. The client should limit his intake to one to two servings per day. The client should report bleeding gums and severe or unexplained bruising, which may indicate an excessive dose of warfarin. The client should use an electric razor to prevent cutting himself while shaving.
A few minutes after beginning a blood transfusion, a nurse notes that a client has chills, dyspnea, and urticaria. The nurse reports this to the health care provider immediately because the client probably is experiencing which problem? A hemolytic reaction caused by bacterial contamination of donor blood A hemolytic allergic reaction caused by an antigen reaction A hemolytic reaction to mismatched blood A hemolytic reaction to Rh-incompatible blood
A hemolytic allergic reaction caused by an antigen reaction -Hemolytic allergic reactions are fairly common and may cause chills, fever, urticaria, tachycardia, dyspnea, chest pain, hypotension, and other signs of anaphylaxis a few minutes after blood transfusion begins. Although rare, a hemolytic reaction to mismatched blood can occur, triggering a more severe reaction and, possibly, leading to disseminated intravascular coagulation. A hemolytic reaction to Rh-incompatible blood is less severe and occurs several days to 2 weeks after the transfusion. Bacterial contamination of donor blood causes a high fever, nausea, vomiting, diarrhea, abdominal cramps and, possibly, shock.
A clinical nurse specialist (CNS) is orienting a new graduate registered nurse to an oncology unit where blood product transfusions are frequently administered. In discussing ABO compatibility, the CNS presents several hypothetical scenarios. The new graduate knows that the greatest likelihood of an acute hemolytic reaction would occur when giving: A-positive blood to an A-negative client. B-positive blood to an AB-positive client. O-positive blood to an A-positive client. O-negative blood to an O-positive client.
A-positive blood to an A-negative client. -An acute hemolytic reaction occurs when there is an ABO or Rh incompatibility. For example, giving A blood to a B client would cause a hemolytic reaction. Likewise, giving Rh-positive blood to an Rh-negative client would cause a hemolytic reaction. It's safe to give Rh-negative blood to an Rh-positive client if there is a blood type compatibility. O-negative blood is the universal donor and can be given to all other blood types. AB clients can receive either A or B blood as long as there isn't an Rh incompatibility.
A client is found to have a low hemoglobin and hematocrit when laboratory work was performed. What does the nurse understand the anemia may have resulted from? Select all that apply. Abnormal erythrocyte production Destruction of normally formed red blood cells Blood loss Inadequate formed white blood cells Infection
Abnormal erythrocyte production Destruction of normally formed red blood cells Blood loss -Most anemias result from (1) blood loss, (2) inadequate or abnormal erythrocyte production, or (3) destruction of normally formed red blood cells. The most common types include hypovolemic anemia, iron-deficiency anemia, pernicious anemia, folic acid deficiency anemia, sickle cell anemia, and hemolytic anemias. Although each form of anemia has unique manifestations, all share a common core of symptoms. Anemia does not result from infection or inadequate formed white blood cells. -
A client's low prothrombin time (PT) was attributed to low vitamin K levels and the client's PT normalized after administration of vitamin K. When performing discharge education in an effort to prevent recurrence, what should the nurse emphasize? Avoidance of NSAIDs Adequate nutrition Constant access to clotting factor concentrates Meticulous hygiene
Adequate nutrition -Vitamin K deficiency is often the result of a nutritional deficit. NSAIDs do not influence vitamin K synthesis and clotting factors are not necessary to treat or prevent a vitamin K deficiency. Hygiene is not related to the onset or prevention of vitamin K deficiency.
Which of the following is the most common hematologic condition affecting elderly patients Thrombocytopenia Anemia Bandemia Leukopenia
Anemia -Anemia is the most common hematologic condition affecting elderly patients: with each successive decade of life, the incidence of anemia increases. Thrombocytopenia is a low platelet count. Leukopenia is a low leukocyte count. Bandemia is an increased number of band cells.
Which nursing intervention should be incorporated into the plan of care to manage the delayed clotting process due to thrombocytopenia in a client with leukemia? Implementing neutropenic precautions Monitoring temperature at least once per shift Applying prolonged pressure to needle sites or other sources of external bleeding Eliminating direct contact with others who are infectious
Applying prolonged pressure to needle sites or other sources of external bleeding -The interventions for a client with thrombocytopenia are the same as those for a client with cancer who is at risk for bleeding. For a client with leukemia, the nurse should apply prolonged pressure to needle sites or other sources of external bleeding. Reduced platelet production results in a delayed clotting process and increases the potential for hemorrhage. Implementing neutropenic precautions and eliminating direct contact with others are interventions to address the risk for infection.
A client in end-stage renal disease is prescribed epoetin alfa and oral iron supplements. Before administering the next dose of epoetin alfa and oral iron supplement, what is the priority action taken by the nurse? Holds the epoetin alfa if the BUN is elevated Questions the administration of both medications Ensures the client has completed dialysis treatment q
Assesses the hemoglobin level -Erythropoietin (epoetin alfa [Epogen]) with oral iron supplements can raise hematocrit levels in the client with end-stage renal disease. The nurse should check the hemoglobin prior to administration of erythropoietin, because too high a hemoglobin level can put the client at risk for heart failure, myocardial infarction, and cerebrovascular accident. Erythropoietin may be administered during dialysis treatments. The BUN will be elevated in the client with end-stage renal disease.
The nurse is planning care for a client with severe fatigue secondary to anemia. What concept will the nurse use as the basis for planning interventions? Assisting in prioritizing activities. Keeping long activity periods to build client stamina. Encouraging early and frequent activities. Determining what days to be active.
Assisting in prioritizing activities. -When planning care for a client with severe fatigue secondary to anemia, the nurse should act collaboratively with the client and assist in prioritizing activities. The client ultimately determines the balance between rest and activity, not the nurse. The nurse will balance activities and group nursing interventions in order to prevent client fatigue.
A patient describes numbness in the arms and hands with a tingling sensation. The patient also frequently stumbles when walking. What vitamin deficiency does the nurse determine may cause some of these symptoms? B12 Folate Iron Thiamine
B12 -The hematologic effects of vitamin B12 deficiency are accompanied by effects on other organ systems, particularly the gastrointestinal tract and nervous system. Patients with pernicious anemia may become confused; more often, they have paresthesias in the extremities (particularly numbness and tingling in the feet and lower legs). They may have difficulty maintaining their balance because of damage to the spinal cord, and they also lose position sense (proprioception).
Which of the following are assessment findings associated with thrombocytopenia? Select all that apply. Hypertension Bleeding gums Bradypnea Hematemesis Epistaxis
Bleeding gums Hematemesis Epistaxis -Pertinent findings of thrombocytopenia include: bleeding gums, epistaxis, hematemesis, hypotension, and tachypnea.
Which is a symptom of hemochromatosis? Inflammation of the mouth Inflammation of the tongue Bronzing of the skin Weight gain
Bronzing of the skin -Clients with hemochromatosis exhibit symptoms of weakness, lethargy, arthralgia, weight loss, and loss of libido early in the illness trajectory. The skin may appear hyperpigmented from melanin deposits or appear bronze in color.
The nurse is instructing a client about taking a liquid iron preparation for the treatment of iron-deficiency anemia. What should the nurse include in the instructions? Iron may cause indigestion and should be taken with an antacid such as Mylanta. Dilute the liquid preparation with another liquid such as juice and drink with a straw. Do not take medication with orange juice because it will delay absorption of the iron. Discontinue the use of iron if your stool turns black.
Dilute the liquid preparation with another liquid such as juice and drink with a straw. -Dilute liquid preparations of iron with another liquid such as juice and drink with a straw to avoid staining the teeth. Avoid taking iron simultaneously with an antacid, which interferes with iron absorption. Drink orange juice or take other forms of vitamin C with iron to promote its absorption. Expect iron to color stool dark green or black.
A client is receiving chemotherapy for cancer. The nurse reviews the client's laboratory report and notes that he has thrombocytopenia. To which nursing diagnosis should the nurse give the highest priority? Impaired oral mucous membranes Impaired tissue integrity Ineffective tissue perfusion: Cerebral, cardiopulmonary, GI Activity intolerance
Ineffective tissue perfusion: Cerebral, cardiopulmonary, GI -These are all appropriate nursing diagnoses for the client with thrombocytopenia. However, the risk of cerebral and GI hemorrhage and hypotension pose the greatest risk to the physiological integrity of the client.
The nurse observes a co-worker who always seems to be eating a cup of ice. The nurse encourages the co-worker to have an examination and diagnostic workup with the health care provider. What type of anemia is the nurse concerned the co-worker may have? Aplastic anemia Megaloblastic anemia Iron deficiency anemia Sickle cell anemia
Iron deficiency anemia -People with iron deficiency anemia may crave ice, starch, or dirt; this craving is known as pica.
Which term refers to an abnormal decrease in white blood cells, red blood cells, and platelets? Leukopenia Pancytopenia Anemia Thrombocytopenia
Pancytopenia -Pancytopenia is defined as an abnormal decrease in WBCs, RBCs, and platelets. The condition may be congenital or acquired. Anemia refers to decreased red cell mass. Leukopenia refers to a less-than-normal amount of WBCs in circulation. Thrombocytopenia refers to a lower-than-normal platelet count.
A client awaiting a bone marrow aspiration asks the nurse to explain where on the body the procedure will take place. What body part does the nurse identify for the client? Posterior iliac crest Sternum Femur Ankle
Posterior iliac crest -In adults, bone marrow is usually aspirated from the posterior iliac crest and rarely from the sternum. Bone marrow is not aspirated from the femur or ankle.
Which of the following is considered an antidote to heparin? Ipecac Vitamin K Narcan Protamine sulfate
Protamine sulfate -Protamine sulfate, in the appropriate dosage, acts quickly to reverse the effects of heparin. Vitamin K is the antidote to warfarin (Coumadin). Narcan is the drug used to reverse signs and symptoms of medication-induced narcosis. Ipecac is an emetic used to treat some poisonings.
The nurse obtains a unit of blood for the client, Donald D. Smith. The name on the label on the unit of blood reads Donald A. Smith. All the other identifiers are correct. What action should the nurse take? Refuse to administer the blood Check with the blood bank first and then administer the blood with their permission Administer the unit of blood Ask the client if he was ever known as Donald A. Smith
Refuse to administer the blood -To ensure a safe transfusion, all components of the identification must be correct. The nurse should refuse to administer the blood and notify the blood bank about the discrepancy. The blood bank should then take the necessary steps to correct the name on the label on the unit of blood.
A client with a pulmonary embolism is being treated with a heparin infusion. What diagnostic finding suggests to the nurse that treatment is effective? Arterial blood sampling tests positive for the presence of factor XIII. The client's activated partial thromboplastin time (aPTT) is 1.5 to 2.5 times the control value. The client's platelet level is below 100,000/mm3. The client's PT is within reference ranges.
The client's activated partial thromboplastin time (aPTT) is 1.5 to 2.5 times the control value. -The therapeutic effect of heparin is monitored by serial measurements of the aPTT; the dose is adjusted to maintain the range at 1.5 to 2.5 times the laboratory control. Heparin dosing is not determined on the basis of platelet levels, the presence or absence of clotting factors, or PT levels.
After receiving chemotherapy for lung cancer, a client's platelet count falls to 98,000/mm3. What term should the nurse use to describe this low platelet count? Anemia Thrombocytopenia Leukopenia Neutropenia
Thrombocytopenia -A normal platelet count is 140,000 to 400,000/mm3 in adults. Chemotherapeutic agents produce bone marrow depression, resulting in reduced red blood cell counts (anemia), reduced white blood cell counts (leukopenia), and reduced platelet counts (thrombocytopenia). Neutropenia is the presence of an abnormally reduced number of neutrophils in the blood and is caused by bone marrow depression induced by chemotherapeutic agents.
A nurse is doing a physical examination of a child with sickle cell anemia. When the child asks why the nurse auscultates the lungs and heart, what would be best the response by the nurse? To detect the evidence of infection such as fever and tachycardia To detect the motor strength and stroke-related signs and symptoms To detect the evidence of dehydration that might have triggered a sickle cell crisis To detect the abnormal sounds suggestive of acute chest syndrome and heart failure
To detect the abnormal sounds suggestive of acute chest syndrome and heart failure -The nurse auscultates the lungs and heart to detect abnormal sounds that indicate pneumonia, acute chest syndrome, and heart failure. The nurse assesses vital signs to detect evidence of infection, such as fever and tachycardia. During the physical examination, the nurse observes the client's appearance, looking for evidence of dehydration, which may have triggered a sickle cell crisis. The nurse assesses mental status, verbal ability, and motor strength to detect stroke-related signs and symptoms.
When evaluating a patient's symptoms that are consistent with a diagnosis of leukemia, the nurse is aware that all leukemias have which common feature? Unregulated accumulation of white cells in the bone marrow, which replace normal marrow elements Compensatory polycythemia stimulated by thrombocytopenia Increased blood viscosity, resulting from an overproduction of white cells Reduced plasma volume in response to a reduced production of cellular elements
Unregulated accumulation of white cells in the bone marrow, which replace normal marrow elements -The term leukemia means "white blood," which is used to describe the neoplastic proliferation of one hematopoietic cell type (granulocytes, monocytes, lymphocytes, and sometimes, erythrocytes and megakaryocytes).
A nurse is caring for a client with thrombocytopenia. What is the best way to protect this client? Limit visits by family members. Maintain accurate fluid intake and output records. Use the smallest needle possible for injections. Encourage the client to use a wheelchair.
Use the smallest needle possible for injections. -Because thrombocytopenia alters coagulation, it poses a high risk of bleeding. To help prevent capillary bleeding, the nurse should use the smallest needle possible when administering injections. The nurse doesn't need to limit visits by family members because they don't pose any danger to the client. The nurse should provide comfort measures and maintain the client on bed rest; activities such as using a wheelchair can cause bleeding. The nurse records fluid intake and output to monitor hydration; however, this action doesn't protect the client from a complication of thrombocytopenia.
A young client is diagnosed with a mild form of hemophilia and is experiencing bleeding in the joints with pain. In preparing the client for discharge, what instructions should the nurse provide? Wear a medical identification bracelet. Take ibuprofen for joint pain. Take warm baths to lessen pain. Undergo genetic testing and counseling if the client is male.
Wear a medical identification bracelet. -Clients with hemophilia should wear a medical identification bracelet about having this disease. Ibuprofen interferes with platelet aggregation and may increase the client's bleeding. A warm bath may lessen pain but increase bleeding. Genetic testing and counseling are not necessary for male clients, because females are the carriers of the genetic material for hemophilia.
A client with sickle cell anemia has a normal hematocrit. normal blood smear. low hematocrit. high hematocrit.
low hematocrit. -A client with sickle cell anemia has a low hematocrit and sickled cells on the smear. A client with sickle cell trait usually has a normal hemoglobin level, a normal hematocrit, and a normal blood smear.
A nurse cares for a client with aplastic anemia. Which laboratory results will the nurse expect to find with this client? Select all that apply. Neutrophil count 1200/microliter Neutrophil count 17,000/microliter White blood cell count 10,000/microliter Platelets 35,000 microliters Hemoglobin 7 g/dL
Neutrophil count 1200/microliter Platelets 35,000 microliters Hemoglobin 7 g/dL -Aplastic anemia causes pancytopenia, or overall decrease to all myeloid stem cell-derived cells. Pancytopenia manifests as neutrophil count less than 1500/microliter, hemoglobin less than 10 g/dL, and platelets less than 50,000/microliter.
The nurse is performing an assessment for a client with anemia admitted to the hospital to have blood transfusions administered. Why would the nurse need to include a nutritional assessment for this patient? It may indicate deficiencies in essential nutrients. It is important for the nurse to determine what type of foods the patient will eat. It is part of the required assessment information. It will determine what type of anemia the patient has.
It may indicate deficiencies in essential nutrients. -A nutritional assessment is important, because it may indicate deficiencies in essential nutrients such as iron, vitamin B12, and folate.
A client diagnosed with systemic lupus erythematosus comes to the emergency department with severe back pain. The client is taking prednisone daily and reported feeling pain after manually opening the garage door. What adverse effect of long-term corticosteroid therapy is most likely responsible for the pain? Truncal obesity Osteoporosis Muscle wasting Hypertension
Osteoporosis -Hypertension, osteoporosis, muscle wasting, and truncal obesity are all adverse effects of long-term corticosteroid therapy; however, osteoporosis commonly causes compression fractures of the spine. Hypertension, muscle wasting, and truncal obesity aren't likely to cause severe back pain.
A client's family member asks the nurse why disseminated intravascular coagulation (DIC) occurs. Which statement by the nurse correctly explains the cause of DIC? "DIC is caused by abnormal activation of the clotting pathway, causing excessive amounts of tiny clots to form inside organs." "DIC occurs when the immune system attacks platelets and causes massive bleeding." "DIC is caused when hemolytic processes destroy erythrocytes." "DIC is a complication of an autoimmune disease that attacks the body's own cells."
"DIC is caused by abnormal activation of the clotting pathway, causing excessive amounts of tiny clots to form inside organs." -The inflammatory response initiates the process of inflammation and coagulation. The natural anticoagulant pathways within the body are simultaneously impaired, and the fibrinolytic system is suppressed, allowing a massive amount of tiny clots forms in the microcirculation. As the platelets and clotting factors form microthrombi, coagulation fails. Thus, the paradoxical result of excessive clotting is bleeding. Decline in organ function is usually a result of excessive clot formation (with resultant ischemia to all or part of the organ).
The nurse is caring for a client with an exacerbation of sickle cell disease (SCD). Which finding indicates to the nurse that the client is experiencing a liver complication from this condition? Glucose intolerance Fatigue Weakness Abdominal pain
Abdominal pain -Sickle cell disease (SCD) is an autosomal recessive disorder caused by inheritance of the sickle hemoglobin (HbS) gene. It is associated with severe hemolytic anemia. The HbS gene results in production of a defective hemoglobin molecule that causes the erythrocyte to change shape when exposed to low oxygen tension. The erythrocyte usually has a round, biconcave, pliable shape which in SCD becomes rigid and sickle shaped. Complications of SCD can affect all body systems. Evidence that the client is experiencing a complication in the liver would be the development of abdominal pain. Fatigue and weakness indicate complications involving the central nervous system and heart. Glucose intolerance is not identified as a complication of SCD.
When assessing a client with anemia, which assessment is essential? Family history Lifestyle assessments, such as exercise routines Age and gender Health history, including menstrual history in women
Health history, including menstrual history in women -When assessing a client with anemia, it is essential to assess the client's health history. Women should be questioned about their menstrual periods (e.g., excessive menstrual flow, other vaginal bleeding) and the use of iron supplements during pregnancy.
A patient with End Stage Kidney Disease is taking recombinant erythropoietin for the treatment of anemia. What laboratory study does the nurse understand will have to be assessed at least monthly related to this medication? Creatinine level Potassium level Hemoglobin level Folate levels
Hemoglobin level -When using recombinant erythropoietin, the hemoglobin must be checked at least monthly (more frequently until a maintenance dose is established) and the dose titrated to ensure the hemoglobin level does not exceed 12 g/dL.
A nurse provides nutritional information for a patient diagnosed with an iron-deficiency anemia. What education should the nurse provide? Increase the intake of green, leafy vegetables. Take an iron supplement with meals to reduce gastric irritation. Decrease the intake of high-fat red meats, especially organ meats. Decrease the intake of citrus fruits because they interfere with iron absorption.
Increase the intake of green, leafy vegetables. -Leafy greens, such as spinach, kale, swiss chard, collard and beet greens contain between 2.5-6.4 mg of iron per cooked cup. Clients should be encouraged to consume more green, leafy vegetables. Red meats, especially organ meats, are iron-rich foods and the client should not be discouraged from eating them. Vitamin C sources (citrus fruit and juices) enhance the absorption of iron, which should be taken 1 hour before or 2 hours after a meal.
A client with a diagnosis of pernicious anemia comes to the clinic reporting of numbness and tingling in his arms and legs. What do these symptoms indicate? Insufficient intake of dietary nutrients Severity of the disease Loss of vibratory and position senses Neurologic involvement
Neurologic involvement -In clients with pernicious anemia, numbness and tingling in the arms and legs and ataxia are the most common signs of neurologic involvement. Some affected clients lose vibratory and position senses. Jaundice, irritability, confusion, and depression are present when the disease is severe. Insufficient intake of dietary nutrients is not indicated by these symptoms
A patient is taking prednisone 60 mg per day for the treatment of an acute exacerbation of Crohn's disease. The patient has developed lymphopenia with a lymphocyte count of less than 1,500 mm3. What should the nurse monitor the client for? Abdominal pain Diarrhea The onset of a bacterial infection Bleeding
The onset of a bacterial infection -Lymphopenia (a lymphocyte count less than 1,500/mm3) can result from ionizing radiation, long-term use of corticosteroids, uremia, infections (particularly viral infections), some neoplasms (e.g., breast and lung cancers, advanced Hodgkin disease), and some protein-losing enteropathies (in which the lymphocytes within the intestines are lost) (Kipps, 2010). When lymphopenia is mild, it is often without sequelae; when severe, it can result in bacterial infections (due to low B lymphocytes) or in opportunistic infections (due to low T lymphocytes).
A patient with sickle cell disease is brought to the emergency department by a parent. The patient has a fever of 101.6°F, heart rate of 116, and a respiratory rate of 32. The nurse auscultates bilateral wheezes in both lung fields. What does the nurse suspect this patient is experiencing? An exacerbation of asthma Pneumocystis pneumonia Acute chest syndrome Pulmonary edema
Acute chest syndrome -Acute chest syndrome is manifested by fever, respiratory distress (tachypnea, cough, wheezing), and new infiltrates seen on the chest x-ray. These signs often mimic infection, which is often the cause. However, the infectious etiology appears to be atypical bacteria such as Chlamydia pneumoniae and Mycoplasma pneumoniae as well as viruses such as respiratory syncytial virus and parvovirus. Other causes include pulmonary fat embolism, pulmonary infarction, and pulmonary thromboembolism. Seventy-five percent of patients who develop acute chest syndrome had a painful vaso-occlusive crisis, usually lasting an average of 2.5 days prior to developing symptoms of acute chest syndrome (Laurie, 2010).
A client is hospitalized 3 days prior to a total hip arthroplasty and reports a high level of pain with ambulation. The client has been taking warfarin at home, which is now discontinued. To prevent the formation of blood clots, which action should the nurse take? Encourage a diet high in vitamin K. Administer the prescribed enoxaparin (Lovenox). Monitor partial thromboplastin (PTT) time. Have the client limit physical activity.
Administer the prescribed enoxaparin (Lovenox). -Clients who are prescribed warfarin at home and need to have a major invasive procedure stop taking warfarin prior to the procedure. Low molecular weight heparin, such as enoxaparin, may be used until the procedure is performed. The client will continue with a diet that has a daily consistent amount of vitamin K. The client needs to ambulate frequently throughout the day. Prothrombin (PT) time is monitored, not PTT, when warfarin had been administered.
A client with sickle cell crisis is admitted to the hospital in severe pain. While caring for the client during the crisis, which is the priority nursing intervention? Limiting the client's intake of oral and IV fluids Limit foods that contain folic acid Encouraging the client to ambulate immediately Administering and evaluating the effectiveness of opioid analgesics
Administering and evaluating the effectiveness of opioid analgesics -The priority nursing intervention is to manage the acute pain. Client-controlled analgesia is frequently used in the acute care setting. A patient with sickle cell crisis experiences severe extreme pain, the use of IV fluids and oral intake is need to hydrate the patient, the patient is initially placed on bed rest during the crisis due to extreme fatigue. The patient must continue to ingest folic acid and are placed on a daily folic acid supplement .
A nurse caring for a client who has hemophilia is getting ready to take the client's vital signs. What should the nurse do before taking a blood pressure? Ask if taking a blood pressure has ever produced bleeding under the skin or in the arm joints. Ask if taking a blood pressure has ever produced pain in the upper arm. Ask if taking a blood pressure has ever caused bruising in the hand and wrist. Ask if taking a blood pressure has ever produced the need for medication.
Ask if taking a blood pressure has ever produced bleeding under the skin or in the arm joints. -Due to the client's enhanced risk for bleeding, before taking a blood pressure, the nurse asks the client if the use of a blood-pressure cuff has ever produced bleeding under the skin or in the arm joints.
The nurse prepares a teaching plan for a client who is hospitalized with sickle cell disease. Which intervention(s) should the nurse include in the teaching plan? Select all that apply. Restrict fluid intake during crisis. Avoid travel to high altitude areas. Wear constrictive clothing to support circulation during exercise. Never exceed the recommended dosages of analgesics. Dress warmly in cold temperatures.
Avoid travel to high altitude areas. Never exceed the recommended dosages of analgesics. Dress warmly in cold temperatures. -A client who is diagnosed with sickle cell disease requires specific education to prevention a sickle cell crisis. Interventions in the client's plan of care include avoiding travel to high altitude, because this may require a need for increased oxygen to prevent sickling; dressing warmly in cold temperatures or when inside an air-conditioned room, because temperature extremes is a risk factor for crisis; and avoiding exceeding recommended dosages of analgesics to decrease the risk for complications. Dehydration is a risk factor for sickle cell crisis; therefore, the client is encouraged to drink water throughout the day, increasing the amount when exercising or spending time in a hot, dry climate. It is important to avoid vigorous physical exercise and leg positions or clothing that cause vasoconstriction.
The nurse is educating a client about iron supplements. The nurse teaches that what vitamin enhances the absorption of iron? A E C D
C -Vitamin C facilitates the absorption of iron. Therefore, iron supplements should be taken with a glass of orange juice or a vitamin C tablet to maximize absorption.
A client is being treated for DIC and the nurse has prioritized the nursing diagnosis of Risk for Deficient Fluid Volume Related to Bleeding. How can the nurse best determine if goals of care relating to this diagnosis are being met? Assess the client's level of consciousness frequently. Assess for edema. Closely monitor intake and output. Assess skin integrity frequently.
Closely monitor intake and output. -The client with DIC is at a high risk of deficient fluid volume. The nurse can best gauge the effectiveness of care by closely monitoring the client's intake and output. Each of the other assessments is a necessary element of care, but none addresses fluid balance as directly as close monitoring of intake and output.
A male client has been receiving a continuous infusion of weight-based heparin for more than 4 days. The client's PTT is at a level that requires an increase of heparin by 100 units per hour. The client has the laboratory findings shown above. What is the most important action for the nurse to take? Begin treatment with the prescribed warfarin (Coumadin). Continue with the present infusion rate of heparin. Consult with the physician about discontinuing heparin. Increase the heparin infusion by 100 units per hour.
Consult with the physician about discontinuing heparin -Platelet counts may decrease with heparin therapy, and this client's platelet count has decreased. The client may have heparin-induced thrombocytopenia (HIT). Treatment of HIT includes discontinuing the heparin. The question asks about the most important action of the nurse and that is to consult with the physician about discontinuing heparin therapy. The nurse may continue with the current rate and should not increase the heparin dose until consulting with the physician. Warfarin is not administered until the platelet count has returned to normal levels.
A patient with end-stage kidney disease (ESKD) has developed anemia. What laboratory finding does the nurse understand to be significant in this stage of anemia? Creatinine level of 6 mg/100 mL Potassium level of 5.2 mEq/L Magnesium level of 2.5 mg/dL Calcium level of 9.4 mg/dL
Creatinine level of 6 mg/100 mL -The degree of anemia in patients with end-stage renal disease varies greatly; however, in general, patients do not become significantly anemic until the serum creatinine level exceeds 3 mg/100 mL.
A client with anemia has been admitted to the medical-surgical unit. Which assessment findings are characteristic of iron deficiency anemia? Nights sweats, weight loss, and diarrhea Dyspnea, tachycardia, and pallor Nausea, vomiting, and anorexia Itching, rash, and jaundice
Dyspnea, tachycardia, and pallor -Signs of iron deficiency anemia include dyspnea, tachycardia, and pallor, as well as fatigue, listlessness, irritability, and headache. Night sweats, weight loss, and diarrhea may signal acquired immunodeficiency syndrome. Nausea, vomiting, and anorexia may be signs of hepatitis B. Itching, rash, and jaundice may result from an allergic or hemolytic reaction.
A thin client is prescribed iron dextran intramuscularly. What is most important action taken by the nurse when administering this medication? Rubs the site vigorously Uses a 23-gauge needle Employs the Z-track technique Injects into the deltoid muscle
Employs the Z-track technique -When iron medications are given intramuscularly, the nurse uses the Z-track technique to avoid local pain and staining of the skin. The gluteus maximus muscle is used. The nurse avoids rubbing the site vigorously and uses a 18- or 20-gauge needle.
A nurse cares for a client with severe hemoglobinuria after an upper respiratory infection and fever. Diagnostic testing reveals degraded hemoglobin within the client's erythrocytes. Which hematological condition does the nurse suspect the client has? Polycythemia vera Sickle cell disease Aplastic anemia Glucose-6-phosphate dehydrogenase deficiency
Glucose-6-phosphate dehydrogenase deficiency -Glucose-6-phosphate dehydrogenase deficiency (G-6-PD) is the deficiency of a gene that produces an enzyme within the erythrocyte essential for membrane stability. Clients are asymptomatic and have normal hemoglobin levels and reticulocyte counts most of the time. However, after a normally-harmless virus or ingestion of a particular medication, clients develop pallor, jaundice, and hemoglobinuria (hemoglobin in the urine). The other answer choices are hematological diseases or conditions; however, these do not present in the same manner.
A client with severe anemia reports symptoms of tachycardia, palpitations, exertional dyspnea, cool extremities, and dizziness with ambulation. Laboratory test results reveal low hemoglobin and hematocrit levels. Based on the assessment data, which nursing diagnoses is mostappropriate for this client? Ineffective tissue perfusion related to inadequate hemoglobin and hematocrit Risk for falls related to complaints of dizziness Imbalanced nutrition, less than body requirements, related to inadequate intake of essential nutrients Fatigue related to decreased hemoglobin and hematocrit
Ineffective tissue perfusion related to inadequate hemoglobin and hematocrit -The symptoms indicate impaired tissue perfusion due to a decrease in the oxygen-carrying capacity of the blood. Cardiac status should be carefully assessed. When the hemoglobin level is low, the heart attempts to compensate by pumping faster and harder in an effort to deliver more blood to hypoxic tissue. This increased cardiac workload can result in such symptoms as tachycardia, palpitations, dyspnea, dizziness, orthopnea, and exertional dyspnea. Heart failure may eventually develop, as evidenced by an enlarged heart (cardiomegaly) and liver (hepatomegaly) and by peripheral edema.
A client with severe anemia reports symptoms of tachycardia, palpitations, exertional dyspnea, cool extremities, and dizziness with ambulation. Laboratory test results reveal low hemoglobin and hematocrit levels. Based on the assessment data, which nursing diagnoses is mostappropriate for this client? Risk for falls related to complaints of dizziness Fatigue related to decreased hemoglobin and hematocrit Imbalanced nutrition, less than body requirements, related to inadequate intake of essential nutrients Ineffective tissue perfusion related to inadequate hemoglobin and hematocrit
Ineffective tissue perfusion related to inadequate hemoglobin and hematocrit -The symptoms indicate impaired tissue perfusion due to a decrease in the oxygen-carrying capacity of the blood. Cardiac status should be carefully assessed. When the hemoglobin level is low, the heart attempts to compensate by pumping faster and harder in an effort to deliver more blood to hypoxic tissue. This increased cardiac workload can result in such symptoms as tachycardia, palpitations, dyspnea, dizziness, orthopnea, and exertional dyspnea. Heart failure may eventually develop, as evidenced by an enlarged heart (cardiomegaly) and liver (hepatomegaly) and by peripheral edema.
During the review of morning laboratory values for a client reporting severe fatigue and a red, swollen tongue, the nurse suspects chronic, severe iron deficiency anemia based on which finding? Elevated red blood cell (RBC) count Enlarged mean corpuscular volume (MCV) A patient describes numbness in the arms and hands with a tingling sensation. The patient also frequently stumbles when walking. What vitamin deficiency does the nurse determine may cause some of these symptoms? B12 Folate Iron Thiamine Elevated hematocrit concentration
Low ferritin level concentration -The most consistent indicator of iron deficiency anemia is a low ferritin level, which reflects low iron stores. As the anemia progresses, the MCV, which measures the size of the erythrocytes, also decreases. Hematocrit and RBC levels are also low in relation to the hemoglobin concentration.
The nurse, caring for a client in the emergency room with a severe nosebleed, becomes concerned when the client asks for a bedpan. The nurse documents the stool as loose, tarry, and black looking. The nurse suspects the client may have thrombocytopenia. What should be the nurse's priority action? Notify the physician Put in an IV line Ask someone to clean the bedpan Stop the nosebleed
Notify the physician -Thrombocytopenia is evidenced by purpura, small hemorrhages in the skin, mucous membranes, or subcutaneous tissues. Bleeding from other parts of the body, such as the nose, oral mucous membrane, and the gastrointestinal tract, also occurs. Internal hemorrhage, which can be severe and even fatal, is possible. This nurse should notify the physician of the suspected disorder.
The nurse provides care for an older adult client, diagnosed with anemia, who has a hemoglobin of 9.6 g/dL and a hematocrit of 34%. To determine the cause of the client's blood loss, which is the priority nursing action? Observe the client's stools for blood. Monitor the client's blood pressure. Monitor the client's body temperature. Evaluate the client's dietary intake.
Observe the client's stools for blood. -If an older adult is anemic, blood loss from the gastrointestinal (GI) or genitourinary (GU) tracts is suspected. Observing the stool for blood will determine if the source of the client's bleeding is in the GI tract. Iron-deficiency anemia is unusual in older adults because the body does not eliminate excessive iron, thus increasing total body iron stores and necessitating maintenance of hydration. If evaluation of the GI and GU tracts does not reveal a source of bleeding, evaluating the client's diet may be appropriate; however, this is not the priority nursing action. Monitoring the client's body temperature and BP will assist the nurse in determining the source of the client's blood loss, but these are not priority nursing actions.
The nurse is preparing information to help a client with neutropenia and limited mobility reduce the risk of infection. Which information will the nurse include in this teaching? Select all that apply. Report a new onset of fever to the health care provider. Use the incentive spirometer every 4 hours. Encourage socialization with others. Avoid working in the garden. Increase the intake of fluids to 3 L per day.
Report a new onset of fever to the health care provider. Use the incentive spirometer every 4 hours. Avoid working in the garden. Increase the intake of fluids to 3 L per day. -Neutropenia is the result of decreased production of neutrophils or increased destruction of cells. Neutrophils are essential in preventing and limiting bacterial infection. A client with neutropenia is at increased risk for infection from both exogenous and endogenous sources. Actions to reduce the risk of an infection include avoiding working in the garden because of microorganisms in the soil. Fluid intake should be increased to 3 L per day. An incentive spirometer may be used every 4 hours while awake for clients with neutropenia who have limited mobility. Any indications of an infection such as a fever should be reported to the health care provider. The client would be advised to avoid people with infections and avoid crowds and not increase the amount of time out of doors with other people.
The nurse is preparing the patient for a test to determine the cause of vitamin B12 deficiency. The patient will receive a small oral dose of radioactive vitamin B12 followed by a large parenteral dose of nonradioactive vitamin B12. What test is the patient being prepared for? Bone marrow biopsy Schilling test Bone marrow aspiration Magnetic resonance imaging (MRI) study
Schilling test -The classic method of determining the cause of vitamin B12 deficiency is the Schilling test, in which the patient receives a small oral dose of radioactive vitamin B12, followed in a few hours by a large, nonradioactive parenteral dose of vitamin B12 (this aids in renal excretion of the radioactive dose).
A patient with sickle cell disease comes to the emergency department and reports severe pain in the back, right hip, and right arm. What intervention is important for the nurse to provide? Start an intravenous line with dextrose 5% in 0.25 normal saline Administer ibuprofen Administer aspirin Begin oxygen at 2 L/M
Start an intravenous line with dextrose 5% in 0.25 normal saline -Adequate hydration is important during a painful sickling episode. Oral hydration is acceptable if the patient can maintain adequate fluid intake; IV hydration with dextrose 5% in water (D5W) or dextrose 5% in 0.25 normal saline solution (3 L/m2/24 h) may be required for a sickle crisis. Supplemental oxygen may also be needed.
A client is prescribed 325 mg/day of oral ferrous sulfate. What does the nurse include in client teaching? Decrease intake of fruits and juices Take with dairy products Decrease intake of dietary fiber Take 1 hour before breakfast
Take 1 hour before breakfast -Instructions the nurse will provide for the client taking oral ferrous sulfate is to administer the medication on an empty stomach. Instructions also include that there is decreased absorption of iron with food, particularly dairy products. The client is to increase vitamin C intake (fruits, juices, tomatoes, broccoli), which will enhance iron absorption. The client is to also increase foods high in fiber to decrease risk of constipation.
A client is treated for anemia. What is the nurse's best understanding about the correlation between anemia and the client's iron stores? There is a weak correlation between iron stores and hemoglobin levels. There is a strong correlation between iron stores and hemoglobin characteristics. There is an inverse relationship between iron stores and hemoglobin levels. There is a strong correlation between iron stores and hemoglobin levels.
There is a strong correlation between iron stores and hemoglobin levels. -A strong correlation exists between laboratory values that measure iron stores and hemoglobin levels. After iron stores are depleted (as reflected by low serum ferritin levels), the hemoglobin level falls.
A nurse on a hematology/oncology floor is caring for a client with aplastic anemia. Which would not be included in the client's discharge instructions? Encourage frequent handwashing. Avoid contact with family/friends who are sick. Use a disposable razor when shaving. Plan for frequent periods of rest.
Use a disposable razor when shaving. -People with aplastic anemia usually have insufficient erythrocytes, leukocytes, and platelets. Encourage behaviors that will lower the risk for bleeding. Avoiding contact with people who are sick reduces the risk of acquiring an infection. Handwashing reduces the risk of acquiring an infection. Anemia can cause fatigue and shortness of breath with even mild exertion.
A client is seen in the emergency department with severe pain related to a sickle cell crisis. What does the nurse understand is occurring with this client? The client has a decreased tolerance of pain related to the chronic nature of the illness. Bone marrow decreases the erythrocyte production causing decrease in hypoxia. Vascular occlusion in small vessels decreasing blood and oxygen to the tissues. Overhydration enlarges the red blood cells.
Vascular occlusion in small vessels decreasing blood and oxygen to the tissues. -The person with sickle cell disease repeatedly suffers from two major problems: (1) episodes of sickle cell crisis from vascular occlusion, which develops rapidly under hypoxic conditions, and (2) chronic hemolytic anemia. During a sickle cell crisis, the sickle-shaped cells lodge in small blood vessels, where they block the flow of blood and oxygen to the affected tissue. The vascular occlusion induces severe pain in the ischemic tissue. The client may have increased tolerance for pain due to the chronic nature of the illness. Bone marrow increases the erythrocyte production. Underhydration increases the client's risk of developing a vaso-occlusive crisis.
