med/surg test 3 prepu chapter 33
Which nursing instructions help parents of a child with hemophilia provide a safe home environment for their child?
"Establish a written emergency plan including what to do in specific situations and the names and phone numbers of emergency contacts." Explanation: Establishing a written emergency plan that includes what to do in specific situations helps the family provide safety measures for their child with hemophilia. Padding corners of furniture and using kneepads don't help provide a safe home environment for children of all ages. Telling the parents to be a role model by wearing a bike helmet is only applicable to children who are old enough to emulate their parent's behaviors. Having the child problem-solve hypothetical health situations doesn't help provide a safe environment; it addresses problem solving.
The nurse is collecting data for a patient who has been diagnosed with iron-deficiency anemia. What subjective findings does the nurse recognize as symptoms related to this type of anemia?
"I have difficulty breathing when walking 30 feet." Explanation: Most clients with iron-deficiency anemia have reduced energy, feel cold all the time, and experience fatigue and dyspnea with minor physical exertion. The heart rate usually is rapid even at rest. The CBC and hemoglobin, hematocrit, and serum iron levels are decreased. The client would feel cold and not hot. The client is fatigue and able to sleep often with a decrease in appetite, not an increase.
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 for the rest of my life." Explanation: 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 (Coumadin). The nurse teaches the client about warfarin therapy. Which statement by the client indicates the need for further teaching?
"I'll eat four servings of fresh, dark green vegetables every day." Explanation: 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 client is prescribed 325 mg/day of oral ferrous sulfate. The nurse includes in client teaching, "Take your iron pill
1 hour before breakfast" Explanation: 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 few minutes after beginning a blood transfusion, a nurse notes that a client has chills, dyspnea, and urticaria. The nurse reports this to the physician immediately because the client probably is experiencing which problem?
A hemolytic allergic reaction caused by an antigen reaction Explanation: Hemolytic allergic reactions are fairly common and may cause chills, fever, urticaria, tachycardia, dyspnoea, 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, diarrhoea, abdominal cramps and, possibly, shock.
Which of the following is the most common hematologic condition affecting elderly patients
Anemia Explanation: 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.
A client with a diagnosis of pernicious anemia comes to the clinic complaining of numbness and tingling in his arms and legs. What do these symptoms indicate?
Neurologic involvement Explanation: 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 client with a diagnosis of pernicious anemia comes to the clinic complaining of numbness and tingling in their arms and legs. What do these symptoms indicate?
Neurologic involvement Explanation: 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.
The nurse is caring for an older adult client who has a hemoglobin of 9.6 g/dL and a hematocrit of 34%. To determine where the blood loss is coming from, what intervention can the nurse provide?
Observe stools for blood. Explanation: Iron-deficiency anemia is unusual in older adults. Normally, the body does not eliminate excessive iron, causing total body iron stores to increase with age and necessitating maintenance of hydration. If an older adult is anemic, blood loss from the gastrointestinal or genitourinary tracts is suspected. Observing the stool for blood will help detect blood from GI loss. Bleeding gums may indicate periodontal disease, or anticoagulation from medication is not related to age. Blood in sputum can be an indicator of various lung disorders that may affect all age groups. Facial droop may indicate an impending stroke or Bell's palsy and would not be a reason for blood loss
When evaluating a patient's symptoms that are consistent with a diagnosis of leukemia, the nurse is aware that a common feature of all leukemias is which of the following?
Unregulated accumulation of white cells in the bone marrow, which replace normal marrow elements Explanation: 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 client with sepsis is experiencing disseminated intravascular coagulation (DIC). The client is bleeding from mucous membranes, venipuncture sites, and the rectum. Blood is present in the urine. The nurse establishes the nursing diagnosis of Risk for deficient fluid volume related to bleeding. The most appropriate and measurable outcome for this client is that the client exhibits
Urine output greater than or equal to 30 mL/hour Explanation: All options could be expected outcomes for a nursing diagnosis of risk for deficient fluid volume. However, the key words are most appropriate and measurable. That would be the option relating to urine output, which is the most direct measurement listed of fluid volume.
A nurse is caring for a client with thrombocytopenia. What is the best way to protect this client?
Use the smallest needle possible for injections. Explanation: 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.
During preparation for bowel surgery, a client receives an antibiotic to reduce intestinal bacteria. The nurse knows that hypoprothrombinemia may occur as a result of antibiotic therapy interfering with synthesis of which vitamin?
Vitamin K Explanation: Intestinal bacteria synthesize such nutritional substances as vitamin K, thiamine, riboflavin, vitamin B12, folic acid, biotin, and nicotinic acid. Antibiotic therapy may interfere with synthesis of these substances, including vitamin K. Intestinal bacteria don't synthesize vitamins A, D, or E.
A client is being admitted to the hospital with abdominal pain, anemia, and bloody stools. He complains of feeling weak and dizzy. He has rectal pressure and needs to urinate and move his bowels. The nurse should help him:
onto the bedpan. Explanation: A client who's dizzy and anemic is at risk for injury because of his weakened state. Assisting him with the bedpan would best meet his needs at this time without risking his safety. The client may fall if walking to the bathroom, left alone to urinate, or trying to stand up.
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, it is important for the nurse to
Administer the prescribed enoxaparin (Lovenox). Explanation: 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
Which of the following nursing interventions should be incorporated into the plan of care to manage the delayed clotting process in a patient with leukemia?
Apply prolonged pressure to needle sites or other sources of external bleeding Explanation: For a patient 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.
Which of the following nursing interventions should be incorporated into the plan of care to manage the delayed clotting process due to thrombocytopenia in a patient with leukemia?
Applying prolonged pressure to needle sites or other sources of external bleeding Explanation: The interventions for a patient with thrombocytopenia are the same as those for a patient with cancer who is at risk for bleeding. For a patient 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.
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. Explanation: 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.
Which of the following is a symptom of Hemochromatosis?
Bronzing of the skin Explanation: Patients 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.
A client reports feeling tired, cold, and short of breath at times. Your assessment reveals tachycardia and reduced energy. What would you expect the physician to order?
CBC Explanation: Most clients with iron-deficiency anemia have reduced energy, feel cold all the time, and experience fatigue and dyspnea with minor physical exertion. The heart rate usually is rapid even at rest. The CBC and hemoglobin, hematocrit, and serum iron levels are decreased. A CBC would be ordered. The CBC and hemoglobin, hematocrit, and serum iron levels are decreased.
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. The most important action of the nurse is to
Consult with the physician about discontinuing heparin. Explanation: 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.
When a nurse is planning discharge teaching for a patient admitted with a sickle cell crisis, which of the following should the nurse include in the teaching?
Correct response: Teach patients to receive pneumococcal and annual influenza vaccinations Explanation: Patients with sickle cell anemia must treat infections promptly with appropriate antibiotics; infections, particularly pneumococcal infections, can be serious. These patients should receive pneumococcal and annual influenza vaccinations
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 Explanation: 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 patient's family member asks the nurse why disseminated intravascular coagulation (DIC) occurs. Which of the following statements made by the nurse correctly explains the cause of DIC?
DIC is caused by an abnormal activation of clotting pathway causing excessive amounts of tiny clots to form inside organs. Explanation: 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 so that 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).
A patient with chronic renal failure is examined by the nurse practitioner for anemia. The nurse knows to review the laboratory data for a decreased hemoglobin level, red blood cell count, and which of the following?
Decreased level of erythropoietin Explanation: As renal function decreases, erythropoietin, which is produced by the kidney, also decreases. Because erythropoietin is produced outside the kidney, some erythropoiesis continues, even in patients whose kidneys have been removed. However, the number of red blood cells produced is small and the degree of erythropoiesis is inadequate
A client with anemia has been admitted to the medical-surgical unit. Which assessment findings are characteristic of iron deficiency anemia?
Dyspnea, tachycardia, and pallor Explanation: 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.
When assessing a female patient with a disorder of the hematopoietic or the lymphatic system, which of the following assessments is most essential?
Health history, such as bleeding, fatigue, or fainting Explanation: When assessing a patient with a disorder of the hematopoietic or the lymphatic system, it is essential to assess the patient's health history. An assessment of drug history is essential because some antibiotics and cancer drugs contribute to hematopoietic dysfunction. Aspirin and anticoagulants may contribute to bleeding and interfere with clot formation. Because industrial materials, environmental toxins, and household products may affect blood-forming organs, the nurse needs to explore exposure to these agents. Age, gender, menstrual history, or lifestyle assessments, such as exercise routines and habits, do not directly affect the hematopoietic or lymphatic system.
A patient with ESRD 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?
Hemoglobin level Explanation: 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 client receiving a blood transfusion experiences an acute hemolytic reaction. Which nursing intervention is the most important?
Immediately stop the transfusion, infuse normal saline solution, call the physician, and notify the blood bank. Explanation: When a transfusion reaction occurs, the transfusion should be immediately stopped, normal saline solution should be infused to maintain venous access, and the physician and blood bank should be notified immediately. Other nursing actions include saving the blood bag and tubing, rechecking the blood type and identification numbers on the blood tags, monitoring vital signs, obtaining necessary laboratory blood and urine samples, providing proper documentation, and monitoring and treating for shock. Because they can cause red blood cell hemolysis, dextrose solutions shouldn't be infused with blood products. Antihistamines are administered for a mild allergic reaction, not a hemolytic reaction.
During the review of morning lab values on a patient complaining of severe fatigue and a red, swollen tongue, the nurse suspects chronic, severe iron deficiency anemia based on which of the following findings?
Low ferritin level Explanation: 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 level.
Which of the following terms refers to a form of white blood cell involved in immune response?
Lymphocyte Explanation: Both B and T lymphocytes respond to exposure to antigens. Granulocytes include basophils, neutrophils, and eosinophils. A spherocyte is a red blood cell without central pallor, seen with hemolysis. A thrombocyte is a platelet.
Vitamin B and folic acid deficiencies are characterised by production of abnormally large erythrocytes called
Megaloblasts Explanation: Megaloblasts are abnormally large erythrocytes. Blast cells are primitive WBCs. Mast cells are cells found in connective tissue involved in defense of the body and coagulation. Monocytes are large WBCs that become macrophages when they leave the circulation and move into body tissues.
A nursing instructor is evaluating a student caring for a neutropenic patient. The instructor concludes that the nursing student demonstrates accurate knowledge of neutropenia based on which of the following interventions?
Monitoring the patient's temperature and reviewing the patient's complete blood count (FBC) with differential Explanation: Patients with neutropenia often do not exhibit classic signs of infection. Fever is the most common indicator of infection, yet it is not always present. There are no definite symptoms of neutropenia until the patient develops an infection. A routine FBC with differential can reveal neutropenia before the onset of infection.
A client with multiple myeloma is complaining of severe pain when the nurse comes in to give a bath and change position. What is the priority intervention by the nurse?
Obtain the pain medication and delay the bath and position change until the medication reaches its peak. Explanation: When pain is severe, the nurse delays position changes and bathing until an administered analgesic has reached its peak concentration level and the client is experiencing maximum pain relief. Pain medication should never be delayed to assist in the control of the level of pain. Pain will not be relieved by a bath and clean sheets, only analgesics at this point in the client's illness.
A client diagnosed with systemic lupus erythematosus comes to the emergency department with severe back pain. She reports that she first felt pain after manually opening her garage door and that she is taking prednisone daily. What adverse effect of long-term corticosteroid therapy is most likely responsible for the pain?
Osteoporosis Explanation: 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
While monitoring a client for the development of disseminated intravascular coagulation (DIC), the nurse should take note of which assessment parameters?
Platelet count, prothrombin time, and partial thromboplastin time Explanation: The diagnosis of DIC is based on the results of laboratory studies of prothrombin time, platelet count, thrombin time, partial thromboplastin time, and fibrinogen level as well as client history and other assessment factors. Blood glucose levels, WBC count, calcium levels, and potassium levels aren't used to confirm a diagnosis of DIC
The Pediatric Nurse Practitioner is doing a physical examination of a client with sickle cell anemia. Why would the nurse practitioner auscultate the lungs and heart?
To detect the abnormal sounds suggestive of acute chest syndrome and heart failure Explanation: 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.