Hematologic & Immune Disorders

A nurse is teaching a client with iron-deficiency anemia about proper dietary choices. Which food(s) will the nurse advise the client to avoid? Select all that apply. 1. Iced tea 2. Yogurt 3. Coffee 4. Steak 5. Broccoli

1, 2, 3. Clients with iron-deficiency anemia should choose foods high in iron, high in fiber, and high in protein. Tea, coffee, and calcium (in yogurt) block iron absorption and thus should be avoided.

A client with rheumatoid arthritis is receiving oral prednisone. Which side effect(s) will the nurse expect to see from prolonged use of this medication? Select all that apply. 1. Weight loss 2. Hyperglycemia 3. Osteoporosis 4. Hirsutism 5. Cataract

2, 3, 4, 5. Prednisone is a corticosteroid used for inflammation. Prolonged use of this drug causes hyperglycemia, osteoperosis, hirsutism, and cataract formation. Clients taking this medication experience weight gain, not weight loss, due to fluid retention.

The nurse is assessing a client who has been experiencing black stools for the past month. The client suddenly reports chest and stomach pain. Which action will the nurse perform first? 1. Give nasal oxygen. 2. Take vital signs. 3. Begin cardiac monitoring. 4. Draw blood for laboratory analysis

2. Taking vital signs would determine hemodynamic stability, and monitoring heart rhythm may be indicated based on assessment findings. Giving nasal oxygen and drawing blood are not part of a screening assessment.

A client is admitted with a serum potassium level of 6.5 mEq/L (6.5 mmol/L). Which medication will the nurse anticipate administering to the client? 1. Potassium chloride 2. Sodium polystyrene 3. Lisinopril 4. Spironolactone

2. The client has an elevated serum potassium level. The normal potassium level is 3.5 to 5.3 mEq/L (3.5 to 5.3 mmol/L). Sodium polystyrene is used to lower serum potassium in clients with hyperkalemia. Giving potassium chloride, an angiotensin-converting enzyme inhibitor (such as lisinopril), or a potassium-sparing diuretic (such as spironolactone) would further increase the serum potassium level.

A client is receiving 1 liter of 0.9% sodium chloride intravenously (IV), to be infused for 12 hours. The IV infusion set has a drop factor of 15 drops per milliliter. How many drops per minute will the nurse set the IV to infuse at? Record your answer using a whole number.

21 gtts/min

The nurse provides education to a group of clients about types of immunity. Which statement will the nurse provide as an example of passive acquired immunity? 1. "A toddler receives the necessary immunizations before beginning preschool." 2. "After having chickenpox, a teenager is unlikely to get the disease again." 3. "A nurse exposed to hepatitis B virus from a needlestick receives hepatitis B immune globulin." 4. "An adult with a history of having a varicella zoster as a child develops shingles."

3. Immune globulin provides a temporary immunity that is passively acquired. Antibodies from one person are recovered and administered to another person to help prevent infection. Because the recipient's immune system did not make the antibodies, the immunity is considered to be passively acquired. Immunizations and actual disease processes, such as chickenpox, cause the body to manufacture antibodies against future exposure to these specific antigens; this is called active immunity. Active immunity produces antibodies that are either permanent or longer lasting than passively acquired immunity. Shingles develops when latent varicella zoster virus is activated. Varicella zoster is the virus that causes chickenpox.

Which instruction is appropriate for the nurse to include when providing education to a client with human immunodeficiency virus (HIV) who is at high risk for altered oral mucous membranes? 1. "Brush your teeth frequently with a firm toothbrush." 2. "Use mouthwash that contains an astringent agent." 3. "You always have to heat the foods you consume." 4. "It is important for you to lubricate your lips."

4. Lubricating the lips keeps them moist and prevents cracking. A firm toothbrush would damage already sensitive gums. An astringent would be painful, as would foods that are too hot.

Which nursing intervention is most appropriate for a client diagnosed with multiple myeloma? 1. Monitoring respiratory status 2. Balancing rest and activity 3. Restricting fluid intake 4. Preventing bone injury

4. When caring for a client with multiple myeloma, the nurse should focus on relieving pain, preventing bone injury and infection, and maintaining hydration. Monitoring respiratory status and balancing rest and activity are appropriate interventions for any client. To prevent such complications as pyelonephritis and renal calculi, the nurse should keep the client well hydrated, not restrict the client's fluid intake.

The nurse is providing teaching about what to expect during bone marrow aspiration. Place the following nursing actions in chronological order according to how the nurse will assist the client during the procedure. Use all of the options. 1. Apply direct pressure over the puncture site. 2. Explain the procedure and obtain consent. 3. Monitor the puncture site for bleeding. 4. Help the client maintain position. 5. Check coagulation studies. 6. Position the client on the lateral decubitus or prone.

Ordered response: 2, 5, 6, 4, 1, 2.

A client is placed on neutropenic precautions. Which nursing action(s) is appropriate? Select all that apply. 1. Placing the client in a private room 2. Asking the client to wear a mask during transport 3. Limiting the number of visitors allowed in the room 4. Placing the client on reverse isolation precautions 5. Brushing the client's teeth with a soft toothbrush

1, 2, 3, 4, 5. A client with neutropenia has a low white blood cell count, which makes it easier for the client to get an infection. Neutropenic precautions involve placing the client in a private room, using reverse isolation (the nurse wears a mask when entering the client's room to prevent infecting the client and the client wears a mask during transport), and avoiding crowds around the client by limiting the number of visitors. A soft toothbrush should be used to prevent damaging the gums, which could lead to an infection.

The nurse is providing education about the adverse reactions of doxorubicin. Which side effect(s) will the nurse include in the teaching for the client? Select all that apply. 1. Chest pain 2. Nausea 3. Dehydration 4. Liver failure 5. Bone damage

1, 2, 3, 4. Doxorubicin is an antineoplastic antibiotic. Adverse reactions to doxorubicin include cardiac changes, liver changes, nausea, and dehydration. Bone damage is not considered an adverse effect of this medication.

A client diagnosed with human immunodeficiency virus (HIV) is receiving zidovudine. Which laboratory data will the nurse monitor closely for this client? Select all that apply. 1. White blood cell count 2. Hemoglobin level 3. Liver function tests results 4. Lactate level 5. Glucose level

1, 2, 3, 4. Zidovudine (AZT), which is used to treat HIV infection, can cause agranulocytosis, anemia, hepatomegaly, and lactic acidosis. Glucose changes are not common with AZT, although the nurse may see hyperglycemia with other HIV medications.

Which finding(s) will the nurse expect to assess in a client diagnosed with systemic lupus erythematosus (SLE)? Select all that apply. 1. Rash on the face 2. A client report of feeling tired 3. Swollen joints bilaterally 4. Petechiae on the chest and back 5. A client report of arthralgia

1, 2, 3, 5. Common signs and symptoms of SLE include a butterfly rash on the face, fatigue, swollen joints, and painful joints (arthralgia). Petechiae is not associated with SLE and would indicate decreased platelets resulting in minor bleeding from broken capillaries.

A client is admitted with serum calcium level of 6 mg/dL (1.5 mmol/L). The nurse will monitor the client for which finding(s)? Select all that apply. 1. Fatigue 2. Muscle weakness 3. Confusion 4. Diarrhea 5. Bradycardia

1, 2, 3. The normal serum calcium level is 8.5 to 10.5 mg/dL (2.1 to 2.6 mmol/L). Common signs and symptoms of hypocalcemia include fatigue, muscle weakness, confusion, and constipation. Diarrhea and bradycardia are not associated with hypocalcemia.

The nurse is assessing a client with suspected pernicious anemia. Which finding(s) suggest to the nurse that the client has this diagnosis? Select all that apply. 1. Cracked corners of the mouth 2. Smooth, bright red tongue 3. Hemoglobin level of 14 g/dL (140 g/L) 4. Sensitivity to cold air 5. Dyspnea when walking

1, 2, 4, 5. Pernicious anemia is a vitamin B₁₂ deficiency due to a lack of the intrinsic factor produced by gastric mucosa. Intrinsic factor is necessary for the absorption of vitamin B₁₂. Clinical manifestations include pallor, fatigue, dyspnea on exertion, cheilosis (scaling of the surface of lips and fissures in the corner of the mouth), and sensitivity to cold. The client also has a smooth, sore, bright red tongue because of the atrophy of the papillae of the tongue due to vitamin B₁₂ deficiency. A hemoglobin level of 14 g/dL (140 g/L) is normal.

A client is admitted with a platelet count of 98,000/μL (98 ✕ 10⁹/L). Which instruction(s) will the nurse provide during the client's education? Select all that apply. 1. Do not use dental floss. 2. Use an electric razor to shave. 3. Do not go to crowded places. 4. Avoid eating crusty or rough foods. 5. Eat fresh, uncooked vegetables.

1, 2, 4. The normal thrombocyte (platelet) count is 150,000/μL (150 ✕ 10⁹/L) to 400,000/μL (400 ✕ 10⁹/L). The client has thrombocytopenia or low platelet count, which predisposes the client to bleeding. The client should avoid using dental floss because it may injure the gums and cause bleeding. Eating crusty or rough foods such as crackers, nuts, and chips may cut the inside of the mouth and cause bleeding. The use of an electric razor rather than a blade is recommended to avoid cuts. Avoiding crowded places and avoiding eating fresh vegetables are precautionary measures for a client with a low white blood cell count.

Which nutritional education will the nurse include while teaching a client with acquired immunodeficiency syndrome (AIDS)? Select all that apply. 1. Thoroughly cook meats. 2. Choose foods low in fat. 3. Choose low-calorie foods. 4. Weigh yourself weekly. 5. Eat small, frequent meals.

1, 2, 5. To prevent foodborne illness, all meat and poultry should be cooked thoroughly. It is necessary to avoid foods high in fats because drugs used to treat AIDS may cause hyperlipidemia. Consuming small, frequent meals consisting of high-calorie, nutrient-dense food helps improve overall nutrition. Daily, not weekly, weighing is important in determining patterns of weight loss.

Which client laboratory test(s) does the nurse recognize as best for confirming the diagnosis of essential thrombocytopenia? Select all that apply. 1. Bleeding time 2. Platelet count 3. Complete blood count (CBC) 4. Immunoglobulin (Ig) G level 5. Prothrombin time (PT) and international normalized ratio (INR)

1, 2. A platelet count and bleeding time are the best tests to determine thrombocytopenia. The platelet count is decreased and bleeding time prolonged in a client with thrombocytopenia. IgG assays are nonspecific but may help determine the diagnosis. A CBC shows the hemoglobin levels, hematocrit, and white blood cell values. PT and INR evaluate the effect of warfarin therapy.

Which information will the nurse include in the discharge instruction(s) for a client diagnosed with hemophilia? Select all that apply. 1. "Swimming is an appropriate form of exercise for you." 2. "Playing basketball is a great way for you to socialize with others." 3. "You should immediately elevate your extremity if you start bleeding." 4. "Take acetaminophen if you experience pain or fever." 5. "If you eat healthy foods, you should not have to worry about bleeding."

1, 3, 4. A client with hemophilia should avoid contact sports such as basketball because of the risk of bleeding with injury. The client can safely participate in non-contact sports such as swimming. The nurse should instruct the client to elevate extremities if bleeding occurs. The client with hemophilia may take acetaminophen for pain or fever but should avoid aspirin because of the increased risk of bleeding. Because hemophilia is a genetic disorder, eating healthy foods does not alter the client's diagnosis of hemophilia.

The nurse prepares to start an intravenous access site in a client with Kaposi sarcoma. Which action(s) will the nurse perform? Select all that apply. 1. Wear gloves. 2. Apply shoe covers. 3. Don a surgical mask. 4. Use aseptic technique. 5. Wash hands prior to performing the procedure.

1, 4, 5. Kaposi sarcoma is a type of skin cancer seen in clients with acquired immunodeficiency syndrome (AIDS). It is a red-brown to purplish skin lesion. The nurse should use standard precautions when caring for clients with AIDS, which include washing hands, wearing gloves, and using aseptic (sterile) technique when starting an intravenous line. Surgical masks are used for droplet precaution. Shoe covers are not necessary.

The nurse cares for a client reporting chest and stomach pain with a history of black, tarry stools for the past 2 months. Which client lab value is priority for the nurse to review? 1. Complete blood count (CBC) 2. Prothrombin time (PT) 3. Fecal occult blood test 4. Serum metabolic panel

1. A CBC determines anemia (hemoglobin) and is priority for the nurse to review based on the client's history. The test for occult blood determines blood in the stool and is helpful to determine the site of bleeding, but knowing the hemoglobin level first helps determine whether the client needs a blood transfusion immediately. A serum metabolic panel includes assessment of glucose, electrolytes, blood urea nitrogen, and creatinine levels. PT is measured to verify bleeding dyscrasias.

A nurse has provided education to a client about taking ferrous sulfate liquid preparation. Which statement by the client indicates to the nurse that additional education is needed? 1. "I should take the iron with an antacid to prevent gastric distress." 2. "I can expect my stools to be dark green or black." 3. "I should rinse my mouth with water after taking the iron." 4. "I should add the iron to juice and drink it with a straw."

1. Antacids interfere with absorption of iron and should be avoided. Dark green or black stools are a common adverse effect of iron supplements. Rinsing the mouth after swallowing liquid iron and drinking the liquid iron through a straw help the client prevent teeth discoloration from contact with the iron preparation.

The nurse is educating a client on about atazanavir. Which adverse effect will the nurse include in the teaching? 1. Hyperglycemia 2. Thrombocytopenia 3. Leukocytosis 4. Hypolipidemia

1. Atazanavir is an antiretroviral-protease inhibitor drug used in combination with other antiretroviral medications to help manage human immunodeficiency virus (HIV) infection. Adverse effects include hyperglycemia, new-onset or worsened diabetes, and lactic-acidosis syndrome but do not include thrombocytopenia, leukocytosis, or hypolipidemia.

The nurse is caring for a client with multiple myeloma. Which laboratory value will the nurse anticipate for this client? 1. Serum calcium of 10.9 mg/dL (2.72 mmol/L) 2. Serum potassium of 5.8 mEq/L (5.8 mmol/L) 3. Serum sodium of 150 mEq/L (150 mmol/L) 4. Serum magnesium of 3.0 mEq/L (1.5 mmol/L)

1. Calcium is released when bone is destroyed. This causes an increase in serum calcium levels. Normal serum calcium level is 8.5 to 10.5 mg/dL (2.1 to 2.6 mmol/L). The normal serum potassium level is 3.5 to 5.3 mEq/L (3.5 to 5.3 mmol/L). The normal sodium level ranges from 135 to 145 mEq/L (135 to 145 mmol/L). The normal magnesium level is 1.5 to 2.5 mEq/L (0.75 mmol/L to 1.25 mmol/L). Multiple myeloma does not affect potassium, sodium, or magnesium levels.

Which nursing action is priority when caring for a client who has been prescribed corticosteroids? 1. Obtain a finger-stick glucose. 2. Perform strict intake and output monitoring. 3. Assess a daily chemistry panel. 4. Promote a nighttime sleeping schedule.

1. Corticosteroids cause elevated blood glucose levels, which increases the client's chance of infection; because insulin may be necessary to maintain normal blood glucose levels, it is priority to assess glucose level. Corticosteroids can cause edema, but strict intake and output is generally unnecessary unless the client also has renal or cardiac disease. Although corticosteroids can cause changes in potassium levels, it is usually not necessary to monitor a daily chemistry panel in clients undergoing corticosteroid therapy. Corticosteroids can alter a client's sleeping pattern, but promoting sleep is not the priority.

A client is receiving epoetin alfa. Which laboratory value indicates to the nurse the treatment is effective for this client? 1. Hemoglobin of 14 g/dL (140 g/L) 2. Hematocrit of 30% (0.30) 3. White blood cell count of 7,000/μL (7.00 ✕ 10⁹/L) 4. Platelet of 350,000/μL ( 350 ✕ 10⁹/L)

1. Epoetin alfa is given to a client to stimulate the production of red blood cells. The normal hemoglobin level for males is 14 to 18 g/dL (140 to 180 g/L) and for females is 12 to 16 g/dL (120 to 160 g/L). The normal hematocrit level for males is 40% to 54% (0.40 to 0.54) and for females is 37% to 47% (0.37 to 0.47). The other findings are unrelated to the drug's effectiveness.

The nurse has instructed the client on self-administration of heparin injections. The nurse determines that teaching is effective when the client makes which statement? 1. "Heparin slows the time it takes for my blood to clot." 2. "Heparin works by stopping my blood from clotting." 3. "Heparin will cause my blood to become thin." 4. "Heparin will dissolve any clots in my blood."

1. Heparin prolongs the time needed for blood to clot; however, it does not thin the blood. If given in large doses, heparin may stop the blood from clotting; however, this is not why heparin is usually given. Heparin does not dissolve clots.

The nurse cares for a client brought to the emergency department for a gunshot wound to the abdomen. The nurse obtains the client's vital signs and notes that the client's pulse is 120 beats/min, respirations 22 breaths/min, and blood pressure 76/42 mm Hg. The client is unresponsive. Which action will the nurse perform first? 1. Give 1 U of O negative packed red blood cells (RBCs). 2. Begin infusion of fresh frozen plasma. 3. Reassess the client's vital signs. 4. Obtain blood for a type and crossmatch.

1. In a trauma situation, the first blood product given is unmatched (O negative) packed RBCs. Fresh frozen plasma is commonly used to replace clotting factors. Reassessment of the client's vital signs can be done after the nurse has intervened. A type and cross-match for blood is not needed in an emergency situation.

A client diagnosed with ankylosing spondylitis is newly prescribed indomethacin. The nurse will notify the healthcare provider if the client states he or she is/are also taking which medication? 1. Heparin 2. Gabapentin 3. Adalimumab 4. Etanercept

1. Indomethacin is a nonsteroidal anti-inflammatory drug (NSAID) used for clients with ankylosing spondylitis. NSAIDs are aspirin and aspirin-like medications that may increase the risk of bleeding when taken with an anticoagulant such as heparin. An anticonvulsant drug (gabapentin) or a tumor necrosis factor inhibitor (adalimumab or etanercept) would not cause a serious drug interaction when taken with indomethacin.

The nurse is preparing to administer medications to four clients. Which prescription will the nurse question? 1. Indomethacin to a client with lymphoma being prepped for a lung biopsy 2. Magnesium sulfate to a client with a current serum magnesium level of 1.2 mEq/L 3. Filgrastim to a client with a low white blood cell count and neutropenia 4. Emtricitabine to a client with acquired immunodeficiency syndrome (AIDS)

1. Indomethacin is an NSAID that may inhibit platelet aggregation. The administration of indomethacin should be questioned prior to invasive procedures because it can increase the risk of bleeding. Magnesium sulfate is given to clients with hypomagnesemia (serum magnesium level less than 1.5 mEq/L). Filgrastim is given to a client with a low white blood cell (WBC) count and neutropenia. Emtricitabine is a non-nucleoside reverse transcriptase inhibitor (NNRTI) drug used for clients with HIV/AIDS.

The nurse is monitoring a client receiving a blood transfusion for volume replacement. The client reports itching about 20 minutes after the infusion begins. Which nursing action is priority? 1. Stop the blood transfusion. 2. Call the healthcare provider. 3. Give oral diphenhydramine. 4. Continue to monitor the client.

1. Itching is a sign of an adverse reaction, so the nurse must stop the infusion. The healthcare provider should be called but only after the infusion has been stopped and the client is assessed. No medications should be administered without first reporting the symptom and having the infusion stopped. The nurse should continue to monitor the client after intervening.

A nurse is educating a group of student nurses on disease prevalence in community health and epidemiologic nursing. The nurse knows the students have an understanding of disease prevalence when they make which statement? 1. "It is the number of individuals affected by a particular disease at a specific time." 2. "It is the rate at which individuals without a specific disease develop that disease." 3. "It is the proportion of individuals affected by the disease who live for a specific period." 4. "It is the amount of individuals without the disease who ultimately develop the disease."

1. Prevalence is the number of individuals affected by the disease at a specific time. Risk is the proportion of individuals without the disease who develop the disease within a particular period. Incidence rate is the rapidity with which individuals without the disease contract it. Survival is the proportion of individuals affected by the disease who live for a particular length of time.

A client is admitted with rheumatoid arthritis. Which dietary recommendation will the nurse make to help reduce the client's inflammation? 1. Consume more salmon. 2. Drink vitamin D-fortified milk. 3. Increase red meat consumption. 4. Consume more spinach.

1. Salmon is high in omega-3 fatty acids. The therapeutic effect of fish oil is to suppress inflammatory mediator production (such as prostaglandins); how it works is unknown. Iron-rich foods, such as spinach and red meats, are recommended to decrease the anemia associated with rheumatoid arthritis. Calcium and vitamin D found in milk may help reduce bone resorption.

The nurse is caring for a client who has just had a total hip replacement. It is priority for the nurse to monitor the client closely for the development of which condition? 1. Anemia 2. Polycythemia 3. Purpura 4. Thrombocytopenia

1. Surgery is a risk factor for anemia. Polycythemia can occur from severe hypoxia due to congenital heart and pulmonary disease. Purpura and thrombocytopenia may result from decreased bone marrow production of platelets, but not from surgery.

A client is admitted with human immunodeficiency virus (HIV). Which statement by the client indicates to the nurse the need for further education regarding safer sex practices? 1. "I should use plenty of oil-based lubricant when using a latex condom." 2. "I should inspect the condom for damage or defects before I use it." 3. "I must check the expiration date on the package before using the condom." 4. "Latex condoms are the best choice for preventing the spread of HIV."

1. Water-based lubricants should be used; oil- or petroleum-based products can damage latex condoms and lead to holes or tearing. Latex condoms, as well as polyurethane condoms, which are a good option if the client has a latex allergy, have been proven to decrease the spread of HIV. Checking for damaged, defective, or expired condoms ensures the integrity of the condoms and decreases the likelihood of HIV transmission.

A client undergoing colon cancer treatment has developed thrombocytopenia. The nurse will assess the client for which manifestation(s)? Select all that apply. 1. Diarrhea 2. Hematuria 3. Ecchymosis 4. Melena 5. Epistaxis

2, 3, 4, 5. With thrombocytopenia, there is an abnormal decrease in the number of blood platelets, which can result in bleeding. Hematuria, ecchymosis, melena, and epistaxis are all signs of bleeding. The client may have constipation but usually not diarrhea.

A nurse is assigned to a client who is a practicing Muslim. Which cultural consideration(s) will the nurse take into account when caring for the client? Select all that apply. 1. Administration of blood and blood products is forbidden. 2. An individual should be treated by a healthcare provider of the same sex. 3. Meat products not ritually slaughtered are forbidden. 4. The right hand should be used in handing over items. 5. Any combination of meat and milk is forbidden. 6. Organ donation and transplantation is not allowed.

2, 3, 4. Muslim clients prefer same-gender healthcare providers to take care of them. Muslims can only eat "halal", or ritually slaughtered, meat products. Eating pork is prohibited in Islam. The left hand is reserved for bodily hygiene and is considered unclean. The nurse should always use the right hand in handing over items. Organ donation is allowed for the purpose of saving life. Administration of blood and blood products is prohibited in Jehovah's Witnesses. Eating meat with milk is prohibited in Judaism.

The nurse is caring for an older adult client. Based on the chart exhibit below, which intervention(s) will the nurse include in the client's plan of care? Select all that apply. Test / Result Hematocrit, 61% (0.61) BUN, 32 mg/dL (11.4 mmol/L) Sodium, 159 mEq/L (159 mmol/L) 1. Check for distended neck vein. 2. Test urine for specific gravity. 3. Weigh the client daily. 4. Record input and output. 5. Limit fluid intake.

2, 3, 4. The client is experiencing dehydration. Signs and symptoms of dehydration include thirst, poor skin turgor, flat neck veins, weight loss, confusion, decreased urine output, increased heart rate, thready pulse, and postural hypotension. Fluid volume deficit causes hemoconcentration. Hematocrit, blood urea nitrogen (BUN), and sodium levels increase when the blood is concentrated. The normal hematocrit level for males is 40% to 54% (0.40 to 0.54) and foe females is 37% to 47% (0.37 to 0.47). The normal BUN level is from 8 to 23 mg/dL (2.9 to 8.2 mmol/L). The normal range for sodium level is from 135 to 145 mEq/L (135 to 145 mmol/L). The kidneys compensate by conserving the remaining fluid in the body, leading to a decrease in urine output. Urine specific gravity increases because the urine is concentrated. The nurse should encourage the client to increase fluid intake.

The nurse is providing education to a group of older adult clients about avoiding infection. Which information will the nurse include in the teaching? Select all that apply. 1. "Decreased cardiac output is a common physiological cause of infection in older adults." 2. "Void frequently to prevent bladder infections as your bladder may not empty completely." 3. "The ability of your skin to heal decreases as you age, so monitor any wounds carefully." 4. "Your visual acuity may improve if you avoid becoming sick during the winter months." 5. "Wash your hands often because as you age your immune system has decreased resistance."

2, 3, 5. Although decreased cardiac output is a common physiological change of aging, this is not a common cause of infection. There is an increase in residual volume of the urine due to the decrease in muscle tone of bladder during aging, which can increase the risk of urinary tract infections. Older adult clients should monitor wounds carefully because the ability for the skin to heal diminishes with aging, and avoiding illness during the winter months does not improve the loss. Washing hands is recommended to prevent illness, as a decreased resistance to infection is a common physiologic change during aging.

A client with multiple myeloma is admitted with a calcium level of 14.6 mg/dL (3.65 mmol/L). Which finding(s) will the nurse anticipate in this client on assessment? Select all that apply. 1. Tetany 2. Renal calculi 3. Positive Chvostek sign 4. Decreased bowel sounds 5. Hyperactive deep tendon reflexes (DTRs)

2, 4. The client has hypercalcemia. Normal calcium level is 8.5 to 10.5 mg/dL (2.1 to 2.6 mmol/L). Calcium acts like a sedative; therefore, too much calcium causes sedative effects such as lethargy, confusion, muscle weakness, decreased DTRs, and decreased bowel sounds. Renal calculi are formed because most kidney stones are calcium stones, usually in the form of calcium oxalate. Tetany and Chvostek sign are both signs of hypocalcemia, in which the muscles are becoming tight due to a decrease in calcium. Chvostek sign is the twitching of the facial muscles in response to gentle tapping over the facial nerve in front of the ear.

The nurse cares for a client experiencing a health crisis. Which nursing action is most important after stabilizing the client? 1. Provide education to the family. 2. Assess the client's emotional status. 3. Determine the client's dietary preference. 4. Offer the client assistance with bathing.

2. Although all of the answers are important in the care of the client, it is most important to determine the individual's ability to cope with the emotional, spiritual, and psychological aspects of the crisis. This will make further care easier to provide.

A nurse is reviewing the laboratory results of a client with anemia. Which laboratory value requires the nurse to contact the healthcare provider immediately? 1. Erythrocyte count of 3.1 ✕ 10⁶/μL (3.10 ✕ 10¹²/L) 2. Neutrophil count of 500/μL (0.5 ✕ 10⁹/L) 3. Leukocyte count of 2,300/μL (2.30 ✕ 10⁹/L) 4. Platelet count of 115,000/μL (115 ✕ 10⁹/L)

2. Anemia is defined as a decreased number of erythrocytes (red blood cells) and is an expected finding for a client with anemia. Leukopenia is a decreased number of leukocytes (white blood cells [WBCs]). Neutropenia is a decreased number of neutrophils (a type of WBC) and is not expected with anemia, indicating that the client may have another hematological disorder. Thrombocytopenia is a decreased number of thrombocytes (platelets).

A client is admitted with multiple myeloma. Which finding will the nurse tell the client to immediately report? 1. Increased appetite 2. Back pain 3. Weight gain 4. Decreased thirst

2. Back pain or paresthesia in the lower extremities may indicate impending spinal cord compression from a spinal tumor. This should be recognized and treated promptly because progression of the tumor may result in paraplegia. The other signs and symptoms are unrelated to multiple myeloma.

A nurse is reviewing the healthcare provider's prescription for a client admitted with fatigue, photosensitivity, and a "butterfly" rash on the face. Which medication will the nurse expect to find in the client's medication administration record? 1. Meperidine 2. Azathioprine 3. Phenylephrine 4. Acyclovir

2. Fatigue, photosensitivity, and a "butterfly" rash on face are all signs and symptoms of systemic lupus erthematosus (SLE). Azathioprine is an immunosuppressant used in the treatment of SLE. Pharmacologic treatment of SLE also involves nonsteroidal anti-inflammatory drugs, corticosteroids, and other immunosuppressive agents. Meperidine is an opioid analgesic, phenylephrine is a vasopressor, and acyclovir is an antiviral drug.

Which symptom reported by a client with systemic lupus erythematosus (SLE) alerts the nurse that the client may be experiencing a life-threatening complication? 1. Joint pain 2. Foamy urine 3. Butterfly rash 4. Fever

2. Foamy urine indicates proteinuria and is associated with kidney damage, which is a life-threatening complication of SLE. Joint pain, rashes, and fever are all common symptoms of SLE but are not life-threatening.

A nurse is providing discharge education to a client who had an anaphylactic reaction. Which nursing recommendation is most appropriate for this client? 1. Dry-mop hardwood and ceramic floors. 2. Wear a medical identification bracelet at all times. 3. Have carpet installed in every room of the house. 4. Advise family and friends not to visit during the winter.

2. If the client becomes unconscious or cannot report allergies, medical identification jewelry could provide that information and help healthcare providers intervene and treat anaphylaxis as soon as possible. The client should wet-mop hardwood and ceramic floors because dry-mopping scatters dust, which can trigger allergies. The client should minimize the amount of carpet in the home because carpet traps allergens, such as dust and dirt. Unless the client is ill, the nurse may encourage visits by family and friends to promote healthy social interaction.

Which activity will the nurse recommend for a client receiving chemotherapy who is not on protective isolation? 1. Continuous bed rest 2. Activity as tolerated 3. Walking to the bathroom only 4. Brief periods in a recliner

2. It is important that the client be able to engage in activities that are of interest and to maintain as much independence and autonomy as possible. Bed rest is not necessary, nor is it necessary to limit the client's activity to just walks to the bathroom or brief periods out of the bed to a recliner.

A disease-modifying antirheumatic drug (DMARD) is prescribed by the healthcare provider to a client with rheumatoid arthritis. Which medication will the nurse anticipate administering? 1. Aspirin 2. Methotrexate 3. Ferrous sulfate 4. Prednisone

2. Methotrexate is considered the first-line disease-modifying antirheumatic drug (DMARD) for most clients with rheumatoid arthritis. Ferrous sulfate is not used to treat rheumatoid arthritis. Prednisone may be used to control inflammation when NSAIDs such as aspirin cannot be tolerated.

A client who received massive packed red blood cell blood transfusions now reports feeling heart palpitations and weakness. Which nursing action is priority? 1. Administer insulin. 2. Apply a cardiac monitor. 3. Assess the client's pain level. 4. Reassess hemoglobin and hematocrit levels.

2. The client is experiencing symptoms of transfusion-associated hyperkalemia. Storing packed red blood cells increases the potassium concentration. The priority nursing action would be to apply a cardiac monitor to assess for cardiac arrhythmias. Intravenous regular insulin pushes potassium from the blood into the cell, decreasing the serum potassium level; however, the nurse would first need to assess the potassium level to determine whether hyperkalemia is present. Severe cases of hyperkalemia require hemodialysis. Reassessing the hemoglobin and hematocrit levels and asking the client about pain can be done after verifying the cardiac rhythm.

A client with scleroderma is prescribed a combination of medications that includes steroids and cyclosporine. Which client education will the nurse provide? 1. Avoid eating home-canned foods. 2. Avoid being in crowded places. 3. Stop the medications if bleeding occurs. 4. Take acetaminophen for a fever.

2. The client should avoid situations in which infections can be transmitted because the ability to resist pathogens is diminished. Steroids impair the immune system, and cyclosporine is given to suppress the immune response. Home-canned foods should be boiled for 20 minutes and inspected before being consumed but generally pose no greater risk of infection than commercially canned foods. Steroids and cyclosporine are not associated with bleeding tendencies and should never be stopped abruptly. Even mild febrile episodes should be reported immediately because the client's immune system is impaired, and taking medications such as acetaminophen could mask the presence of serious infections.

Immediately after giving an injection, a nurse is inadvertently stuck with the needle. When is the best time to test the nurse for human immunodeficiency virus (HIV) antibodies? 1. Immediately, and then again in 6 weeks 2. Immediately, and then again in 3 months 3. In 2 weeks, and then again in 6 months 4. In 2 weeks, and then again in 1 year

2. The nurse should be tested immediately to determine whether a preexisting infection is present, and then again in 3 months to detect sero-conversion as a result of the needlestick. Waiting 2 weeks to perform the first test is too late to detect preexisting infection. Retesting sooner than 3 months may yield false-negative results.

The nurse is caring for a client with leukemia who is receiving chemotherapy. Which client need will the nurse consider a priority? 1. Discussing self-image 2. Planning appropriate nutrition 3. Encouraging family support 4. Enhancing mobility

2. The priority should be the client's nutritional needs because chemotherapy may cause nausea, vomiting, stomatitis, and diarrhea. All the other needs are also important but not the priority. According to Maslow's hierarchy of needs, physiologic needs should be met first before psychosocial needs.

A nurse is caring for a client with leukemia who has had a bone marrow transplant. Which nursing intervention is priority? 1. Assisting the client with daily hygiene needs 2. Listening to the breath sounds every 2 hours 3. Palpating the client's pedal pulse every 2 hours 4. Administering pain medication as necessary

2. The two major complications of bone marrow transplantation are bleeding and infection. Listening to the client's breath sounds frequently, comparing them with the baseline, and immediately reporting any congestion helps prevent complications due to infection. Although hygiene and comfort needs should be addressed, they do not take priority over assessing for infection. Collecting data for potentially impaired peripheral circulation is not a priority for clients after a bone marrow transplant.

The nurse is reviewing the client's chart exhibit noted below. Based on the results, which intervention(s) will the nurse include in the client's care plan? Select all that apply. Test / Result Sodium, 133 mEq/L (133 mmol/L) Potassium 4.1 mEq/L (4.1 mmol/L) Chloride, 94 mEq/L (94 mmol/L) Calcium, 11.2 mg/dL (2.79 mmol/L) Magnesium, 1.2 mEq/L (0.49 mmol/L) Phosphorus, 3.1 mg/dL (1 mmol/L) 1. Give daily hydrochlorothiazide per the healthcare provider's prescription. 2. Encourage the client to eat yogurt, milk, cheese, and almonds. 3. Administer magnesium sulfate per the healthcare provider's prescription. 4. Observe for muscle cramps and hyperactive deep tendon reflexes. 5. Limit fluid intake and monitor for jugular vein distension (JVD)/

3, 5. The client has hypercalcemia, hypomagnesemia, hyponatremia, and hypochloremia. The normal calcium level is 8.5 to 10.5 mg/dL (2.1 to 2.6 mmol/L). Normal sodium level is 135 to 145 mEq/L (135 to 145 mmol/L). Normal chloride level is 98 to 107 mEq/L (98 to 107 mmol/L). Normal magnesium level is 1.5 to 2.5 mEq/L (0.62 to 1.03 mmol/L). The nurse should encourage the client to avoid foods high in calcium, such as dairy products and almonds. The nurse should monitor for signs of fluid volume overload related to hyponatremia and hypochloremia by assessing for JVD and should limit fluid intake. The nurse should administer magnesium sulfate because the magnesium level is low. Hydrochlorothiazide is a thiazide diuretic that is contraindicated with hypercalcemia because it inhibits calcium secretion. Signs and symptoms of hypocalcemia, which include muscle cramps, tetany, positive Chvostek sign, positive Trousseau sign, arrhythmias, and hyperactive deep tendon reflexes, would not be expected. All the other laboratory results are normal.

An anemic client is admitted with pallor, fatigue, dry lips, and a smooth, bright red tongue. Which diagnostic test will the nurse anticipate preparing the client for to confirm the client's specific type of anemia? 1. Bone marrow examination 2. Ventilation-perfusion scan 3. Schilling test 4. Tensilon test

3. A smooth, bright red tongue is a sign of a vitamin B₁₂ deficiency. The Schilling test is performed to evaluate vitamin B₁₂ absorption and to diagnose pernicious anemia. Pernicious anemia is caused by a lack of intrinsic factor produced by gastric mucosa, which is necessary for vitamin B₁₂ absorption. In the Schilling test, radioactive vitamin B₁₂ is given orally and then urine is collected over the next 24 hours to measure whether the vitamin B₁₂ is normally absorbed. Bone marrow examination is used for aplastic anemia. A ventilation-perfusion scan is used to help diagnose a client with pulmonary embolism. The Tensilon test is a test for myastenia gravis.

A pregnant woman arrives at the emergency department with abruptio placentae at 34 weeks' gestation. The nurse will closely monitor the client for which blood dyscrasia? 1. Thrombocytopenia 2. Idiopathic thrombocytopenic purpura (ITP) 3. Disseminated intravascular coagulation (DIC) 4. Heparin-associated thrombocytopenia and thrombosis (HATT)

3. Abruptio placentae is a cause of DIC because of activation of the clotting cascade after hemorrhage. Thrombocytopenia results from decreased bone marrow production. ITP can result in IDC but not because of abruptio placentae. A client with abruptio placentae would not receive heparin and, as a result, would not be at risk for HATT.

The healthcare provider prescribes a bone marrow biopsy and a platelet transfusion for a client with a bleeding disorder. When will the nurse anticipate the platelets will be administered? 1. Immediately following the bone marrow biopsy 2. One to two hours before the bone marrow biopsy 3. Immediately before the start of the bone marrow biopsy 4. Slowly, while the client is undergoing the bone marrow biopsy

3. Administering platelets immediately before beginning an invasive procedure increases the number of circulating platelets, thereby providing the greatest protection from potential hemorrhage. Administering platelets following the procedure may have some benefit but is not as effective and may not prevent hemorrhage. Administering platelets too early may result in fewer circulating platelets during the procedure. Platelets are fragile and are administered as rapidly as the client can tolerate to minimize their destruction.

Which action is the priority for the nurse to perform for a client infected with human immunodeficiency virus (HIV)? 1. Monitor viral load and CD4 count. 2. Encourage the client to eat high-protein foods. 3. Administer prescribed medications as scheduled. 4. Educate the client about receiving a pneumonia vaccine.

3. Compliance with the prescribed medications is a priority intervention in delaying the onset of acquired immunodeficiency syndrome (AIDS). Eating a diet high in protein to assist with cellular repair, preventative vaccinations, and monitoring viral load and CD4 count is important to assist in the management of HIV. However, administering prescribed medications (antiretrovirals) is priority to delaying or preventing the progression of HIV to AIDS.

A client is receiving dabigatran. Which medication instruction will the nurse include during education? 1. "We will monitor your partial thromboplastin (PT) time and international normalized ratio." 2. "Avoid consuming green leafy vegetables while you are taking dabigatran." 3. "If you experience an upset stomach, immediately report it to your healthcare provider." 4. "To avoid unwanted side effects, take this medication with food or milk."

3. Dabigatran is a direct thombin inhibior, which reduces the risk of stroke, atrial fibrillation, deep vein thrombosis, and pulmonary embolism. The major side effect of this medication is bleeding. Stomach upset should be immediately reported because it may be a sign of gastric ulcer, which would cause bleeding. Unlike with warfarin, monitoring PT and INR and avoiding green leafy vegetables are not necessary while taking dabigatran. This medication can be taken with or without food.

A client is scheduled for a magnetic resonance imaging (MRI). Which situation will require further assessment by the nurse? 1. The client has history of leukemia. 2. The client is allergic to barium. 3. The client is afraid of using elevators. 4. The client is experiencing phototherapy.

3. During an MRI, the client is confined in a small, enclosed, tube-shaped machine. The client who is afraid of using an elevator needs further data collection because this fear may indicate claustrophobia. The other findings are not associated with an MRI.

The nurse suspects enlarged upper chest and neck lymph nodes in a client with Hodgkin lymphoma if which symptoms are noted during assessment? 1. Fever, weight loss, and night sweats 2. Bone pain and jaundice 3. Cough, dysphagia, and stridor 4. Weight loss and malaise

3. Enlarged lymph nodes of the neck and upper chest can produce such symptoms as cough, dysphagia, and stridor due to pressure and obstruction of the structures of the respiratory system and esophagus. Although fever, weight loss, night sweats, and malaise are also seen with Hodgkin lymphoma, these symptoms are not directly related to enlargement of neck and chest lymph nodes. Bone pain and jaundice may indicate bone and liver metastasis.

Which action will the nurse perform when caring for a client with multiple myeloma? 1. Maintain the client on strict bed rest. 2. Encourage dairy products in the diet. 3. Ensure that intravenous fluids are infusing. 4. Assess the client's platelet level.

3. Ensuring fluids are infusing is necessary to dilute calcium and uric acid, and thereby reduce the risk of renal dysfunction for the client with multiple myeloma. Walking, not strict bed rest, is encouraged to prevent further bone demineralization. Clients should avoid dairy products because of high calcium levels. Platelets are not typically affected in multiple myeloma.

While the nurse is teaching a client about the adverse effects of filgrastim, which adverse effect will the nurse tell the client to immediately report to the healthcare provider? 1. Nausea 2. Bone pain 3 Petechiae 4. Fatigue

3. Filgrastim is a leukocyte growth factor used to stimulate the production of white blood cells (WBCs). It is used to decrease the incidence of infection in clients with neutropenia. Adverse effects include petechiae, related to thrombocytopenia, which indicates bleeding. The other conditions are side effects of filgrastim use that do not need to be immediately reported. Fatigue is a common client report with chemotherapy.

A client with multiple myeloma has developed hypercalcemia. Which nursing intervention is priority? 1. Protecting the client from trauma 2. Elevating the head of bed 45 degrees 3. Monitoring fluid intake and output 4. Providing a quiet, darkened room

3. Hypercalcemia may lead to renal dysfunction. By carefully monitoring fluid intake and output, the nurse would be alerted to decreased urine output. All clients should be protected from trauma. Elevating the head of the bed is an intervention for impaired ventilation, gastroesophageal reflux disease, and increased intracranial pressure. A quiet, dark room is commonly used to decrease sensory stimulus for clients who have meningitis or preeclampsia.

The nurse understands that which client is at the highest risk of developing anemia? 1. A client with a colostomy following colon resection 2. A client with gastroesophageal reflux disease (GERD) 3. A client who has had a gastrectomy 4. A client diagnosed with dumping syndrome

3. Lack of intrinsic factor following gastrectomy would cause pernicious anemia due to the client's inability to absorb vitamin B12. The presence of a colostomy, GERD, or dumping syndrome would not place a client at risk for developing anemia.

The nurse assesses a client with a history of bacterial infection and notes the following vital signs: a blood pressure reading of 80/54 mm Hg, a hearty rate of 128 beats/minute, a respiratory rate of 26 breaths/minute, cool and clammy skin, and a decreased level of consciousness. Which nursing action is priority? 1. Obtain a temperature. 2. Ask about pain. 3. Initiate intravenous (IV) line access. 4. Assess urine output.

3. Signs and symptoms of septic shock would include a change in the level of consciousness; cool, clammy, and pale skin; hypotension; tachycardia; and tachpnea. The priority intervention for a client in septic shock is to initiate IV access to begin an infusion. Although obtaining a temperature, asking about pain, and assess urinary output are important, the nurse has enough information about this client to begin a life-saving intervention before continuing to assess the client.

A client with human immunodeficiency virus (HIV) experiences frequent bouts of diarrhea. The nurse determines that dietary teaching is effective when the client chooses which food? 1. Coffee 2. Cheese pizza 3. Chicken soup 4. Hot chocolate

3. The client may consume chicken soup and broiled meat. Clients with chronic diarrhea may develop intolerance to lactose, which may worsen the diarrhea. Other foods that the client should avoid include fatty foods, other lactose-containing foods, caffeine, and sugar.

The nurse in a family health clinic is caring for a client with a hemoglobin level of 9 g/dL (90 g/L). Which instruction will the nurse provide to the client? 1. Restrict activity as much as possible. 2. Eat foods that are high in calcium. 3. Space activities to allow time to rest. 4. Be supervised when ambulating.

3. The normal hemoglobin levels for males is 14 to 18 g/dL (140 to 180 g/L) and for females is 12 to 16 g/dL (120 to 160 g/L). Clients with anemia become fatigued easily and need rest between activities to conserve energy. Activities do not need to be severely restricted for clients with anemia. The client needs to eat food that is high in iron (not calcium), such as lean red meat and fortified breakfast cereal. The client does not need close supervision when walking.

A nurse is caring for a client with rheumatoid arthritis. When is the best time for the nurse to schedule the client for ambulation? 1. Each morning when the client first awakens 2. After returning from physical therapy 3. After the client has taken a bath 4. Daily, just before the noontime meal

3. Warmth and the movement of the extremities during a bath ease the stiffness and pain of rheumatoid arthritis. When the client first awakens is the worst time for ambulation because pain and stiffness are greatest after long periods of immobility. The client may be too tired to walk soon after returning from therapy. There is no relationship between eating and ease of ambulation in rheumatoid arthritis.

The registered nurse (RN) is making assignments for the next shift. Which client(s) will the RN assign to the licensed practical nurse (LPN)? Select all that apply. 1. A client scheduled for initial chemotherapy treatment 2. A client admitted with generalized petechiae and bruising 3. A client is ready to be discharged home after surgery 4. A client with hypocalcemia receiving calcitrol orally 5. A client with hemophilia who needs pain medication

4, 5. An LPN can administer pain medication or oral calcitrol (vitamin D). A client scheduled for initial chemotherapy treatment requires education and needs to be monitored by an RN. The initial admission assessment of a client admitted with petechiae and bruising should be performed by an RN. A client who is ready to be discharged home after surgery requires discharge education by the RN.

The nurse is making assignments for the assistive personnel (AP). Which task(s) can the nurse safely assign to AP? Select all that apply. 1. Providing information on dietary changes for a client with anemia 2. Assisting the client with hyperphosphatemia in choosing a meal 3. Teaching a client with rheumatoid arthritis how to use the cane 4. Bathing a client who is diagnosed with ankylosing spondylitis 5. Turning a client diagnosed with AIDS who is poorly nourished.

4, 5. Assistive personnel (AP) can safely perform bathing and turning a client. The registered nurse (RN) should only delegate routine, unchanging tasks and tasks with lower priority. Teaching a client how to use the cane and providing educatio0n on dietary choices that are high in iron or low in phosphorus are not within the scope of AP's practice.

A nurse receives the laboratory results below for a hospitalized adult client who has acute leukemia. Which result will the nurse immediately report to the healthcare provider? Test / Result White blood cells, 12,000/μL (12.0 ✕ 10⁹/L) Red blood cells, 4.2 x 10⁶/μL (4.20 ✕ 10¹²/L) Hemoglobin, 12 g/dL (120 g/L) Hematocrit, 30% (0.30) Platelets, 15,000/μL (15 ✕ 10⁹/L) 1. Red blood cell (RBC) count 2. Hemoglobin level 3. Hematocrit level 4. Platelet count

4. A platelet count below 20,000/μL (20 ✕ 10⁹/L) is considered a life-threatening situation and generally requires medical treatment of immediate platelet transfusions. The RBC count, hemoglobin level, and hematocrit level are lower than normal but do not require immediate intervention if the client is asymptomatic. The white blood cell count is slightly elevated and would be expected in a client with leukemia.

The nurse assesses a client diagnosed with human immunodeficiency virus (HIV) infection. Which scenario suggests to the nurse the client has acquired immunodeficiency syndrome (AIDS) wasting syndrome? 1. A 34-year-old male with oral pain, dysphagia, and yellow-white plaques in his mouth and throat 2. A 42-year-old female with recurrent vaginitis causing intense itching and white, thick vaginal discharge 3. A 52-year old male with impaired memory, hallucinations, loss of balance, and personality changes 4. A 46-year-old female who has lost 12% of her body weight, with weakness, fever, and chronic diarrhea for the past 35 days

4. AIDS wasting syndrome is diagnosed when there is a loss of 10% or more of body weight and the presence of one or more of the following for more than 30 days: fever, weakness, and at least two loose stools daily. Oral pain with visible yellow-white plaques and vaginitis with a white, cottage cheese-like discharge suggest infection with Candida albicans. Impaired intellect and motor functioning indicate HIV infection of the central nervous system with AIDS dementia complex.

Which statement by a client with sickle cell disease indicates to the nurse that further education is needed? 1. "I should avoid vacationing or traveling in areas of high altitude." 2. "Cigarette smoking can cause me to have a sickle cell crisis." 3. "I should drink 4 to 6 liters of fluids every day." 4. "Taking an aspirin daily will help prevent a sickle cell crisis."

4. Aspirin inhibits platelet aggregation and will not help prevent sickle cell crisis. Hydroxyurea is prescribed for some people to help prevent sickle cell crisis. High altitudes increase oxygen demand and therefore can also precipitate a crisis. Tobacco, alcohol, and dehydration can precipitate a sickle cell crisis and should be avoided.

A client is prescribed aspirin. Which other medication prescription will cause the nurse to notify the healthcare provider? 1. Acetaminophen 2. Furosemide 3. Pyridoxine 4. Heparin

4. Aspirin, also known as acetylslicylic acid, is used for mild-to-moderate pain, fever, inflammation, and atrial fibrillation stroke prevention. Aspirin may increase the risk of bleeding when taken with heparin. Acetaminophen, furosemide, and pyridoxine do not increase the risk of bleeding.

An older adult client has a wound on the lower leg that is not healing normally. Which intervention will the nurse include in the plan of care? 1. Assess blood urea nitrogen (BUN) and creatinine levels. 2. Administer an influenza vaccination. 3. Elevate the client's leg on a pillow. 4. Encourage ambulation around the unit.

4. Immune function is important in the healing process, and diminished response may slow or prevent the healing process from taking place. Although immune function declines with age, there are healthy behaviors that will enhance the older adult's response to tissue trauma (e.g., exercise). Reviewing BUN and creatinine levels is important but does not improve the client's wound. Although elevation of the leg may improve edema, it could decrease circulation, which could prevent wound healing. Older adults should be encouraged to receive vaccinations, include the influenza vaccine, but this does not improve wound healing of the leg.

The nurse is reviewing the chart exhibit noted below. Based on the findings, which disorder will the nurse suspect? Test / Result White blood cells, 3,500/μL (3.50 ✕ 10⁹/L) Red blood cells, 3.8 ✕ 10⁶/μL (3.80 ✕ 10¹²/L) Platelets, 90,000/μL (90 ✕ 10⁹/L) Antinuclear antibody, Positive 1. Aplastic anemia 2. Rheumatoid arthritis 3. Ankylosing spondylitis 4. Systemic lupus erythematosus (SLE)

4. Laboratory findings for clients with SLE usually show pancytopenia and a positive antinuclear antibody (ANA) titer. The normal erythrocyte (red blood cell) count for an adult male is 4.6 ✕ 10⁶/μL (4.60 ✕ 10¹²/L) to 6.2 ✕ 10⁶/μL (6.20 ✕ 10¹²/L) and for an adult female is 4.2 ✕ 10⁶/μL (4.20 ✕ 10¹²/L) to 5.4 ✕ 10⁶/μL (5.40 ✕ 10⁹/L). The normal leukocyte (white blood cell) count is 4.500/μL (4.50 ✕ 10⁹/L) to 11,000/μL (11.00 ✕ 10⁹/L), and the normal thrombocyte (platelet) count is 150,000/μL (150 ✕ 10⁹/L) to 400,000/μL (400 ✕ 10⁹/L). A client with rheumatoid arthritis is expected to have a positive ANA titer, but pancytopenia is not expected. Pancytopenia is expected with aplastic anemia, but positive ANA titer is not. Neither pancytopenia nor a positive ANA titer is expected with ankylosing spondylitis.

A client with leukemia has neutropenia. Which assessment finding will require the nurse to contact the healthcare provider immediately? 1. Self-report of fatigue 2. Bowel sounds hypoactive 3. A heart rate of 105 beats/min 4. Crackles bilaterally in the lungs

4. Pneumonia‒viral and fungal‒is a common cause of death in clients with neutropenia, so frequent assessment of respiratory rate and breath sounds is required. Signs and symptoms of pneumonia should be reported to the healthcare provider immediately. Although fatigue, tachycardia, and hypoactive bowel sounds could be reported to the healthcare provider, the priority is to report infection.

The nurse is reviewing a client's complete blood count (CBC) and notes an erythrocyte count of 8.2 ✕ 10⁶/μL (8.20 ✕ 10¹²/L), leukocytes of 12,100/μL (12.10 ✕ 10⁹/L), and thrombocytes of 400,000/μL (400 ✕ 10⁹/L). The nurse will suspect the client has which condition? 1. Pernicious anemia 2. Aplastic anemia 3. Sickle cell anemia 4. Polycythemia vera

4. Polycythemia vera is an overproduction of erythrocytes in the bone marrow. Clients with polycythemia vera may have elevated levels of hemoglobin, red blood cells (RBCs), white blood cells (WBCs), and platelets. The normal erythrocyte (RBC) count for an adult male is 4.6 ✕ 10⁶/μL (4.60 ✕ 10¹²/L) to 6.2 ✕ 10⁶/μL (6.20 ✕ 10¹²/L) and female is 4.2 ✕ 10⁶/μL (4.20 ✕ 10¹²/L) to 5.4 ✕ 10⁶/μL (5.4 ✕ 10¹²/L). The normal leukocyte (WBC) is 4,500/μL (4.50 ✕ 10⁹/L) to 11,000/μL (11.00 ✕ 10⁹/L), and the normal thrombocyte (platelet) count is 150,000/μm (150 ✕ 10⁹/L) to 400,000/μL (400 ✕ 10⁹/L).

A client with thrombocytopenia, secondary to leukemia, begins bleeding around the intravenous (IV) site. What will the nurse do first? 1. Discontinue the IV. 2. Attempt to flush the IV. 3. Elevate the client's arm. 4. Apply pressure to the site.

4. The initial action for a client with thrombocytopenia who is bleeding is to apply pressure to the site to stop bleeding. After applying pressure, the nurse can elevate the arm and discontinue the IV. If the IV site is bleeding, it is not appropriate to flush the IV.

Which food will the nurse inform a client with leukocyte count of 2,500/μL (2.50 ✕ 10⁹/L) to avoid? 1. Breakfast cereal 2. Chicken pot pie 3. Steamed broccoli 4. Soft boiled eggs

4. The normal leukocyte (WBC) count is 4,500/μL (4.50 ✕ 10⁹/L) to 11,000/μL ( 11.00 ✕ 10⁹/L). A WBC count of 2,500/μL (2.50 ✕ 10⁹/L) is low, making the client prone to infection. A low-bacteria diet is indicated, which excludes consuming raw fruits and vegetables or undercooked meat and eggs.

A client is admitted with a platelet count of 75,000/μL (75 ✕ 10⁹/L). Which finding(s) will the nurse anticipate during the assessment? Select all that apply. 1. Nausea 2. Dizziness 3. Vomiting 4. Purpura 5. Fever

4. The normal thrombocytes (platelet) count is 150,000/μL (150 ✕ 10⁹/L) to 400,000/μL (400 ✕ 10⁹/L). The client has thrombocytopenia or low platelet count. Platelets are ncessary for clot formation, so purpura is a sign of a decreased number of platelets. Petechiae is also a sign of low platelets. Nausea, dizziness, fever, and vomiting are not usual signs of thrombocytopenia.

A nurse is assigned to a medical-surgical floor. Which client will the nurse see first? 1. A client with systemic lupus erythematosus (SLE) reporting fatigue and stiffness 2. A client with scleroderma reporting blanching and erythema of fingers while eating 3. A client with vasculitis reporting malaise and is taking prednisone daily 4. A client with hemophilia reporting joint pain after bumping into the bed

4. The nurse should see the client with hemophilia first because an injury that causes joint pain after coming into contact with an object can also cause bleeding in a client with hemophilia. Therefore, the nurse should see this client first to evaluate for signs of bleeding and elevate the extremity. Fatigue and joint stiffness are commonly seen in clients with SLE. A client with scleroderma who reports blanching, erythema, and cyanosis of fingers may have Raynaud phenomenon, which is expected with scleroderma. A client with vasculitis is expected to have malaise and to take prednisone to decrease inflammation.

The nurse expects a client admitted with Pneumocytis jirovecii pneumonia (PJP) to have a history of which condition? 1. Type 2 diabetes mellitus 2. Right-sided heart failure 3. Chronic obstructive pulmonary disease (COPD) 4. Acquired immunodeficiency syndrome (AIDS)

4. PJP is a type of pneumonia caused by the fungus P. jirovecii. It is one of the opportunistic infections seen in clients who are immunocompromised, particularly in clients with HIV/AIDS. PJP is not associated with type 2 diabetes mellitus, right-sided heart failure, or COPD.