Lippincott Hematologic health problems

Which of the following nursing assessments is a late symptom of polycythemia vera? A Headache B Dizziness C Pruritus D Shortness of breath

C Pruritus is a late symptom that results from abnormal histamine metabolism. Headache and dizziness are early symptoms from engorged veins. Shortness of breath is an early symptom from congested mucous membrane and ineffective gas exchange.

The nurse is assisting in the care of a client who is to be cardioverted. The nurse plans to set the monophasic defibrillator to which of the following starting energy range levels, depending on the specific physician prescription? 1 50 to 100 joules 2 200 to 250 joules 3 250 to 300 joules 4 350 to 400 joules

1 Cardioversion is synchronized countershock to convert an undesirable rhythm to a stable rhythm. When a client is cardioverted, the defibrillator is charged to the energy level prescribed by the physician. Cardioversion is usually started at 50 to 100 joules. Options 2, 3, and 4 are incorrect and identify energy levels that are too high for cardioversion.

The nurse sends a sputum specimen to the laboratory for culture from a client with suspected active tuberculosis (TB). The results report that Mycobacterium tuberculosis is cultured. How would the nurse correctly analyze these results? 1 The results are positive for active tuberculosis. 2 The results indicate a less virulent strain of tuberculosis. 3 The results are inconclusive until a repeat sputum specimen is sent. 4 The results are unreliable unless the client has also had a positive Mantoux test.

1 Culture of Mycobacterium tuberculosis from sputum or other body secretions or tissue confirms the diagnosis of active tuberculosis. Options 2 and 3 are incorrect statements. The Mantoux test is performed to assist in diagnosing TB but does not confirm active disease.

A client with significant flail chest has arterial blood gases (ABGs) that reveal a PaO2 of 68 and a PaCO2 of 51. Two hours ago the PaO2 was 82 and the PaCO2 was 44. Based on these changes, the nurse obtains which of the following items? 1 Intubation tray 2 Chest tube insertion set 3 Portable chest x-ray machine 4 Injectable lidocaine (Xylocaine)

1 Flail chest occurs from a blunt trauma to the chest. The loose segment from the chest wall becomes paradoxical to the expansion and contraction of the rest of the chest wall. The client with flail chest has painful, rapid, shallow respirations while experiencing severe dyspnea. The effort of breathing and the paradoxical chest movement have the net effect of producing hypoxia and hypercapnia. The client develops respiratory failure and requires intubation and mechanical ventilation, usually with positive end expiratory pressure (PEEP); therefore an intubation tray is necessary.

Intravenous immune globulin (IVIG) therapy is prescribed for a child with idiopathic thrombocytopenic purpura (ITP). The nurse determines that this medication is prescribed for the child to: 1 Increase the number of circulating platelets. 2 Provide immunity to the child against infection. 3 Decrease the production of antiplatelet antibodies. 4 Prevent infection after exposure to communicable diseases.

1 IVIG is usually effective to rapidly increase the platelet count. It is thought to act by interfering with the attachment of antibody-coded platelets to receptors on the macrophage cells of the reticuloendothelial system. Corticosteroids may be prescribed to enhance vascular stability and decrease the production of antiplatelet antibodies. Options 2, 3, and 4 are unrelated to the administration of this medication.

The nurse is caring for a client with multiple myeloma who is receiving intravenous hydration at 100 mL per hour. Which finding indicates a positive response to the treatment plan? 1 Creatinine of 1.0 mg/dL 2 Weight increase of 1 kilogram 3 White blood cell count of 6000/mm3 4 Respirations of 18 breaths per minute

1 Multiple myeloma is a malignant proliferation of plasma cells within the bone. Renal failure is a concern in the client with multiple myeloma. In multiple myeloma, hydration is essential to prevent renal damage resulting from precipitation of protein in the renal tubules and excessive calcium and uric acid in the blood. Creatinine is the most accurate measure of renal status. Options 3 and 4 are unrelated to the subject of hydration. Weight gain is not a positive sign when concerned with renal status.

40. The nurse is to administer subcutaneous heparin to an older adult. What facts should the nurse keep in mind when administering this dose? Select all that apply. ■ 1. It should be administered in the anterior area of the iliac crest. ■ 2. The onset is immediate. ■ 3. Use a 27G, 5/8″ needle. ■ 4. Cephalosporin potentiates the effects of heparin. ■ 5. Double check the dose with another nurse.

1, 3, 4, 5. Older adults may have little subcutaneous tissue, so the area around the anterior iliac crest is a suitable site for these clients. The nurse should use a 27G, 5/8″ needle. Cephalosporin and penicillin potentiate the effects of heparin. Two nurses should check the dose because a dose error could cause hemorrhage. The onset of heparin is not immediate when given subcutaneously

A client with an abdominal aortic aneurysm is having a high resolution computed tomography (CT) scan to determine the feasibility for an endovascular repair. Which collaborative interventions should a nurse anticipate to decrease the client's likelihood of developing nephrotoxicity? SELECT ALL THAT APPLY. 1. Administration of sodium bicarbonate 1 hour before injection of the intravenous (IV) contrast dye 2. Administration of 0.9% NaCl at 100 mL per hour before and after the CT scan 3. Administration of acetylcysteine (Mucomyst®) orally before and after the study 4. Monitoring aPTT level before and after the CT scan 5. Placing the client on a low potassium diet

123 The contrast dye used in a high resolution presents a risk to the client's renal function. Intravenous fluids are administered to maintain hydration and enhance excretion of the dye. Sodium bicarbonate is administered 1 hour before and 6 hours after the IV contrast dye. Acetylcysteine is administered orally the day before and the day of the CT scan to prevent acute renal failure. Both sodium bicarbonate and acetylcysteine are free-radical scavengers that sequester the contract by-products that are destructive to renal cells. The aPTT (activated thromboplastin time) is a measure of blood coagulation and is not related to nephrotoxicity. A low potassium diet may be ordered for a client with renal failure but is not a preventive measure.

A client is hospitalized with a diagnosis of sickle cell crisis. Which findings should lead a nurse to conclude that outcomes have been achieved for this client? SELECT ALL THAT APPLY. 1. Leukocyte count 7,500/mm3 2. Describes the importance of keeping warm 3. Acute pain controlled at less than 3 on a 0 to 10 scale with analgesics 4. Free of chest pain or dyspnea 5. Blood transfusions effective in diminishing cell sickling 6. Hydroxyurea (Hydrea®) effective in suppressing leukocyte formation

1234 A leukocyte count of 7,500/mm3 is within normal range (5,000 to 10,000/mm3 indicates the absence of an infection). Keeping warm and avoiding chills will help to prevent infection. Also, cold causes vasoconstriction, slowing blood flow and aggravating the sickling process. Acute pain is due to tissue hypoxia from the agglutination of sickled cells within blood vessels. Acute chest syndrome and pulmonary hypertension are two of the many complications associated with sickle cell disease. Red blood cell transfusions may help to prevent complications, but transfusions do not alter the person's body from producing the deformed erythrocytes. Hydroxyurea can decrease the permanent formation of sickled cells. A side effect (not therapeutic effect) of Hydroxyurea is suppression of leukocyte formation.

The nurse is planning care for a client diagnosed with deep vein thrombosis (DVT) of the left leg who is experiencing severe edema and pain in the affected extremity. Which intervention(s) should the nurse plan to include in the care of this client? Select all that apply. r 1 Elevate the left leg. r 2 Apply moist heat to the left leg. r 3 Administer acetaminophen (Tylenol). r 4 Ambulate in the hall three times per shift. r 5 Administer anticoagulation as prescribed.

1235 Management of the client with DVT who is experiencing severe edema and pain includes bed rest; limb elevation; relief of discomfort with warm moist heat and analgesics as needed; anticoagulant therapy; and monitoring for signs of pulmonary embolism. In current practice, activity restriction may not be prescribed if the client is receiving low-molecularweight anticoagulation; however, some physicians may still prefer bed rest for the client.

The nurse is developing a plan of care for a client with a dissecting abdominal aortic aneurysm. Which interventions should be included in the plan of care? Select all that apply. r 1 Assess peripheral circulation r 2 Monitor for abdominal distention. r 3 Tell the client that abdominal pain is expected r 4 Turn the client to the side to look for ecchymoses on the lower back r 5 Perform deep palpation of the abdomen to assess the size of the aneurysm

124 If the client has an abdominal aortic aneurysm, the nurse is concerned about rupture and monitors the client closely. The nurse tells the client to report abdominal pain, or back pain, which may radiate to the groin, buttocks, or legs because this is a sign of rupture. The nurse also avoids deep palpation in the client in whom a dissecting abdominal aortic aneurysm is known or suspected. Doing so could place the client at risk for rupture. The nurse should assess peripheral circulation and monitor for abdominal distention. The nurse also looks for ecchymoses on the lower back to determine if the aneurysm is leaking.

A nurse explains to another nurse that chronic lymphocytic leukemia (CLL) is: SELECT ALL THAT APPLY. 1. a malignancy of activated B lymphocytes. 2. the most common malignancy of older adults. 3. unresponsive to chemotherapy treatment. 4. often not treated in its early stages but the client is monitored. 5. an excessive accumulation of immature lymphocytes in the bone marrow. 6. often asymptomatic and diagnosed incidentally during routine physical examination.

1246 CLL derives from a malignant clone of B lymphocytes. T-lymphocytic CLL is rare. Two-thirds of all persons with CLL are older than 60 years at diagnosis. Treatment is initiated when symptoms are severe (night sweats, painful lymphadenopathy) or the disease progresses to later stages. Because many persons are asymptomatic, it is often diagnosed during a routine physical or treatment for another condition. Treatment for CLL includes chemotherapy with fludarabine (Fludara®), but a major side effect is prolonged bone marrow suppression. In CLL there is an accumulation of mature-appearing but functionally inactive lymphocytes. Excessive accumulation of immature lymphocytes occurs in acute lymphocytic leukemia (ALL). ALL after 15 years of age is relatively uncommon. Be older and mature" (B = B lymphocytes; o = older adult; a = asymptomatic; m = mature but inactive lymphocytes).

A client with symptoms of intermittent claudication receives treatment with a peripheral percutaneous transluminal angioplasty procedure with placement of an endovascular stent. During a follow- up home visit, a nurse determines that the client is making lifestyle changes to decrease the likelihood of re-stenosis and arterial occlusion. Which observations of the client's actions support this conclusion? SELECT ALL THAT APPLY. 1. States participating in an exercise program 2. Abstaining from nicotine 3. Wearing support hose 4. States receiving foot care from a podiatrist 5. Following a low saturated fat diet 6. Taking the medication rosuvastatin calcium (Crestor®)

1256 Reducing client risk factors in order to slow the arteriosclerotic process may delay progression of the disease. Exercising promotes collateral circulation. Smoking cessation, following a low saturated fat diet, and taking medications to lower cholesterol also deter the arteriosclerotic process. There is evidence that more than 30% of clients having procedures to improve claudication seek further intervention within a year. Wearing support hose may impede circulation. Receiving professional foot care is a positive factor but does not prevent the progressive nature of peripheral arterial disease.

A client has undergone a vaginal hysterectomy. The nurse writes which appropriate interventions on the client's nursing care plan to decrease the risk of deep vein thrombosis or thrombophlebitis? Select all that apply. r 1 Using pneumatic compression boots r 2 Maintaining bedrest for 24 to 48 hours r 3 Assisting with range of motion leg exercises r 4 Applying antiembolism stockings and removing them twice daily for assessment r 5 Elevating the knees with the knee gatch on the bed

134 The client is at risk for deep vein thrombosis or thrombophlebitis after this surgery, as for any other major surgery. For this reason, the nurse implements measures that will prevent this complication. Ambulation, pneumatic compression boots, range of motion exercises, and antiembolism stockings are all helpful. The nurse should avoid elevating the knees using the knee gatch in the bed, which inhibits venous return, and places the client more at risk for deep vein thrombosis or thrombophlebitis.

A nurse is preparing a client for a thoracic aneurysm repair. Which assessment findings lead the nurse to suspect that a rupture has occurred? SELECT ALL THAT APPLY. 1. Severe chest pain radiating to the back 2. Abdominal distention 3. Hypotension 4. Dyspnea 5. Oliguria

1345 A thoracic aneurysm that ruptures will cause pain in the thoracic area. Blood loss will lead to low blood pressure and scant urinary output. The pressure from the hemorrhage will interfere with the client's breathing. A thoracic aneurysm does not cause abdominal distention because the bleeding is in the thoracic area.

\. The nurse is monitoring a client who is receiving a blood transfusion when the client complains of diaphoresis, warmth, and a backache. The nurse suspects a transfusion reaction and should take which actions? Select all that apply. r 1 Contact the physician. r 2 Remove the IV catheter. r 3 Document the occurrence. r 4 Stop the blood transfusion. r 5 Hang 0.9% sodium chloride solution

1345 If a client experiences a transfusion reaction, the nurse stops the transfusion and prevents the infusion of any additional blood; then the nurse hangs a bag of 0.9% sodium chloride solution. This maintains IV access and helps maintain the client's intravascular volume. To preserve the IV access, the nurse should not discontinue the IV site. The physician is notified, as is the blood bank. The nurse follows agency procedures with regard to additional actions to take, such as obtaining a urine specimen and returning the blood bag and tubing to the blood bank. The nurse also documents the occurrence, the actions taken, and the client's response

A client with a diagnosis of chronic obstructive pulmonary disease (COPD) has developed polycythemia vera, and a nurse has completed teaching on measures to prevent complications. During a home health visit, the nurse evaluates that the client is correctly following the teaching when the client: SELECT ALL THAT APPLY. 1. tells the nurse about discontinuing iron supplements. 2. relays increasing alcohol intake to decrease blood viscosity. 3. records the amount consumed after drinking a glass of water. 4. discusses yesterday's phlebotomy treatment to remove blood. 5. shows the nurse a menu plan for eating three large meals daily. 6. reclines in a recliner chair with legs uncrossed, wearing antiembolic stockings (TEDS®).

1346 Iron supplements, including those in multivitamins, should be avoided because the iron stimulates red blood cell production. Increasing fluid intake to 3,000 mL daily will help decrease blood viscosity. Phlebotomy is performed on a routine or intermittent basis to diminish blood viscosity, deplete iron stores, and decrease the client's ability to manufacture excess erythrocytes. Elevating the legs, avoiding constriction or crossing the legs, and wearing antiembolic socks help prevent deep vein thrombosis. Alcohol increases the risk of bleeding. Frequent, small meals are better tolerated, especially if the liver is involved.

nurse is planning care for a client admitted with a new diagnosis of persistent atrial fibrillation with rapid ventricular response. Although the client has had no previous cardiac problems, the client has been in atrial fibrillation for more than 2 days. The nurse should anticipate that the health-care provider is likely to initially order: SELECT ALL THAT APPLY. 1. oxygen. 2. immediate cardioversion. 3. administration of amiodarone (Cordarone®). 4. initiation of a IV heparin infusion. 5. immediate catheter-directed ablation of the AV node. 6. administration of a calcium channel antagonist such as diltiazem (Cardizem®).

1346 The ineffective atrial contractions or loss of atrial kick with atrial fibrillation can decrease cardiac output. Administering oxygen enhances tissue oxygenation. Amiodarone is used for pharmacological cardioversion of the atrial fibrillation rhythm. The client is at risk for thrombi in the atria from stasis. Anticoagulant therapy is used to prevent thromboembolism. Diltiazem, a calcium channel antagonist, is prescribed to slow the ventricular response to atrial fibrillation. An alternative to a calcium channel antagonist would be the use of a beta blocker, such as esmolol, metoprolol, or propranolol. Cardioversion would only be considered if medications were ineffective in converting the client's rhythm and only after the presence of an atrial clot has been ruled out. Ablation of the AV node would only be considered if medications were ineffective in controlling the client's heart rate.

A nurse is preparing to perform a Mantoux skin test. Which interventions apply in relation to this test? Select all that apply. r 1 Explain the procedure to the client. r 2 Obtain a 3-mL syringe with a ½-inch needle for the injection. r 3 Mark the test area to locate it for reading 48 to 72 hours after injection. r 4 Bunch up the skin and insert the needle with the needle bevel facing downward. r 5 Ask the client about a previous history of a positive purified protein derivative (PPD) reaction. r 6 Cleanse the injection site on the lower dorsal surface of the forearm with alcohol and allow it to dry.

1356q The nurse would always explain the procedure to the client and then assess him or her for a previous history of a PPD reaction. The test should not be administered if the client has such a history. The nurse would use a tuberculin syringe (not a 3-mL syringe) with a ½-inch 26- or 27-gauge needle. The injection site on the lower dorsal surface of the forearm is cleansed with alcohol and allowed to dry. The skin is stretched taut and 0.1 mL of solution containing 0.5 tuberculin units of PPD is injected. The injection is made just under the surface of the skin with the needle bevel facing upward to provide a discrete elevation of the skin (a wheal) 6 to 10 mm in diameter. The test area is marked to locate it for reading and the test area is read 48 to 72 hours after injection.

90. A nurse is teaching a client to use a metereddose inhaler (MDI) to administer his bronchodilator medication. Indicate the correct order of the steps the client should take to use the MDI appropriately. 1. Shake the inhaler immediately before use 2. Hold breath for 5 to 10 seconds and then exhale. 3. Activate the MDI on inhalation. 4. Breathe out through the mouth.

1432 When using inhalers, clients should fi rst shake the inhaler to activate the MDI, and then breathe out through the mouth. Next, the client should activate the MDI while inhaling, hold the breath for 5 to 10 seconds, and then exhale normally.

A nurse discusses the self-care guidelines to minimize the side effects of radiation on the skin. Which actions, to reduce radiation skin reactions, should the nurse explain to the client? SELECT ALL THAT APPLY. 1. Wear loose-fitting, soft clothing over the treated skin. 2. Use a straightedged razor to shave the hair in the treated area. 3. Swim only in swimming pools to avoid stagnant water. 4. Use only skin-care products suggested by the radiation staff. 5. Apply skin products immediately before radiation treatment. 6. Wash treated area gently with lukewarm water and mild soap.

146 Wearing loose-fitting, soft clothing over the treated skin, using only skin-care products suggested by the radiation staff, and washing the treated area gently with lukewarm water and mild soap are recommended skin-care activities to reduce radiation skin reactions. The use of electric razors for shaving a treated area is recommended. Clients are advised to avoid swimming in chlorinated water and to delay the application of skin-care products within 4 hours of radiation treatment.

A nurse receives a serum laboratory report for six different clients with admitting diagnoses of chest pain. After reviewing all of the lab reports, in which order should the nurse address each lab value? Prioritize the order in which the nurse should address each of the clients' results. ______ Troponin T 42 ng/mL (0.0-0.4 ng/mL) ______ WBC 11,000 K/μL ______ Hgb 7.2 g/dL ______ SCr 2.2 mg/dL ______ K 2.2 mEq/L ______ Total cholesterol 430 mg/dL

163425 The nurse should address the elevated troponin level first. Cardiospecific troponins (troponin T, cTnT, and troponin I, cTnI) are released into circulation after myocardial injury and are highly specific indicators of myocardial infarction. Since "time is muscle," the client needs to be treated immediately to prevent extension of the infarct and possible death. The nurse should address the decreased serum potassium level (K) second. The normal serum K level is 3.5 to 5.8 mEq/L. A low serum K level can cause life-threatening dysrhythmias. The normal hemoglobin (Hgb) is 13.1 to 17.1 g/dL. A low Hgb can contribute to inadequate tissue perfusion and contribute to myocardial ischemia. The normal serum creatinine (SCr) is 0.4 to 1.4 mg/dL. Impaired circulation may be causing this alteration and further client assessment is needed. Medication doses may need to be adjusted with impaired renal perfusion. The normal total serum cholesterol should be less than 200 mg/dL. This is a risk factor for development of coronary artery disease. The client needs teaching. The normal white blood cell (WBC) count is 3.9 to 11.9 K/μL. Because the finding is normal, it can be addressed last.

A client admitted with unstable angina is started on intravenous heparin and nitroglycerin. The client's chest pain resolves, and the client is weaned from the nitroglycerin. Noting that the client had a synthetic valve replacement for aortic stenosis 2 years ago, a physician writes an order to restart the oral warfarin (Coumadin®) 5 mg at 1900 hours. Which is the nurse's best action? 1. Administer the warfarin as prescribed. 2. Call the physician to question the warfarin order. 3. Discontinue the heparin drip and then administer the warfarin. 4. Hold the dose of warfarin until the heparin has been discontinued.

1Both heparin and warfarin are anticoagulants, but their actions are different. Oral warfarin requires 3 to 5 days to reach effective levels. It is usually begun while the client is still on heparin. Calling the physician is unnecessary. The nurse's scope of practice does not permit altering medication orders. The nurse should neither discontinue the heparin nor hold the warfarin without a written order.

The nurse notes an isolated premature ventricular contraction (PVC) on the cardiac monitor. The appropriate nursing action is to: 1 Prepare for defibrillation. 2 Continue to monitor the rhythm. 3 Notify the physician immediately. 4 Prepare to administer lidocaine hydrochloride (Xylocaine).

2 As an isolated occurrence, the PVC is not life threatening. In this situation, the nurse should continue to monitor the client. Frequent PVCs, however, may be precursors of more life-threatening rhythms, such as ventricular tachycardia and ventricular fibrillation. If this occurs, the physician needs to be notified. Defibrillation is done to treat ventricular fibrillation. Lidocaine hydrochloride is not needed to treat isolated PVCs; it may be used to treat frequent PVCs in a client who is symptomatic and is experiencing decreased cardiac output.

A client diagnosed with Hodgkin's lymphoma develops radiation pneumonitis 3 months after radiation treatment. For which symptoms of radiation pneumonitis should a nurse observe the client? 1. Tachypnea, hypotension, and fever 2. Cough, fever, and dyspnea 3. Bradypnea, cough, and decreased urine output 4. Cough, tachycardia, and altered mental status

2 Cough, fever, and dyspnea are classic symptoms in radiation pneumonitis due to a decrease in the surfactant in the lung. Hypotension, decreased urine output, and altered mental status are symptoms that are not common in radiation pneumonitis.

nurse is preparing to teach the parents of a child with anemia about the dietary sources of iron that are easy for the body to absorb. Which food item should the nurse include in the teaching plan? 1 Fruits 2 Poultry 3 Apricots 4 Vegetables

2 Dietary sources of iron that are easy for the body to absorb include meat, poultry, and fish. Vegetables, fruits, cereals, and breads are also dietary sources of iron, but they are harder for the body to absorb

A client with unstable ventricular tachycardia (VT) loses consciousness and becomes pulseless after an initial treatment with a dose of lidocaine (Xylocaine) intravenously. The nurse caring for the client would immediately obtain which of the following needed items? 1 A pacemaker 2 A defibrillator 3 A second dose of lidocaine 4 An electrocardiogram machine

2 For the client with VT who becomes pulseless, the physician or qualified advanced cardiac life support personnel immediately defibrillates the client. In the absence of this equipment, cardiopulmonary resuscitation is initiated immediately. Options 1, 3, and 4 are not items that are needed immediately in this situation.

A client's laboratory test results reveal a decreased serum transferrin and total ironbinding capacity (TIBC). Which disorder is the most likely cause of the client's anemia? 1 Infection 2 Malnutrition 3 Iron deficiency 4 Sickle cell disease

2 Malnutrition can cause reductions in the serum transferrin and the TIBC. Infection is an unrelated option. Sickle cell anemia is diagnosed by determining that the client has hemoglobin S. Iron-deficiency anemia is usually characterized by decreased iron-binding capacity but increased transferrin levels. Additionally, in clinical practice, the hemoglobin level is routinely used to detect iron-deficiency anemia.

A client is diagnosed with pernicious anemia. The nurse reviews the client's health history for disorders involving which organ responsible for vitamin B12 absorption? 1 Liver 2 Ileum 3 Hepatobiliary 4 Gastrointestinal

2 Pernicious anemia can occur in a client who has a disease involving the ileum, where vitamin B12 is absorbed. The nurse checks the client's history for small bowel disorders to detect this risk factor. The liver is not usually related to impaired B12 absorption. Hepatobiliary refers to the liver and gallbladder, and gastrointestinal refers to the organ systems that include organs such as the stomach, liver, gallbladder, and ileum.

The nurse is assessing a client with a diagnosis of polycythemia vera. Which clinical manifestation would the nurse expect to note in this client? 1 Pallor 2 Hypertension 3 A low hematocrit level 4 Pale mucous membranes

2 Polycythemia vera is a myeloproliferative disease that causes increased blood viscosity and blood volume. Manifestations of polycythemia vera include a ruddy complexion, dusky red mucosa, hypertension, dizziness, headache, and a sense of fullness in the head. Signs of congestive heart failure may also be present. The hematocrit level is usually greater than 54% in men and 49% in women.

A client with Raynaud's disease is seen in a vascular clinic 6 weeks after nifedipine (Procardia®) has been prescribed. A nurse evaluates that the medication has been effective when which findings are noted? 1. The client's blood pressure is 110/68 mm Hg. 2. The client states experiencing less pain and numbness. 3. The client states that tolerance to heat is improved. 4. The client walks without claudication

2 Raynaud's disease is a disease in which cutaneous arteries in the extremities have recurrent episodes of vasospasm with blanching and then redness. The episodes are brought on by cold and result in pain and numbness. Nifedipine, a calcium channel blocker, causes vasodilation, which reduces pain and numbness. Nifedipine is used as an antihypertensive agent but that is not the purpose here. The client is at risk to develop hypotension as an adverse effect. Tolerance to cold, not heat, should improve. Claudication is not associated with Raynaud's disease but is associated with arteriosclerotic changes in the larger arteries.

A nurse is reviewing the serum laboratory test results for a client with sickle cell anemia. Which parameter does the nurse anticipate will be elevated? 1 Sodium 2 Hemoglobin-S 3 Hemoglobin A1c 4 Prothrombin time

2 Sickle cell anemia is a severe anemia that affects African Americans predominantly and is characterized by sickled hemoglobin, or Hgb-S. The client must have two abnormal genes yielding hemoglobin- S to have sickle cell anemia. A client could have sickle cell trait by carrying one hemoglobin-A gene and one hemoglobin-S gene; then, the client has a less severe form of sickle cell anemia. Options 1, 3, and 4 are unrelated to sickle cell anemia

The nurse is administering epoetin alfa (Epogen) to a client with chronic renal failure. The nurse monitors the client for which adverse effect of this therapy? 1 Anemia 2 Hypertension 3 Iron intoxication 4 Bleeding tendencies

2 The client taking epoetin alfa is at risk of hypertension and seizure activity as the most serious adverse effects of therapy. This medication is used to treat anemia. The medication does not cause iron intoxication. Bleeding tendencies is not an adverse effect of this medication.

A nurse is caring for multiple clients on a medical unit. Which client, who has been diagnosed with a lower extremity deep venous thrombosis (DVT), should the nurse plan for possible placement of a filter in the inferior vena cava to protect against pulmonary embolism? 1. A 22-year-old female who has been taking oral contraceptives 2. A 65-year-old client admitted with a bleeding gastric ulcer 3. A 55-year-old client who had a total knee joint replacement 4. A 52-year-old female who had a vaginal hysterectomy 6 weeks earlier

2 The client with the bleeding gastric ulcer is not a candidate for anticoagulant therapy and, therefore, needs the inferior vena cava filter to prevent an embolus from the DVT reaching the pulmonary circulation. The other clients have no contraindications listed for anticoagulant therapy.

64. A client who has been diagnosed with tuberculosis has been placed on drug therapy. The medication regimen includes rifampin (Rifadin). Which of the following instructions should the nurse include in the client's teaching plan related to the potential adverse effects of rifampin? Select all that apply. ■ 1. Having eye examinations every 6 months. ■ 2. Maintaining follow-up monitoring of liver enzymes. ■ 3. Decreasing protein intake in the diet. ■ 4. Avoiding alcohol intake. ■ 5. The urine may have an orange color.

2, 4, 5. A potential adverse effect of rifampin (Rifadin) is hepatotoxicity. Clients should be instructed to avoid alcohol intake while taking rifampin and keep follow-up appointments for periodic monitoring of liver enzyme levels to detect liver toxicity. Rifampin causes the urine to turn an orange color and the client should understand that this is normal. It is not necessary to restrict protein intake in the diet or have the eyes examined due to rifampin therapy.

A nurse is planning care for a client with a chest tube attached to a Pleur-Evac drainage system. The nurse includes which interventions in the plan? Select all that apply. r 1 Clamping the chest tube intermittently r 2 Changing the client's position frequently r 3 Maintaining the collection chamber below the client's waist r 4 Adding water to the suction control chamber as it evaporates r 5 Taping the connection between the chest tube and the drainage system

2345 To prevent a tension pneumothorax, the nurse avoids clamping the chest tube, unless specifically prescribed. In many facilities, clamping of the chest tube is contraindicated by agency policy. Changing the client's position frequently is necessary to promote drainage and ventilation. Maintaining the system below waist level is indicated to prevent fluid from reentering the pleural space. Adding water to the suction control chamber is an appropriate nursing action and is done as needed to maintain the full suction level prescribed. Taping the connection between the chest tube and system is also indicated to prevent accidental disconnection

nurse is teaching a client newly diagnosed with chronic stable angina. Which instructions should the nurse incorporate in the teaching session on measures to prevent future angina? SELECT ALL THAT APPLY. 1. Increase isometric arm exercises to build endurance. 2. Wear a face mask when outdoors in cold weather. 3. Take nitroglycerin before a stressful situation even though pain is not present. 4. Perform most exertional activities in the morning. 5. Avoid straining at stool. 6. Eliminate tobacco use.

2356 Blood vessels constrict in response to cold and increase the workload of the heart. Sexual activity and straining at stool increases sympathetic stimulation and cardiac workload. Nitroglycerin produces vasodilation and improves blood flow to the coronary arteries; it can be used prophylactically to prevent angina. Nicotine stimulates catecholamine release, producing vasoconstriction and an increased heart rate. Isometric exercise of the arms can cause exertional angina. Exertional activity increases the heart rate, thus reducing the time the heart is in diastole, when blood flow to the coronary arteries is the greatest. A period of rest should occur between activities and activities should be spaced.

A client presents to an emergency department following a motorcycle crash. A nurse assesses the client and notes uncoordinated or paradoxical chest rise and fall as well as multiple bruises across the client's chest and torso, crepitus, and tachypnea. Based on this assessment, the nurse should: 1. assist in the placement of a cervical collar. 2. anticipate the need to intubate the client. 3. provide chest compressions. 4. tape the chest wall.

2The assessment data implies a client with multiple broken ribs and potentially flail chest. In the case of flail chest, more invasive interventions are generally required, including management of the client's airway with intubation. The client would most likely already have a cervical collar on, and this is not the intervention that would address the assessment data. There is no evidence to suggest that chest compressions are warranted. Taping the chest wall is an intervention for broken ribs that has proven to not be as effective as once believed.

A nurse observes for early manifestations of acute respiratory distress syndrome (ARDS) in a client being treated for smoke inhalation. Which signs indicates the possible onset of ARDS in this client? 1. Cough with blood-tinged sputum and respiratory alkalosis 2. Decrease in both white and red blood cell counts 3. Diaphoresis and low SaO2 unresponsive to increased oxygen administration 4. Hypertension and elevated PaO2

3 ARDS is manifested and similar to an extreme state of respiratory distress that would include diaphoresis, tachypnea, and use of accessory muscles. Because of damage and alterations in lung tissue, the client would not be able to increase his or her oxygenation despite an increase in the flow or amount of oxygen. Blood pressure and acid-base imbalances vary depending on the stage of ARDS.

A client was admitted to the hospital 24 hours ago after sustaining blunt chest trauma. The nurse monitors for which earliest clinical manifestation of acute respiratory distress syndrome (ARDS)? 1 Cyanosis and pallor 2 Diffuse crackles and rhonchi on chest auscultation 3 Increase in respiratory rate from 18 to 30 breaths per minute 4 Haziness or "white-out" appearance of lungs on chest radiograph

3 Acute respiratory distress syndrome usually develops within 24 to 48 hours after an initiating event, such as chest trauma. In most cases tachypnea and dyspnea are the earliest clinical manifestations as the body compensates for mild hypoxemia through hyperventilation. Cyanosis and pallor are late findings and are the result of severe hypoxemia. Breath sounds in the early stages of ARDS are usually clear but then progress to diffuse crackles and rhonchi as pulmonary edema occurs. Chest radiographic findings may be normal during the early stages but will show diffuse haziness or "white-out" appearance in the later stages.

A primary care provider prescribes lisinopril (Zestril®, Prinivil®) to treat a client with hypertension. The client returns to the clinic for a follow-up appointment. A nurse should evaluate the client for adverse effects by asking the client if he or she is experiencing: 1. muscle weakness. 2. bleeding gums. 3. persistent cough. 4. petechiae

3 Coughing is a common adverse effect of angiotensin-converting enzyme (ACE) inhibitors and warrants discontinuing the medication. The cough occurs from the action of ACE inhibitors in inhibition of kinase II and accumulation of bradykinin. Muscle weakness can be associated with statin therapy and warrants discontinuing the medication. Bleeding gums and petechiae are associated with bleeding. Petechiae are signs of low platelet counts

A nurse is caring for a client in an emergency department who has five fractured ribs from blunt chest trauma. The client is rating pain at 9 out of 10 on a 0 to 10 numeric scale. For which pain management modality should the nurse advocate? 1. NSAIDs 2. Oral analgesics (narcotic + acetaminophen) 3. Regional/local analgesia (epidural or intercostal injection) 4. Intravenous (IV) bolus meperidine (Demerol®)

3 Epidural analgesics and intercostal nerve blocks are the most optimal modality for blunt chest trauma because they directly target the injury site. Oral analgesics generally are not adequate to manage the pain associated with rib fractures. Meperidine is not the ideal narcotic for managing this type of pain because of its multiple adverse side effects.

A client diagnosed with class II heart failure according to the New York Heart Association Functional Classification has been taught about the initial treatment plan for this disease. A nurse determines that the client needs additional teaching if the client states that the treatment plan includes: 1. diuretics. 2. a low-sodium diet. 3. home oxygen therapy. 4. angiotensin-converting enzyme (ACE) inhibitors.

3 In class II heart failure, normal physical activity results in fatigue, dyspnea, palpitations, or anginal pain. The symptoms are absent at rest. Home oxygen therapy is unnecessary unless there are other comorbid conditions. Diuretics mobilize edematous fluid, act on the kidneys to promote excretion of sodium and water, and reduce preload and pulmonary venous pressure. Dietary restriction of sodium aids in reducing edema. ACE inhibitors block the conversion of angiotensin I to the vasoconstrictor angiotensin II, prevent the degradation of bradykinin and other vasodilatory prostaglandins, and increase plasma renin levels and reduce aldosterone levels. The net result is systemic vasodilation, reduced systemic vascular resistance, and improved cardiac output.

nurse is performing a respiratory assessment on a client being treated for an asthma attack. The nurse determines that the client's respiratory status is worsening if which of the following occurs? 1 Loud wheezing 2 Wheezing on expiration 3 Noticeably diminished breath sounds 4 Wheezing during inspiration and expiration

3 Noticeably diminished breath sounds are an indication of severe obstruction and impending respiratory failure. Wheezing is not a reliable manifestation to determine the severity of an asthma attack. Clients with minor attacks may experience loud wheezes, whereas others with severe attacks may not wheeze. The client with severe asthma attacks may have no audible wheezing because of the decrease of airflow. For wheezing to occur, the client must be able to move sufficient air to produce breath sounds. Wheezing usually occurs first on expiration. As the asthma attack progresses, the client may wheeze during both inspiration and expiration.

A client learning about chronic obstructive pulmonary disease self-care at a community health class, asks a nurse why the participants are being taught about the "lip-breathing." The nurse should respond by explaining that pursed-lip breathing can help to: 1. reduce upper airway inflammation. 2. reduce anxiety through humor. 3. strengthen respiratory muscles. 4. increase effectiveness of inhaled medications

3 Pursed-lip breathing increases the strength of respiratory muscles and helps to keep alveoli open. It does not have an affect on upper airway inflammation, provide humor therapy, and is not a part of medication administration.

A client with acute respiratory distress syndrome has a prescription to be placed on a continuous positive airway pressure (CPAP) face mask. The nurse implements which of the following for this procedure to be most effective? 1 Obtains baseline arterial blood gases 2 Obtains baseline pulse oximetry levels 3 Applies the mask to the face with a snug fit 4 Encourages the client to remove the mask frequently for coughing and deep breathing exercises

3 The CPAP face mask must be applied over the nose and mouth with a snug fit, which is necessary to maintain positive pressure in the client's airways. The nurse obtains baseline respiratory assessments and arterial blood gases to evaluate the effectiveness of therapy, but these are not done to increase the effectiveness of the procedure. A disadvantage of the CPAP face mask is that the client must remove it for coughing, eating, or drinking. This removes the benefit of positive pressure in the airway each time it is removed.

A client with chronic obstructive pulmonary disease (COPD) is in the third postoperative day following right-sided thoracotomy. During the day shift, the client has required 10 L oxygen by mask to keep his or her oxygen saturations greater than 88%. Based on this information, which action should be taken by the evening shift nurse? 1.Work to wean oxygen down to 3 L by mask 2. Call respiratory therapy for a nebulizer treatment 3. Check respiratory rate and notify the physician 4. Administer dose of ordered pain medications

3 The night shift nurse should check the client's respiratory rate and report abnormal findings to the physician. Although uncommon, clients with COPD on high flow oxygen can lose their respiratory drive. Working to wean down oxygen by mask below 3 L will cause retention of CO2; oxygen by mask generally should be set at 4 L or greater. Although a nebulizer and pain medications may assist the client, the immediate need is to determine if the high flow oxygen is affecting the client's respiratory drive and to further determine the cause of the low oxygen saturations.

The nurse admits a client who is in sickle cell crisis to the hospital. Which does the nurse prepare as the priority in the management of the client? 1 Pain management 2 Fluid administration 3 Oxygen administration 4 Red blood cell transfusion

3 The priority nursing intervention for a client in sickle cell crisis is to administer supplemental oxygen because the client is hypoxemic, and as a result, the red blood cells change to the sickle shape. In addition, oxygen is the priority because airway and breathing are more important than circulatory needs. The nurse also plans for fluid therapy to promote hydration and reverse the agglutination of sickled cells, opioid analgesics for relief from severe pain, and, blood transfusions to increase the blood's oxygen-carrying capacity.

The nurse has applied the patch electrodes of an automatic external defibrillator (AED) to the chest of a client who is pulseless. The defibrillator has interpreted the rhythm to be ventricular fibrillation. The nurse then: 1 Administers rescue breathing during the defibrillation 2 Performs cardiopulmonary resuscitation (CPR) for 1 minute before defibrillating 3 Charges the machine and immediately pushes the "discharge" buttons on the console 4 Orders any personnel away from the client, charges the machine, and defibrillates through the console

4 If the AED advises to defibrillate, the nurse or rescuer orders all persons away from the client, charges the machine, and pushes both of the "discharge" buttons on the console at the same time. The charge is delivered through the patch electrodes, and this method is known as "handsoff" defibrillation, which is safest for the rescuer. The sequence of charges is similar to that of conventional defibrillation. Option 1 is contraindicated for the safety of any rescuer. Performing CPR delays the defibrillation attempt.

A client has been defibrillated three times using an automatic external defibrillator (AED). The nurse observes that the attempts to convert the ventricular fibrillation (VF) were unsuccessful. Based on an evaluation of the situation, the nurse determines that which action would be best? 1 Terminating the resuscitation effort 2 Preparing for the administration of sodium bicarbonate intravenously 3 Performing cardiopulmonary resuscitation (CPR) for 5 minutes, then defibrillating three more times at 400 joules 4 Performing cardiopulmonary resuscitation (CPR) for 1 minute, then defibrillating up to three more times at 360 joules

4 After three unsuccessful defibrillation attempts using an AED, CPR should be done for 1 minute, followed by three more shocks, each delivered at 360 joules. There is no information in the question to indicate that life support should be terminated. Sodium bicarbonate may be prescribed but is not the best action. Giving CPR for 5 minutes may not help oxygenation to the brain and myocardium and is not the best action. It would be best to administer CPR for 1 minute and then resume attempts to convert the rhythm to a viable one.

Chemical cardioversion is prescribed for the client with atrial fibrillation. The nurse who is assisting in preparing the client would expect that which medication specific for chemical cardioversion will be needed? 1 Nitroglycerin 2 Nifedipine (Procardia) 3 Lidocaine (Xylocaine) 4 Amiodarone (Cordarone)

4 Amiodarone is an antidysrhythmic that is useful in restoring normal sinus rhythm for the client experiencing atrial fibrillation. Both nitroglycerin and nifedipine are vasodilators. Lidocaine is used for control of ventricular dysrhythmias.

A client admitted to a telemetry unit with a diagnosis of Prinzmetal's angina, has the following medications ordered. Upon interpretation of the client's electrocardiogram (ECG) rhythm, the nurse notes a prolonged PR interval of 0.32 second. Based on this information, which medication order should the nurse question administering to the client? 1. Isosorbide mononitrate (Imdur®) 20 mg oral daily upon awakening 2. Amlodipine (Norvasc®) 10 mg oral daily 3. Nitroglycerin (Nitrostat®) 0.4 mg sublingual prn for chest pain 4. Atenolol (Tenormin®) 50 mg oral daily.

4 Atenolol, a beta-blocker, blocks stimulation of beta1 (myocardial)- adrenergic receptors, causing a reduction in blood pressure and heart rate. A side effect of the medication is a prolongation of the PR interval (normal PR interval is 0.12 to 0.20 second). Continued use of the drug can result in heart block. Nitrates and calcium channel blockers (CCBs) are the mainstays of medical therapy for variant angina rather than beta blockers. Isosorbide mononitrate, a nitrate, causes vasodilatation of the large coronary arteries. Nitrates act as an exogenous source of nitric oxide, which causes vascular smooth muscle relaxation resulting in a decrease in myocardial oxygen consumption and may have a modest effect on platelet aggregation and thrombosis. Amlodipine, a CCB, relaxes coronary smooth muscle and produces coronary vasodilation, which in turn improves myocardial oxygen delivery. Nitroglycerin sublingual effectively treats episodes of angina and myocardial ischemia within minutes of administration, and the long-acting nitrate preparation (Imdur®) reduces the frequency of recurrent events.

On the first postoperative day following right-sided thoracotomy, a nurse is assisting a client with arm and shoulder exercises. The client reports pain with the exercises and wants to know why they must be performed. The nurse should explain that the exercises: 1. promote respiratory function. 2. increase blood flow back to the heart and venous system. 3. improve muscle mass to compensate for muscle removed during the procedure. 4. prevent stiffening and loss of function.

4 Because of the location of the incision, disuse can cause contractures and loss of muscle tone. The exercises help to preserve function of the arm and shoulder. Activity will promote respiratory function and improve venous return, but these are not the reasons for the exercises. Although the girdle muscles are cut, they are generally not removed.

A client with tuberculosis (TB) is preparing for discharge from the hospital, and the nurse provides instructions to the client about home care. Which client statement indicates that further instructions are necessary? 1 "I need to place used tissues in a plastic bag when I am home." 2 "I need to eat foods that are high in iron, protein, and vitamin C." 3 "It is not necessary to maintain respiratory isolation when I am at home." 4 "If I miss a dose of medication because of nausea, I just skip that dose and then resume my regular schedule

4 Because of the resistant strains of TB, the nurse must emphasize that noncompliance regarding medication could lead to an infection that is difficult to treat and that may cause total drug resistance. Clients may prevent nausea related to the medications by taking the daily dose at bedtime, and antinausea medications may also prevent this symptom. Medication doses should not be skipped. Options 1, 2, and 3 are correct statements.

A client who has had an abdominal aortic aneurysm repair is 1 day postoperative. The nurse performs an abdominal assessment and notes the absence of bowel sounds. The nurse should: 1 Feed the client. 2 Call the physician immediately. 3 Remove the nasogastric (NG) tube. 4 Document the finding and continue to assess for bowel sounds.

4 Bowel sounds may be absent for 3 to 4 days postoperative because of bowel manipulation during surgery. The nurse should document the finding and continue to monitor the client. The NG tube should stay in place if present, and the client is kept NPO until after the onset of bowel sounds. Additionally, the nurse does not remove the tube without a prescription to do so. There is no need to call the physician immediately at this time.

A client remains in atrial fibrillation with rapid ventricular response despite pharmacological intervention. Synchronous cardioversion is scheduled to convert the rapid rhythm. The nurse plans for implementation of which important action to ensure safety and prevent complications of this procedure? 1 Cardiovert the client at 360 joules. 2 Sedate the client before cardioversion. 3 Ensure that emergency equipment is available. 4 Ensure that the defibrillator is set on the synchronous mode.

4 Cardioversion is similar to defibrillation with two major exceptions: (1) the countershock is synchronized to occur during ventricular depolarization (QRS complex), and (2) less energy is used for the countershock. The rationale for delivering the shock during the QRS complex is to prevent the shock from being delivered during repolarization (T wave), often termed the "vulnerable period." If the shock is delivered during this period, the resulting complication is ventricular fibrillation. It is crucial that the defibrillator is set on the "synchronous" mode for a successful cardioversion. Cardioversion usually begins with 50 to 100 joules. Options 2 and 3 will not prevent complications

Which does the nurse assess for in a client who has pernicious anemia? 1 Constipation 2 Shortness of breath 3 Dusky lips and gums 4 Smooth, sore, red tongue

4 Classic clinical indicators of pernicious anemia include weakness, mild diarrhea, and a smooth, sore red tongue. The client may also have neurological findings, such as paresthesias, confusion, and difficulty with balance. Pernicious anemia does not affect tissue oxygenation, so the mucous membranes do not become dusky, and the client does not exhibit shortness of breath (options 2 and 3). Constipation is not a common finding with pernicious anemia.

A nurse hears the alarm sound on the telemetry monitor, looks at the monitor, and notes that a client is in ventricular tachycardia. The nurse rushes to the client's room. Upon reaching the client's bedside, the nurse should take which action first? 1 Call a code. 2 Prepare for cardioversion. 3 Prepare to defibrillate the client. 4 Check the client's level of consciousness.

4 Determining unresponsiveness is the first assessment action to take. When a client is in ventricular tachycardia, there is a significant decrease in cardiac output. However, assessing for unresponsiveness helps to determine whether the client is affected by the decreased cardiac output. If the client is unconscious, cardiopulmonary resuscitation is initiated Give O2 and antiarrythmia

During a code, a physician is about to defibrillate a client in ventricular fibrillation and says in a loud voice "CLEAR!" Which of the following should the nurse immediately perform? 1 Shut off the mechanical ventilator. 2 Shut off the intravenous infusion going into the client's arm. 3 Place the conductive gel pads for defibrillation on the client's chest. 4 Step away from the bed and make sure that all others have done the same

4 For the safety of all personnel, when the defibrillator paddles are being discharged, all personnel must stand back and be clear of all contact with the client or the client's bed. It is the primary responsibility of the person defibrillating to communicate the "clear" message loudly enough for all to hear and ensure their compliance. All personnel must immediately comply with this command. A ventilator is not in use during a code; rather an Ambu (resuscitation) bag is used. Shutting off the intravenous infusion has no useful purpose. The gel pads should have been placed on the client's chest before the defibrillator paddles were applied. Stepping back from the bed prevents the nurse or others from being defibrillated along with the client.

client taking medication for treatment of essential hypertension has a serum potassium level of 3.2 mEq/L. A nurse is reviewing the list of medications being taken by the client. Which medication on the list should the nurse conclude to be the causative factor for this serum potassium level? 1. Spironolactone (Aldactone®) 2. Potassium chloride (K-Dur®) 3. Enalapril (Vasotec®) 4. Hydrochlorothiazide (Esidrix®, HydroDIURIL®)

4 Hydrochlorothiazide is a thiazide diuretic that blocks sodium and water reabsorption in the distal tubule of the kidney and promotes potassium excretion, putting the client at risk for hypokalemia. Spironolactone acts by inhibiting sodium reabsorption in exchange for potassium (potassium-sparing diuretic). Potassium chloride is a potassium supplement. Enalapril is an angiotensin-converting enzyme (ACE) inhibitor that causes some clients to retain potassium.

A nurse is assisting a client with a chest tube to get out of bed, and the chest tubing accidentally gets caught in the bed rail and disconnects. While trying to reestablish the connection, the Pleur-Evac drainage system falls over and cracks. The nurse takes which immediate action? 1 Calls the physician 2 Clamps the chest tube 3 Applies a petrolatum gauze over the end of the chest tube 4 Immerses the chest tube in a bottle of sterile normal saline

4 If a chest tube accidentally disconnects from the tubing of the drainage apparatus, the nurse should first reestablish an underwater seal to prevent tension pneumothorax and mediastinal shift. This can be accomplished by reconnecting the chest tube, or in this case, immersing the end of the chest tube in a bottle of sterile normal saline or water. The physician should be notified after taking corrective action. If the physician is called first, tension pneumothorax has time to develop. Clamping the chest tube could also cause tension pneumothorax. A petrolatum gauze would be applied to the skin over the chest tube insertion site if the entire chest tube was accidentally removed from the chest

clinic nurse provides home care instructions to an adolescent with iron deficiency anemia about the administration of oral iron preparations. The nurse tells the adolescent that it is best to take the iron with: 1 Cola 2 Soda 3 Water 4 Tomato juice

4 Iron should be administered with vitamin C-rich fluids, because vitamin C enhances the absorption of the iron preparation. Tomato juice has a high ascorbic acid (vitamin C) content, whereas water, soda, and cola do not contain vitamin C.

A client has developed oral mucositis as a result of radiation to the head and neck. The nurse should teach the client to incorporate which of the following measures in his or her daily home care routine? 1 Oral hygiene should be performed in the morning and evening. 2 A glass of wine per day will not pose any further harm to the oral cavity. 3 High-protein foods such as peanut butter should be incorporated in the diet. 4 A combination of a weak saline and water solution should be used to rinse the mouth before and after each meal.

4 Oral mucositis (irritation, inflammation, and/or ulceration of the mucosa) also known as stomatitis, commonly occurs in clients receiving radiation to the head and neck. Measures need to be taken to soothe the mucosa as well as provide effective cleansing of the oral cavity. A combination of a weak saline and water solution is an effective cleansing agent. Oral hygiene should be performed more frequently than in the morning and evening. Alcohol would dry and irritate the mucosa. Peanut butter has a thick consistency and will stick to the irritated mucosa

The nurse is performing an admission assessment for a client admitted to the hospital with a diagnosis of Raynaud's disease. The nurse assesses for the symptoms associated with Raynaud's disease by: 1 Checking for a rash on the digits 2 Observing for softening of the nails or nail beds 3 Palpating for a rapid or irregular peripheral pulse 4 Palpating for diminished or absent peripheral pulses

4 Raynaud's disease is vasospasm of the arterioles and arteries of the upper and lower extremities. It produces closure of the small arteries in the distal extremities in response to cold, vibration, or external stimuli. Palpation for diminished or absent peripheral pulses checks for interruption of circulation. Skin changes include hair loss, thinning or tightening of the skin, and delayed healing of cuts or injuries. A rash on the digits is not a characteristic of this disorder. The nails grow slowly, become brittle or deformed, and heal poorly around the nail beds when infected. Although palpation of peripheral pulses is correct, a rapid or irregular pulse would not be noted.

nurse is providing emergency treatment for a client in ventricular tachycardia and is preparing to defibrillate the client. Which nursing action provides for the safest environment during a defibrillation attempt? 1 Ensuring that no lubricant is on the paddles 2 Placing the charged paddles one at a time on the client's chest 3 Holding the client's upper torso stable while the defibrillation is performed 4 Performing a visual and verbal check that all assisting personnel are clear of the client and the client's bed

4 Safety during defibrillation is essential for preventing injury to the client and the personnel assisting with the procedure. The person performing the defibrillation ensures that all personnel are standing clear of the bed by a verbal and visual check of "all clear." For the shock to be effective, some type of conductive medium (e.g., lubricant, gel) must be placed between the paddles and the skin. Both paddles are placed on the client's chest.

The nurse has provided instructions to a client who is receiving external radiation therapy. Which statement by the client indicates a need for further instructions regarding self-care related to the radiation therapy? 1 "I need to eat a high-protein diet." 2 "I need to avoid exposure to sunlight." 3 "I need to wash my skin with a mild soap and pat it dry." 4 "I need to apply pressure on the irritated area to prevent bleeding."

4 The client receiving external radiation therapy should avoid pressure on the irritated area and wear loose-fitting clothing. Specific physician instructions would be necessary to obtain if an alteration in skin integrity occurred as a result of the radiation therapy. Options 1, 2, and 3 are accurate measures regarding radiation therapy.

A client is suspected of having pulmonary tuberculosis. The nurse assesses the client for which signs and symptoms of tuberculosis? 1 High fever and chest pain 2 Increased appetite, dyspnea, and chills 3 Weight gain, insomnia, and night sweats 4 Low-grade fever, fatigue, and productive cough

4 The client with pulmonary tuberculosis generally has a productive or nonproductive cough, anorexia and weight loss, fatigue, low-grade fever, chills and night sweats, dyspnea, hemoptysis, and chest pain. Breath sounds may reveal crackles.

A nurse admits a client to a hospital and obtains a nursing history. The client tells the nurse that he had an endovascular repair of an abdominal aortic aneurysm found 1 year earlier during a routine screening. The nurse understands that this procedure consists of: 1. excision of the aneurysm and placement of a graft percutaneously. 2. an angioplasty with placement of a stent around the outside of the aorta. 3. placement of a filter within the aneurysm to block clots from becoming emboli. 4. placement of a stent graft inside the aorta that excludes the aneurysm from circulation.

4 The endovascular repair consists of placement of the endovascular stent graft inside the aorta extending above and below the aneurysmal area to seal it off from the circulation. The aneurysm is left in place. Angioplasty (ballooning of plaque from the inside) is not

A nurse is assessing a blood pressure of an adult client with a manual sphygmomanometer. The nurse places the bell diaphragm of the stethoscope over the brachial artery and pumps the cuff up to 180 mm Hg. The valve is released to allow a drop of 2 mm Hg per second. At 162 mm Hg the nurse hears the first tapping sound. The sound becomes muffled at 148 mm Hg. The sound changes to a soft thumping at the 138 mm Hg. The sound fades to a muffled blowing sound at 128 mm Hg and is last heard at 94 mm Hg. There is silence at 92 mm Hg. The nurse should document the blood pressure as: 1. 138/92 mm Hg. 2. 148/94 mm Hg. 3. 162/92 mm Hg. 4. 162/94 mm Hg.

4 The systolic blood pressure is elicited at the pressure where the first clear tapping sound is heard. The diastolic blood pressure is elicited at the pressure where the last sound is heard

A client comes into the health clinic 3 years after undergoing a resection of the terminal ileum complaining of weakness, shortness of breath, and a sore tongue. Which client statement indicates a need for intervention and client teaching? A "I have been drinking plenty of fluids." B "I have been gargling with warm salt water for my sore tongue." C "I have 3 to 4 loose stools per day." D "I take a vitamin B12 tablet every day.

4 Vitamin B12 combines with intrinsic factor in the stomach and is then carried to the ileum, where it is absorbed in the bloodstream. In this situation, vitamin B12 cannot be absorbed regardless of the amount of oral intake of sources of vitamin B12 such as animal protein or vitamin B12 tablets. Vitamin B12 needs to be injected every month, because the ileum has been surgically removed. Replacement of fluids and electrolytes is important when the client has continuous multiple loose stools on a daily basis. Warm salt water is used to soothe sore mucous membranes. Crohn's disease and small bowel resection may cause several loose stools a day.

When reviewing the laboratory results of a client with leukemia who is receiving chemotherapy, the registered nurse notes that the neutrophil count is less than 500/mm3. The registered nurse informs the nursing student caring for the client about the results and asks the student to identify the appropriate precautions that need to be instituted. Which intervention identified by the student indicates a need for teaching? 1 Restricting visitors with colds or respiratory infections 2 Removing all live plants, flowers, and stuffed animals in the client's room 3 Placing the client on a low-bacteria diet that excludes raw foods and vegetables 4 Padding the side rails and removing all hazardous and sharp objects from the envt

4 When the neutrophil count is less than 500/mm3, visitors should be screened for the presence of infection, and any visitors or staff with colds or respiratory infections should not be allowed in the client's room. All live plants, flowers, and stuffed animals are removed from the client's room. The client is placed on a low-bacteria diet that excludes raw fruits and vegetables. Padding the side rails and removing all hazardous and sharp objects from the environment would be instituted if the client is at risk for bleeding. This client is at risk for infection

70. The nurse is developing a care plan for a client with leukemia. The plan should include which of the following? Select all that apply. ■ 1. Monitor temperature and report elevation. ■ 2. Recognize signs and symptoms of infection. ■ 3. Avoid crowds. ■ 4. Maintain integrity of skin and mucous membranes. ■ 5. Take a baby aspirin each day.

1, 2, 3, 4. Nursing care of a client with leukemia includes managing and preventing infection, maintaining integrity of skin and mucous membranes, instituting measures to prevent bleeding, and monitoring for bleeding. Aspirin is an anticoagulant; bleeding tendencies, such as petechiae, ecchymosis, epistaxis, gingival bleeding, and retinal hemorrhages are likely due to thrombocytopenia

THE CLIENT WITH WHITE BLOOD CELL DISORDERS 67. A 10-year-old client is diagnosed with infectious mononucleosis. Her white blood cell (WBC) count is 19,000/μL. She has a streptococcal throat infection and her spleen is enlarged. She has aching muscles. Which of the following instructions should the nurse include in discharge planning with the client and her parents? Select all that apply. ■ 1. Stay on bed rest until the temperature is normal. ■ 2. Gargle with warm saline while the throat is irritated. ■ 3. Increase intake of fluids until the infection subsides. ■ 4. Take aspirin as long as the fever and myalgia persist. ■ 5. Avoid contact sports while the spleen is enlarged.

1, 2, 3, 5. The nurse should teach this client to stay on bed rest if she has a fever, gargle with warm saline, and increase her oral fl uids to prevent dehydration from the elevated temperature. The client with an enlarged spleen should avoid contact sports due to the increased risk of injury due to the enlargement. The nurse should tell the client to avoid aspirin if she has a fever because of the risk of Reye's syndrome. Instead, nonsteroidal anti-infl ammatory drugs should be used to treat fever and myalgia.

A client is to have a transfusion of packed red blood cells from a designated donor. The client asks if any diseases can be transmitted by this donor. The nurse should inform the client that which of the following diseases can be transmitted by a designated donor? Select all that apply. 1. Epstein-Barr virus. 2. Human immunodefi ciency virus (HIV). 3. Cytomegalovirus (CMV). 4. Hepatitis A. 5. Malaria.

1, 2, 3. Using designated donors does not decrease the risk of contracting infectious diseases, such as the Epstein-Barr virus, HIV, or CMV. Hepatitis A is transmitted by the oral-fecal route, not the blood route; however, hepatitis B and C can be contracted from a designated donor. Malaria is transmitted by mosquitoes.

26. The nurse should instruct a young female adult with sickle cell anemia to do which of the following? Select all that apply. ■ 1. Drink plenty of fl uids when outside in hot weather. ■ 2. Avoid travel to cities where the oxygen level is lower. ■ 3. Be aware that since she is homozygous for HbS, she carries the sickle cell trait. ■ 4. Know that pregnancy with sickle cell disease increases the risk of a crisis. ■ 5. Avoid fl ying on commercial airlines.

1, 2, 4. The nurse should teach the client to drink plenty of fl uids when outside in hot weather to avoid becoming dehydrated. The client should avoid high altitudes, such as mountains, where the oxygen levels are low and may precipitate a sickle cell crisis. The nurse should alert young women with sickle cell anemia that pregnancy increases the risk of a crisis. People who are homozygous for HbS have sickle cell anemia; the heterozygous form is the sickle cell carrier trait. A client with sickle cell anemia may fl y on commercial airlines; the airplane is pressurized for an adequate oxygen level.

A client with iron deficiency anemia is refusing to take the prescribed oral iron medication because the medication is causing nausea. The nurse should do which of the following? Select all that apply. 1. Suggest that the client use ginger when taking the medication. 2. Ask the client what she thinks is causing the nausea 3. Tell the client to use stool softeners to minimize constipation. 4. Offer to administer the medication by an intramuscular injection. 5. Suggest that the client take the iron with orange juice.

1, 2, 5. Nausea and vomiting are common adverse effects of oral iron preparations. The nurse should first ask the client why she does not want to take the oral medication, and then suggest ways to decrease the nausea and vomiting. Ginger may help minimize the nausea and the client can try this remedy and evaluate its effectiveness. Iron should be taken on an empty stomach but can be taken with orange juice. The client can evaluate if this helps the nausea. Stool softeners should not be used in client with iron deficiency anemia. Instead, constipation can be prevented by following a high-fiber diet. Administering iron intramuscularly is done only if other approaches are not effective.

87. The nurse is teaching the client how to use a metered-dose inhaler (MDI) to administer a corticosteroid. Which of the following client actions indicates that he is using the MDI correctly? Select all that apply. ■ 1. The inhaler is held upright. ■ 2. The head is tilted down while inhaling the medicine. ■ 3. The client waits 5 minutes between puffs. ■ 4. The mouth is rinsed with water following administration. ■ 5. The client lies supine for 15 minutes following administration.

1, 4. The client should shake the inhaler and hold it upright when administering the drug. The head should be tilted back slightly. The client should wait about 1 to 2 minutes between puffs. The mouth should be rinsed following the use of a corticosteroid MDI to decrease the likelihood of developing an oral infection. The client does not need to lie supine; instead, the client will likely to be able to breathe more freely if sitting upright.

18. When a client is receiving a cephalosporin, the nurse must monitor the client for which of the following? I 1. Drug-induced hemolytic anemia. I 2. Purpura. I 3. Infectious emboli. I 4. Ecchymosis.

1. Drug-induced hemolytic anemia is acquired, antibody-mediated, RBC destruction precipitated by medications, such as cephalosporins, sulfa drugs, rifampin, methyldopa, procainamide, quinidine, and thiazides. Purpura is a condi- tion with various manifestations characterized by hemorrhages into the skin, mucous membranes, internal organs, and other tissues. Infectious emboli are clumps of bacteria present in blood or lymph. Ecchymoses are skin discolorations due to extrava- sations of blood into the skin or mucous mem- branes.

13. A client was admitted to the hospital with iron deficiency anemia and blood-streaked emesis. Which question is most appropriate for the nurse to ask in determining the extent of the client's activity intolerance? I 1. "What daily activities were you able to do 6 months ago compared with the present?" I 2. "How long have you had this problem?" I 3. "Have you been able to keep up with all your usual activities?" I 4. "Are you more tired now than you used to be?"

1. It is difficult to determine activity intoler- ance without objectively comparing activities from one time frame to another. Because iron deficiency anemia can occur gradually and individual endur- ance varies, the nurse can best assess the client's activity tolerance by asking the client to compare activities 6 months ago and at present. Asking a cli- ent how long a problem has existed is a very open- ended question that allows for too much subjectivity for any definition of the client's activity tolerance. Also, the client may not even identify that a "prob- lem" exists. Asking the client whether he is stay- ing abreast of usual activities addresses whether the tasks were completed, not the tolerance of the client while the tasks were being completed or the resulting condition of the client after the tasks were completed. Asking the client if he is more tired now than usual does not address his activity tolerance. Tiredness is a subjective evaluation and again can be distorted by factors such as the gradual onset of the anemia or the endurance of the individual.

49. The nurse should assess a client with throm- bocytopenia who has developed a hemorrhage for which of the following? I 1. Tachycardia. I 2. Bradycardia. I 3. Decreased PaCO2. I 4. Narrowed pulse pressure.

1. The nurse observes tachycardia in the hemorrhaging client because the heart beats faster to compensate for decreased circulating volume and decreased numbers of oxygen-carrying RBCs. The degree of cardiopulmonary distress and anemia will be related to the amount of hemorrhage that occurred and the period of time over which it occurred. Bradycardia is a late symptom of hemorrhage; it occurs after the client is no longer able to compromise and is debilitating further into shock. If bradycardia is left untreated, the client will die from cardiovascular collapse. Decreased PaCO2 is a late symptom of hemorrhage, after transport of oxygen to the tissue has been affected. A narrowed pulse pres- sure is not an early sign of hemorrhage.

17. A client returned home from an overseas tour of duty and tells the nurse he is always tired. He has a temperature of 99.5° F (37.5° C). His skin is dark bronze, and his urine has a dark color. His hemoglobin level is 9 g/dL; his hematocrit is 49, and red blood cells are 2.75 million/μL. What should the nurse do fi rst? ■ 1. Initiate an intake and output record. ■ 2. Place the client on bed rest. ■ 3. Place the client on contact isolation. ■ 4. Keep the client out of sunlight.

1. The nurse should prepare to start an intake and output record because the client is exhibiting clinical manifestations of anemia with jaundice and is demonstrating a fluid imbalance. The client does not need to be on bed rest at this point. The client is not contagious and does not need to be placed in contact isolation. The changes in the color of the skin and urine are related to the jaundice and will not be affected by sunlight.

41. A client has a platelet count of 31,000/μL. The nurse should instruct the client to: ■ 1. Pad sharp surfaces to avoid minor trauma when walking. ■ 2. Assess for spontaneous petechiae in the extremities. ■ 3. Keep the room darkened. ■ 4. Check for blood in the urine.

1. A client with a platelet count of 30,000 to 50,000/μL is susceptible to bruising with minor trauma. Padding areas that the client might bump, scratch, or hit may help prevent minor trauma. A platelet count of 15,000 to 30,000/μL may result in spontaneous petechiae and bruising, especially on the extremities. Safety measures to pad surfaces would still be used, but the focus would be on assessing for new spontaneous petechiae. Keeping the room dark does not help the client with a low platelet count. When the count is lower than 20,000/μL, the client is at risk for spontaneous bleeding from the mucous membranes (oral, nasal, urinary, and rectal) and intracranial bleeding

38. When a client is diagnosed with aplastic anemia, the nurse should assess the client for changes in which of the following physiologic functions? I 1. Bleeding tendencies. I 2. Intake and output. I 3. Peripheral sensation. I 4. Bowel function.

1. Aplastic anemia decreases the bone mar- row production of RBCs, white blood cells, and platelets. The client is at risk for bruising and bleed- ing tendencies. A change in the client's intake and output is important, but assessment for the potential for bleeding takes priority. Change in the peripheral nervous system is a priority problem specific to clients with vitamin B12 deficiency. Change in bowel function is not associated with aplastic anemia.

31. A client is to receive epoetin (Epogen) injections. What laboratory value should the nurse assess before giving the injection? ■ 1. Hematocrit. ■ 2. Partial thromboplastin time. ■ 3. Hemoglobin concentration. ■ 4. Prothrombin time.

1. Epoetin (Epogen) is a recombinant DNA form of erythropoietin, which stimulates the production of RBCs and therefore causes the hematocrit to rise. The elevation in hematocrit causes an elevation in the blood pressure; therefore, the blood pressure is a vital sign that should be checked. The partial thromboplastin time, hemoglobin level, and prothrombin time are not monitored for this drug

118. For a client with rib fractures and a pneumothorax, the physician prescribes morphine sulfate, 1 to 2 mg/hour, given I.V. as needed for pain. The nursing care goal is to provide adequate pain control so that the client can breathe effectively. Which of the following outcomes would indicate successful achievement of this goal? ■ 1. Pain rating of 0 on a scale of 0 to 10 by the client. ■ 2. Decreased client anxiety. ■ 3. Respiratory rate of 26 breaths/minute. ■ 4. PaO2 of 70 mm Hg.

1. If the client reports no pain, then the objective of adequate pain relief has been met. Decreased anxiety is not related only to pain control; it could also be related to other factors. A respiratory rate of 26 breaths/minute is not within normal limits. A PaO2of 70 mm Hg is not within normal limits

92. Which of the following health promotion activities should the nurse include in the discharge teaching plan for a client with asthma? ■ 1. Incorporate physical exercise as tolerated into the daily routine. ■ 2. Monitor peak fl ow numbers after meals and at bedtime. ■ 3. Eliminate stressors in the work and home environment. ■ 4. Use sedatives to ensure uninterrupted sleep at night.

1. Physical exercise is benefi cial and should be incorporated as tolerated into the client's schedule. Peak fl ow numbers should be monitored daily, usually in the morning (before taking medication). Peak fl ow does not need to be monitored after each meal. Stressors in the client's life should be modifi ed but cannot be totally eliminated. Although adequate sleep is important, it is not recommended that sedatives be routinely taken to induce sleep

85. A client experiencing a severe asthma attack has the following arterial blood gas: pH 7.33; PCO2 48; PO2 58; HCO3 26. Which of the following orders should the nurse perform fi rst? ■ 1. Albuterol (Proventil) nebulizer. ■ 2. Chest x-ray. ■ 3. Ipratropium (Atrovent) inhaler. ■ 4. Sputum culture.

1. The arterial blood gas reveals a respiratory acidosis with hypoxia. A quick-acting bronchodilator, albuterol, should be administered via nebulizer to improve gas exchange. Ipratropium is a maintenance treatment for bronchospasm that can be used with albuterol. A chest x-ray and sputum sample can be obtained once the client is stable.

22. An African-American woman had experienced severe palpitations, weakness, and shortness of breath after taking bacitracin (Bactrim). As a part of the discharge planning, the nurse should evaluate the client's knowledge about: ■ 1. Increased folic acid needs. ■ 2. Congenital enzyme defi ciency. ■ 3. Restricted activity in hot weather. ■ 4. Need for blood transfusions.

2 This client presented with the typical signs of glucose-6-phosphate dehydrogenase (G6PD)-deficiency anemia. Ten percent of African Americans inherit an X-linked recessive disorder of the G6PD enzyme in the red blood cell (RBC). When cells with decreased levels of G6PD are exposed to certain drugs, such as sulfonamides, acetylsalicylic acid, thiazide diuretics, and vitamin K, the RBC may hemolyze and anemia and jaundice may occur. The reaction is self-limited as soon as the causative agent is withheld. No further treatment is necessary except counseling to prevent acute incidence by avoiding exposure to specifi c drugs. There is no need for increased folic acid, restricted activity in hot weather, or blood transfusions.

37. The nurse is teaching a client with polycythemia vera about potential complications from this disease. Which manifestations should the nurse include in the client's teaching plan? Select all that apply. ■ 1. Hearing loss. ■ 2. Visual disturbance. ■ 3. Headache. ■ 4. Orthopnea. ■ 5. Gout. ■ 6. Weight loss

2, 3, 4, 5. Polycythemia vera, a condition in which too many RBCs are produced in the blood serum, can lead to an increase in the hematocrit and hypervolemia, hyperviscosity, and hypertension. Subsequently, the client can experience dizziness, tinnitus, visual disturbances, headaches, or a feeling of fullness in the head. The client may also experience cardiovascular symptoms such as heart failure (shortness of breath and orthopnea) and increased clotting time or symptoms of an increased uric acid level such as painful, swollen joints (usually the big toe). Hearing loss and weight loss are not manifestations associated with polycythemia vera.

29. Which safety measures would be most important to implement when caring for a client who is receiving 2 units of packed red blood cells (PRBCs)? Select all that apply. ■ 1. Verify that the ABO and Rh of the 2 units are the same. ■ 2. Infuse a unit of PRBCs in less than 4 hours. ■ 3. Stop the transfusion if a reaction occurs, but keep the line open. ■ 4. Take vital signs every 15 minutes while the unit is transfusing. ■ 5. Inspect the blood bag for leaks, abnormal color, and clots. ■ 6. Use a 22-gauge catheter for optimal fl ow of a blood transfusion.

2, 3, 5. The American Association of Blood Banks recommends that two qualified people, such as two registered nurses or a physician and a registered nurse, compare the name and number on the identification bracelet with the tag on the blood bag. Verifying that the two units are the same is not a recommendation. Rather, the verification is always with the client, not with bags of blood. A unit of blood should infuse in 4 hours or less to avoid the risk of septicemia since no preservatives are used. When a blood transfusion reaction occurs, the blood transfusion should be stopped immediately, but the I.V. line should be kept open so that emergency medications and fluids can be administered. The unit of PRBCs should be inspected for contamination by looking for leaks, abnormal color, clots, and excessive air bubbles. When a unit of PRBCs is being transfused, vital signs are assessed before the transfusion begins, after the first 15 minutes, and then every hour until 1 hour after the transfusion has been completed. When PRBCs are being administered, a 20-gauge or larger needle is needed to avoid destroying the RBCs passing through the lumen and to allow for maximal flow rate.

55. A client has been on long-term prednisone therapy. The nurse should instruct the client to consume a diet high in which of the following? Select all that apply. ■ 1. Carbohydrate. ■ 2. Protein. ■ 3. Trans fat. ■ 4. Potassium. ■ 5. Calcium. ■ 6. Vitamin D.

2, 4, 5, 6. Adverse effects of prednisone are weight gain, retention of sodium and fluids with hypertension and cushingoid features, a low serum albumin level, suppressed inflammatory processes with masked symptoms, and osteoporosis. A diet high in protein, potassium, calcium, and vitamin D is recommended. Carbohydrates would elevate glucose and further compromise a client's immune status. Trans fat does not counteract the adverse effects of steroids such as prednisone.

57. The nurse is teaching a client who has been diagnosed with tuberculosis how to avoid spreading the disease to family members. Which statement(s) by the client indicate(s) that he has understood the nurse's instructions? Select all that apply. ■ 1. "I will need to dispose of my old clothing when I return home." ■ 2. "I should always cover my mouth and nose when sneezing." ■ 3. "It is important that I isolate myself from family when possible." ■ 4. "I should use paper tissues to cough in and dispose of them promptly." ■ 5. "I can use regular plates and utensils whenever I eat."

2, 4, 5. When teaching the client how to avoid the transmission of tubercle bacilli, it is important for the client to understand that the organism is transmitted by droplet infection. Therefore, covering the mouth and nose when sneezing, using paper tissues to cough in with prompt disposal, and using regular plates and utensils indicate that the client has understood the nurse's instructions about preventing the spread of airborne droplets. It is not essential to discard clothing, nor does the client need to isolate himself from family members.

35. A client with macrocytic anemia has a burn on her foot and states that she had been watch- ing television while lying on a heating pad. Which action should be the nurse's first response? I 1. Assess for potential abuse. I 2. Check for diminished sensations. I 3. Document the findings. I 4. Clean and dress the area

2. Macrocytic anemias can result from deficiencies in vitamin B12 or ascorbic acid. Only vita- min B12 deficiency causes diminished sensations of peripheral nerve endings. The nurse should assess for peripheral neuropathy and instruct the client in self-care activities for her diminished sensation to heat and pain (e.g., using a heating pad at a lower heat setting, making frequent checks to protect against skin trauma). The burn could be related to abuse, but this conclusion would require more sup- porting data. The findings should be documented, but the nurse would want to address the client's sen- sations first. The decision of how to treat the burn should be determined by the physician.

65. A client with disseminated intravascular coagulation develops clinical manifestations of microvascular thrombosis. The nurse should assess the client for: I 1. Hemoptysis. I 2. Focal ischemia. I 3. Petechiae. I 4. Hematuria.

2. Clinical manifestations of microvascular thrombosis are those that represent a blockage of blood flow and oxygenation to the tissue that results in eventual death of the organ. Examples of microvascular thrombosis include acute respira- tory distress syndrome, focal ischemia, superficial gangrene, oliguria, azotemia, cortical necrosis, acute ulceration, delirium, and coma. Hemoptysis, pete- chiae, and hematuria are signs of hemorrhage.

44. The nurse evaluates that the client correctly understands how to report signs and symptoms of bleeding when the client makes which of the follow- ing statements? I 1. "Petechiae are large, red skin bruises." I 2. "Ecchymoses are large, purple skin bruises." I 3. "Purpura is an open cut on the skin." I 4. "Abrasions are small pinpoint red dots on the skin."

2. Large, purplish skin lesions caused by hemorrhage are called ecchymoses. Small, flat, red pinpoint lesions are petechiae. Numerous petechiae result in a reddish, bruised appearance called purpura. An abrasion is a wound caused by scraping.

48. A client's bone marrow report reveals normal stem cells and precursors of platelets (megakaryocytes) in the presence of decreased circulating plate- lets. The nurse recognizes a knowledge deficit when the client makes which of the following statements? I 1. "I need to stop flossing and throw away my hard toothbrush." I 2. "I am glad that my report turned out normal." I 3. "Now I know why I have all these bruises." I 4. "I shouldn't jump off that last step anymore."

2. The client who states that the test results are normal has only heard that the bone marrow is functioning. The etiology is in the destruction of circulating platelets. Further tests must be completed to determine the cause (e.g., a coating of the platelets with antibodies that are seen as foreign bodies). The bone marrow result does rule out other potential diagnoses such as anemia, leukemia, or myeloproliferative disorders that involve bone marrow depression. The client needs to stop flossing and throw away his hard toothbrush, which can lead to bleed- ing of the gums. The destruction of the circulating platelets accounts for the easy bruising and the need to protect oneself from further bruising. The client should not jump or increase exertion of joints, which may lead to bleeding in the joints and joint pain.

15. Which position would most help to decrease a client's discomfort when the client's spouse injects vitamin B12 using the ventrogluteal site? ■ 1. Lying on the side with legs extended. ■ 2. Lying on the abdomen with toes pointed inward. ■ 3. Leaning over the edge of a low table with hips fl exed. ■ 4. Standing upright with the feet one shoulderwidth apart.

2. To promote comfort when injecting at the ventrogluteal site, the position of choice is with the client lying on the abdomen with toes pointed inward. This positioning promotes muscle relaxation, which decreases the discomfort of making an injection into a tense muscle. Lying on the side with legs extended will not provide the greatest muscle relaxation. Leaning over the edge of a table with the hips fl exed and standing upright with the feet apart will increase muscular tension.

46. The nurse should instruct the client with a platelet count of less than 150,000/μL to avoid which of the following activities? I 1. Ambulation. I 2. Valsalva's maneuver. I 3. Visiting with children. I 4. Semi-Fowler's position.

2. When the platelet count is less than 150,000/μL, prolonged bleeding can occur from trauma, injury, or straining such as with Valsalva's maneuver. Clients should avoid any activity that causes straining to evacuate the bowel. Clients can ambulate, but pointed or sharp surfaces should be padded. Clients can visit with their families but should avoid any scratches, bumps, or scrapes. Clients can sit in a semi-Fowler's position but should change positions to promote circulation and check for petechiae.

43. When a client with thrombocytopenia has of a severe headache, the nurse interprets that this may indicate which of the following? I 1. Stress of the disease. I 2. Cerebral bleeding. I 3. Migraine headache. I 4. Sinus congestion.

2. When the platelet count is very low, RBCs leak out of the blood vessels and into the tissue. If the blood pressure is elevated and the platelet count falls to less than 15,000/μL, internal bleeding in the brain can occur. A severe headache occurs from meningeal irritation when blood leaks out of the cerebral vasculature. When a client has thrombocytopenia, the nurse should always assess for cerebral bleeding by check- ing vital signs and performing neurologic checks. Headaches can be caused by stress, migraines, and sinus congestion. However, the concern here is the risk of internal bleeding into the brain.

A client with pernicious anemia asks why she must take vitamin B12 injections for the rest of her life. Which is the nurse's best response? 1. "The reason for your vitamin deficiency is an inability to absorb the vitamin because the stomach is not producing sufficient acid." 2. "The reason for your vitamin deficiency is an inability to absorb the vitamin because the stomach is not producing sufficient intrinsic factor." 3. "The reason for your vitamin deficiency is an excessive excretion of the vitamin because of kidney dysfunction."4. "The reason for your vitamin deficiency is an increased requirement for the vitamin because of rapid red blood cell production."

2. "The reason for your vitamin deficiency is an inability to absorb the vitamin because the stomach is not producing sufficient intrinsic factor." Most clients with pernicious anemia have deficient production of intrinsic factor in the stomach. Intrinsic factor attaches to the vitamin in the stomach and forms a complex that allows the vitamin to be absorbed in the small intestine. The stomach is producing enough acid, there is not an excessive excretion of the vitamin, and there is not a rapid production of red blood cells in this condition.

103. The nurse explains to the client with Hodgkin's disease that a bone marrow biopsy will be taken after the aspiration. What should the nurse explain about the biopsy? ■ 1. "Your biopsy will be performed before the aspiration because enough tissue may be obtained so that you won't have to go through the aspiration." ■ 2. "You will feel a pressure sensation when the biopsy is taken but should not feel actual pain; if you do, tell the doctor so that you can be given extra numbing medicine." ■ 3. "You may hear a crunch as the needle passes through the bone, but when the biopsy is taken, you will feel a suction-type pain that will last for just a moment." ■ 4. "You will be shaved and cleaned with an antiseptic agent, after which the doctor will inject a needle without making an incision to aspirate out the bone marrow."

2. A biopsy needle is inserted through a separate incision in the anesthetized area. The client will feel a pressure sensation when the biopsy is taken but should not feel actual pain. The client should be instructed to inform the physician if pain is felt so that more anesthetic agent can be administered to keep the client comfortable. The biopsy is performed after the aspiration and from a slightly different site so that the tissue is not disturbed by either test. The client will feel a suction-type pain for a moment when the aspiration is being performed, not the biopsy. A small incision is made for the biopsy to accommodate the larger-bore needle. This may require a stitch.

30. A client who had received 25 mL of packed red blood cells (PRBCs) has low back pain and pruritus. After stopping the infusion, the nurse should take what action next? ■ 1. Administer prescribed antihistamine and aspirin. ■ 2. Collect blood and urine samples and send to the lab. ■ 3. Administer prescribed diuretics. ■ 4. Administer prescribed vasopressors

2. ABO- and Rh-incompatible blood causes an antigen-antibody reaction that produces hemolysis or agglutination of red blood cells (RBCs). At the fi rst indication of any sign/symptom of reaction, the blood transfusion is stopped. Blood and urine samples are obtained from the client and sent to the lab along with the remaining untransfused blood. Hemoglobin in the urine and blood samples taken at the time of the reaction provides evidence of a hemolytic blood transfusion reaction. Antihistamine, aspirin, diuretics, and vasopressors may be administered with different types of transfusion reactions.

34. A client with microcytic anemia is having trouble selecting food from the hospital menu. Which food is best for the nurse to suggest for satisfying the client's nutritional needs? ■ 1. Egg yolks. ■ 2. Brown rice. ■ 3. Vegetables. ■ 4. Tea.

2. Brown rice is a source of iron from plant sources (nonheme iron). Other sources of nonheme iron are whole-grain cereals and breads, dark green vegetables, legumes, nuts, dried fruits (apricots, raisins, dates), oatmeal, and sweet potatoes. Egg yolks have iron but it is not as well absorbed as iron from other sources. Vegetables are a good source of vitamins that may facilitate iron absorption. Tea contains tannin, which combines with nonheme iron, preventing its absorption

10. The nurse devises a teaching plan for the client with aplastic anemia. Which of the following is the most important concept to teach for health promotion and maintenance? ■ 1. Eat animal protein and dark green, leafy vegetables every day. ■ 2. Avoid exposure to others with acute infections. ■ 3. Practice yoga and meditation to decrease stress and anxiety. ■ 4. Get 8 hours of sleep at night and take naps during the day.

2. Clients with aplastic anemia are severely immunocompromised and at risk for infection and possible death related to bone marrow suppression and pancytopenia. Strict aseptic technique and reverse isolation are important measures to prevent infection. Although diet, reduced stress, and rest are valued in supporting health, the potentially fatal consequence of an acute infection places it as a priority for teaching the client about health maintenance. Animal meat and dark green leafy vegetables, good sources of vitamin B12 and folic acid, should be included in the daily diet. Yoga and meditation are good complementary therapies to reduce stress. Eight hours of rest and naps are good for spacing and pacing activity and rest.

54. The nurse is teaching a client with a history of acquired thrombocytopenia about how to prevent and control hemorrhage. Which statement indicates that the client needs further instruction? ■ 1. "I can apply direct pressure over small cuts for at least 5 to 10 minutes to stop a venous bleed." ■ 2. "I can count the number of tissues saturated to detect blood loss during a nosebleed." ■ 3. "I can take hormones to decrease blood loss during menses." ■ 4. "I can count the number of sanitary napkins to detect excess blood loss during menses."

2. The client needs further teaching if she thinks that the number of tissues saturated represents all of the blood lost during a nosebleed. During a nosebleed, a signifi cant amount of blood can be swallowed and go undetected. It is important that clients with severe thrombocytopenia do not take a nosebleed lightly. Clients with thrombocytopenia can apply pressure for 5 to 10 minutes over a small, superfi cial cut. Clients with thrombocytopenia can take hormones to suppress menses and control menstrual blood loss. Clients can also count the number of saturated sanitary napkins to approximate blood loss during menses. Some authorities estimate that a completely soaked sanitary napkin holds 50 mL.

9. Which of the following lab values should the nurse report to the health care provider when the client has anemia? I 1. Schilling test result, elevated. I 2. Intrinsic factor, absent. I 3. Sedimentation rate, 16 mm per hour. I 4. Red blood cells (RBCs) within normal range.

2. The defining characteristic of pernicious anemia, a megaloblastic anemia, is lack of the intrinsic factor which results from atrophy of the stomach wall. Without the intrinsic factor, vitamin B12 cannot be absorbed in the small intestine and folic acid needs vitamin B12 for deoxyribonucleic acid synthesis of RBCs. The gastric analysis is done to determine the primary cause of the anemia. An elevated excretion of the injected radioactive vitamin B12, which is protocol for the first and second stage of the Schilling test, indicates that the cli- ent has the intrinsic factor and can absorb vitamin B12 in the intestinal tract. A sedimentation rate of 16 mm/hour is normal for both men and women and is a nonspecific test to detect the presence of inflammation; it is not specific to anemias. An RBC value within the normal range does not indicate an anemia.

93. The nurse should teach the client with asthma that which of the following is one of the most common precipitating factors of an acute asthma attack? ■ 1. Occupational exposure to toxins. ■ 2. Viral respiratory infections. ■ 3. Exposure to cigarette smoke. ■ 4. Exercising in cold temperatures.

2. The most common precipitator of asthma attacks is viral respiratory infection. Clients with asthma should avoid people who have the fl u or a cold and should get yearly fl u vaccinations. Environmental exposure to toxins or heavy particulate matter can trigger asthma attacks; however, far fewer asthmatics are exposed to such toxins than are exposed to viruses. Cigarette smoke can also trigger asthma attacks, but to a lesser extent than viral respiratory infections. Some asthmatic attacks are triggered by exercising in cold weather.

23. The nurse is assessing a client's activity tolerance by having the client walk on a treadmill for 5 minutes. Which of the following indicates an abnormal response? 1. Pulse rate increased by 20 beats per minute (bpm) immediately after the activity. 2. Respiratory rate decreased by 5 breaths/minute. 3. Diastolic blood pressure increased by 7 mm Hg. 4. Pulse rate within 6 bpm of resting pulse after 3 minutes of rest.

2. The normal physiologic response to activity is an increased metabolic rate over the resting basal rate. The decrease in respiratory rate indicates that the client is not strong enough to complete the mechanical cycle of respiration needed for gas exchange. The postactivity pulse is expected to increase immediately after activity but by no more than 50 bpm if it is strenuous activity. The diastolic blood pressure is expected to rise but by no more than 15 mm Hg. The pulse returns to within 6 bpm of the resting pulse after 3 minutes of rest.

27. The nurse is teaching a client and his family about the client's new diagnosis of hemochromatosis. Which of the following details should the nurse include? ■ 1. Hemochromatosis is an autoimmune disorder that affects the HFE gene. ■ 2. Individuals who are heterozygous for hemochromatosis rarely develop the disease. ■ 3. Individuals who are homozygous for hemochromatosis are carriers of hemochromatosis. ■ 4. Men are at greater risk for hemochromatosis

2. The nurse should teach the client and family that individuals who are heterozygous for hemochromatosis rarely develop the disease. The nurse should teach that men and women are equally at risk for hemochromatosis, but men are diagnosed earlier because women do not usually have manifestations until menopause. Hemochromatosis is the most common genetic disorder in the United States. Individuals who are homozygous for hemochromatosis received a defective gene from each parent. Those with homozygous genes may develop the disease.

124. The nurse has placed the intubated client with acute respiratory distress syndrome (ARDS) in prone position for 30 minutes. Which of the following would require the nurse to discontinue prone positioning and return the client to the supine position? Select all that apply. ■ 1. The family is coming in to visit. ■ 2. The client has increased secretions requiring frequent suctioning. ■ 3. The SpO2 and PO2 have decreased. ■ 4. The client is tachycardic with drop in blood pressure. ■ 5. The face has increased skin breakdown and edema.

3, 4, 5. The prone position is used to improve oxygenation, ventilation, and perfusion. The importance of placing clients with ARDS in prone positioning should be explained to the family. The positioning allows for mobilization of secretions and the nurse can provide suctioning. Clinical judgment must be used to determine the length of time in the prone position. If the client's hemodynamic status, oxygenation, or skin is compromised, the client should be returned to the supine position for evaluation. Facial edema is expected with the prone position, but the skin breakdown is of concern.

59. A client is scheduled for an elective splenec- tomy. Immediately before the client goes to surgery, the nurse should determine that the client has: I 1. Voided completely. I 2. Signed the consent. I 3. Vital signs recorded. I 4. Name band on wrist.

3. An elective surgical procedure is scheduled in advance so that all preparations can be completed ahead of time. The vital signs are the final check that must be completed before the cli- ent leaves the room so that continuity of care and assessment is provided for. The first assessment that will be completed in the preoperative holding area or operating room will be the client's vital signs. The client should have emptied the bladder before receiving preoperative medications so that the blad- der is empty when it is time for transport into the operating room. The client should have signed the consent before the transport time so that if there were any questions or concerns there was time to meet with the surgeon. Also, the consent form must be signed before any sedative medications are given. The client's name band should be placed as soon as the client arrives in the perioperative setting, and it remains in place through discharge.

12. A client who follows a vegetarian diet was referred to a dietitian for nutritional counseling for anemia. Which client outcome indicates that the client does not understand nutritional counseling? The client: I 1. Adds dried fruit to cereal and baked goods. I 2. Cooks tomato-based foods in iron pots. I 3. Drinks coffee or tea with meals. I 4. Adds vitamin C to all meals.

3. Coffee and tea increase gastrointestinal motility and inhibit the absorption of nonheme iron. Clients are instructed to add dried fruits to dishesat every meal because dried fruits are a nonhemeor nonanimal iron source. Cooking in iron cook- ware, especially acid-based foods such as tomatoes, adds iron to the diet. Clients are instructed to adda rich supply of vitamin C to every meal becausethe absorption of iron is increased when food with vitamin C or ascorbic acid is consumed.

57. The nurse is preparing to administer platelets. The nurse should: I 1. Check the ABO compatibility. I 2. Administer the platelets slowly. I 3. Gently rotate the bag. I 4. Use a whole blood tubing set.

3. The bag containing platelets needs to be gently rotated to prevent clumping. ABO compat- ibility is not a necessary requirement, but human leukocyte antigen (HLA) matching of lymphocytes may be completed to avoid development of anti- HLA antibodies when multiple platelet transfusions are necessary. Platelets should be administered as fast as can be tolerated by the client to avoid aggregation. Most institutions use tubing especially for platelets instead of tubing for blood and blood prod- ucts.

51. A client is to be discharged on prednisone. Which of the following statements indicates that the client understands important concepts about the medication therapy? I 1. "I need to take the medicine in divided doses at morning and bedtime." I 2. "I am to take 40 mg of prednisone for 2 months and then stop." I 3. "I need to wear or carry identification that I am taking prednisone." I 4. "Prednisone will give me extra protection from colds and flu."

3. The client needs to wear or carry infor- mation containing the name of the drug, dosage, physician and contact information, and emergency instructions because additional corticosteroid drug therapy would be needed during emergency situa- tions. Prednisone should be taken in the morning because it can cause insomnia and because exog- enous corticosteroid suppression of the adrenal cortex is less when it is administered in the morn- ing. Prednisone must never be stopped suddenly. It must be tapered off to allow for the adrenal cortex to recover from drug-induced atrophy so that it can resume its function. Prednisone suppresses the immune response and masks infections. It does not provide extra protection against infection.

60. When receiving a client from the postanesthesia care unit after a splenectomy, which should the nurse assess after obtaining vital signs? I 1. Nasogastric drainage. I 2. Urinary catheter. I 3. Dressing. I 4. Need for pain medication.

3. After a splenectomy, the client is at high risk for hypovolemia and hemorrhage. The dress- ing should be checked often; if drainage is present, a circle should be drawn around the drainage and the time noted to help determine how fast bleed- ing is occurring. The nasogastric tube should be connected, but this can wait until the dressing has been checked. A urinary catheter is not needed. The last pain medication administration and the client's current pain level should be communi- cated in the exchange report. Checking for hem- orrhage is a greater priority than assessing pain level.

102. A client is undergoing a bone marrow aspiration and biopsy. What is the best way for the nurse to help the client handle her stress? ■ 1. Allow the client's family to stay with her as long as possible. ■ 2. Stay with the client and hold her hand without speaking. ■ 3. Encourage the client to take slow, deep breaths to relax. ■ 4. Allow the client time to express her feelings.

3. Encouraging the client to take slow, deep breaths during uncomfortable parts of procedures is the best method of decreasing the stress response of tightening and tensing the muscles. Slow, deep breathing affects the level of carbon dioxide in the brain to increase the client's sense of well-being. Allowing the client's family to stay with her may be appropriate if the family has a calming effect on the client. Silence can be therapeutic, but when the client is faced with a potentially life-threatening diagnosis and a new, invasive procedure, she really needs words in addition to touch unless another health care provider is talking to her. Expressing feelings is important, but the client will have to hold still for the procedure.

24. When comparing the hematocrit levels of a postoperative client, the nurse notes that the hematocrit decreased from 36% to 34% on the third day even though the RBC count and hemoglobin value remained stable at 4.5 million/μL and 11.9 g/dL, respectively. The nurse should next: ■ 1. Check the dressing and drains for frank bleeding. ■ 2. Call the physician. ■ 3. Continue to monitor vital signs. ■ 4. Start oxygen at 2 L/minute per nasal cannula.

3. The nurse should continue to monitor the client because this value refl ects a normal physiologic response. The physician does not need to be called, and oxygen does not need to be started based on these laboratory fi ndings. Immediately after surgery, the client's hematocrit refl ects a falsely high value related to the body's compensatory response to the stress of sudden loss of fl uids and blood. Activation of the intrinsic pathway and the renin-angiotensin cycle via antidiuretic hormone produces vasoconstriction and retention of fl uid for the fi rst 1 to 2 days postoperatively. By the second to third day, this response decreases and the client's hematocrit level is more refl ective of the amount of RBCs in the plasma. Fresh bleeding is a less likely occurrence on the third postoperative day but is not impossible; however, the nurse should have expected to see a decrease in the RBC count and hemoglobin value accompanying the hematocrit.

81. The nurse administers theophylline (Theo- Dur) to a client. To evaluate the effectiveness of this medication, which of the following drug actions should the nurse anticipate? ■ 1. Suppression of the client's respiratory infection. ■ 2. Decrease in bronchial secretions. ■ 3. Relaxation of bronchial smooth muscle. ■ 4. Thinning of tenacious, purulent sputum.

3. Theophylline (Theo-Dur) is a bronchodilator that is administered to relax airways and decrease dyspnea. Theophylline is not used to treat infections and does not decrease or thin secretions.

103. While assessing a thoracotomy incisional area from which a chest tube exits, the nurse feels a crackling sensation under the fi ngertips along the entire incision. Which of the following should be the nurse's fi rst action? ■ 1. Lower the head of the bed and call the physician. ■ 2. Prepare an aspiration tray. ■ 3. Mark the area with a skin pencil at the outer periphery of the crackling. ■ 4. Turn off the suction of the chest drainage system.

3. This crackling sensation is subcutaneous emphysema. Subcutaneous emphysema is not an unusual fi nding, and it is not dangerous if confi ned. But progression can be serious, especially if the neck is involved; a tracheotomy may be needed. If emphysema progresses noticeably in 1 hour, the physician should be notifi ed. Lowering the head of the bed will not arrest the progress or provide any further information. A tracheotomy tray would be useful if subcutaneous emphysema progresses to the neck. Subcutaneous emphysema may progress if the chest drainage system does not adequately remove air and fl uid; therefore, the system should not be turned off.

The nurse is assisting with a bone marrow aspiration and biopsy. In which order, from first to last, should the nurse complete the following tasks? 1. Position the client in a side-lying position. 2. Clean the skin with an antiseptic solution. 3. Verify the client has signed an informed consent. 4. Apply ice to the biopsy site.

3. Verify the client has signed an informed consent. 1. Position the client in a side-lying position. 2. Clean the skin with an antiseptic solution. 4. Apply ice to the biopsy site. First, the nurse must verify that the client has vol- untarily signed a consent form before the procedure begins, and check that the client understands the procedure. The nurse then positions the client in a side-lying, or lateral decubitus, position with the affected side up. Then the nurse should clean the skin site and surrounding area with an antiseptic solution such as Betadine before the health care provider numbs the site and collects the specimen. When the procedure is finished, the nurse must apply ice to the biopsy site to reduce pain.

32. When beginning I.V. erythropoietin (Epogen, Procrit) therapy, the nurse should do which of the following? Select all that apply. ■ 1. Checking the hemoglobin levels before administering subsequent doses. ■ 2. Shaking the vial thoroughly to mix the concentrated white, milky solution. ■ 3. Keeping the multidose vial refrigerated between scheduled twice-a-day doses. ■ 4. Administering the medication through the I.V. line without other medications. ■ 5. Adjusting the initial doses according to the client's changes in blood pressure. ■ 6. Educating the client to avoid driving and performing hazardous

4, 5, 6. Erythropoietin is administered to decrease the need for blood transfusions by stimulating RBC production. The medication should be administered through the I.V. line without other medications to avoid a reaction. The hematocrit, a simple measurement of the percent of RBCs in the total blood volume, is used to monitor this therapy. When initiating I.V. erythropoietin therapy, the nurse should monitor the hematocrit level so that it rises no more than four points in any 2-week period. In addition, the initial doses of erythropoietin are adjusted according to the client's changes in blood pressure. The nurse should tell the client to avoid driving and performing hazardous activity during the initial treatment due to possible dizziness and headaches secondary to the adverse effect of hypertension. The hematocrit, not the hemoglobin level, is used for monitoring the effectiveness of therapy. The vial of erythropoietin should not be shaken because it may be biologically inactive. The solution should not be used if it is discolored. The nurse should not reenter the vial once it has been entered; it is a one-time use vial. All remaining erythropoietin should be discarded since it does not contain preservatives.

14. A physician orders vitamin B12 for a client with pernicious anemia. Which site is appropriate for the nurse to administer vitamin B12? Select all that apply. I 1. Median cutaneous. I 2. Greater femur trochanter. I 3. Acromion muscle. I 4. Ventrogluteal. I 5. Upper back. I 6. Dorsogluteal.

4, 6. A client with pernicious anemia has lost the ability to absorb vitamin B12 either because of the lack of an acidic gastric environment or the lack of the intrinsic factor. Vitamin B12 must be adminis- tered by a deep intramuscular route. The ventroglu- teal and dorsogluteal locations are the most accept- able sites for a deep intramuscular injection. The other sites are not acceptable.

A client who had a splenectomy is being discharged. Of the following discharge instructions, which is most specific to the client's surgical procedure? 1 Do not drive. 2 Alternate rest and activity. 3 Make an appointment for the staples to be removed. 4 Report early signs of infection.

4. Clients who have had a splenectomy are especially prone to infection. The reduction of immunoglobulin M leaves the client especially at risk for immunologic deficiency infections. All cli- ents who have had major abdominal surgery usually receive discharge instructions not to drive because the stomach muscles are not strong enough to brake hard or quickly after the abdominal muscles have been separated. All clients need to pace activity and rest when going home after major surgery. Rest and sleep allow the growth hormone to repair the tissue, and activity allows the energy and strength to build endurance and muscle strength. An appointment is usually made to see the surgeon in the office 1 week after discharge for follow-up and to remove sutures or staples if this has not already been done.

53. The nurse is preparing a teaching plan about increased exercise for a female client who is receiv- ing long-term corticosteroid therapy. What type of exercise is most appropriate for this client? I 1. Floor exercises. I 2. Stretching. I 3. Running. I 4. Walking.

4. The best exercise for females who are on long-term corticosteroid therapy is a low-impact, weight-bearing exercise such as walking or weight lifting. Floor exercises do not provide for the weight bearing. Stretching is appropriate but does not offer sufficient weight bearing. Running provides for weight bearing but is hard on the joints and may cause bleeding.

58. Which of the following indicates that a client has achieved the goal of correctly demonstrating deep breathing for an upcoming splenectomy? The client: Breathes in through the nose and out through the mouth. Breathes in through the mouth and out through the nose. Uses diaphragmatic breathing in the lying, sitting, and standing positions. Takes a deep breath in through the nose, holds it for 5 seconds, and blows out through pursed lips.

4. The correct technique for deep breathing postoperatively to avoid atelectasis and pneumonia is to take in a deep breath through the nose, hold it for 5 seconds, then blow it out through pursed lips. The goal is to fully expand and empty the lungs for pulmonary hygiene.

42. A client with a history of systemic lupus erythematosus was admitted with a severe viral respiratory tract infection and diffuse petechiae. Based on these data, it is most important that the nurse further evaluate the client's recent: ■ 1. Quality and quantity of food intake. ■ 2. Type and amount of fl uid intake. ■ 3. Weakness, fatigue, and ability to get around. ■ 4. Length and amount of menstrual fl ow.

4. A recent viral infection in a female client between the ages of 20 and 30 with a history of systemic lupus erythematosus and an insidious onset of diffuse petechiae are hallmarks of idiopathic thrombocytopenic purpura. It is important to ask whether the client's recent menses have been lengthened or are heavier. Determining her ability to clot can help determine her risk of increased bleeding tendency until a platelet count is drawn. Petechiae are not caused by poor nutrition. Because of poor food and fl uid intake or weakness and fatigue, the client may have gotten bruises from falling or bumping into things, but not petechiae.

5. A client has been admitted with active rectal bleeding. He has been typed and cross-matched for 2 units of packed red blood cells (RBCs). Within 10 minutes of admission the client faints when getting up to go to the bedside commode. The nurse notifies the health care provider, who orders a unit of blood immediately. The nurse should expect which type of packed RBCs will be used for immediate transfusion? 1. A negative. 2. B negative. 3. AB negative. 4. O negative.

4. A routine serology study to confirm compatibility between a blood donor and recipient takes about 1 hour. In an emergency, O negative RBCs can be safely administered to most clients, which is why a person with O-negative blood is called a universal donor. The other types of RBCs may cause an adverse reaction.

85. The nurse is assessing a client with chronic myeloid leukemia (CML). The nurse should assess the client for: ■ 1. Lymphadenopathy. ■ 2. Hyperplasia of the gum. ■ 3. Bone pain from expansion of marrow. ■ 4. Shortness of breath..

4. Although the clinical manifestations of CML vary, clients usually have confusion and shortness of breath related to decreased capillary perfusion to the brain and lungs. Lymphadenopathy is rare in CML. Hyperplasia of the gum and bone pain are clinical manifestations of AML.

47. A client who is taking Bufferin Arthritis Strength caplets develops prolonged bleeding from a superfi cial skin injury on the forearm. The nurse should tell the client to do which of the following fi rst? ■ 1. Place the forearm under a running stream of lukewarm water. ■ 2. Pat the injury with a dry washcloth. ■ 3. Wrap the entire forearm from the wrist to the elbow. ■ 4. Apply an ice pack for 20 minutes

4. Bufferin contains aspirin, which is an anticoagulant; bleeding time can be prolonged. Intermittent use of ice packs to the site may stop the bleeding; ice causes blood vessels to vasoconstrict. Use of lukewarm water, patting the injury, and wrapping the entire forearm do not promote vasoconstriction to stop bleeding.

76. The nurse should remind the unlicensed personnel that which of the following is the most important goal in the care of the neutropenic client in isolation? ■ 1. Listening to the client's feelings of concern. ■ 2. Completing the client's care in a nonhurried manner. ■ 3. Completing all of the client's care at one time. ■ 4. Instructing the client to dispose of tissue after blowing the nose.

4. The most common source of infection and microbial colonization in neutropenic clients is their own nonpathogenic normal fl ora. Attention to personal hygiene, such as oral, pulmonary, urinary, and rectal care, is essential. It is important to acknowledge the client's concerns and fears and to provide organized, nonhurried, caring care, but it is more important to teach the client how to prevent an infection that could be life-threatening.

25. The nurse is administering packed red blood cells (PRBCs) to a client. The nurse should first: 1. Discontinue the IV catheter if a blood transfusion reaction occurs. 2. Administer the PRBCs through a percutaneously inserted central catheter line with a 20-gauge needle. 3. Flush PRBCs with 5% dextrose and 0.45% normal saline solution. 4. Stay with the client during the first 15 minutes of infusion.

4. The most likely time for a blood transfusion reaction to occur is during the first 15 minutes or first 50 mL of the infusion. If a blood transfusion reaction does occur, it is imperative to keep an established I.V. line so that medication can be administered to prevent or treat cardiovascular collapse in case of anaphylaxis. PRBCs should be administered through a 19-gauge or larger needle a peripherally inserted central catheter line is not recommended, in order to avoid a slow flow. RBCs will hemolyze in dextrose or lactated Ringer's solution and should be infused with only normal saline solution.

8. The nurse has just admitted a 35-year-old female client who has a serum vitamin B12 concentration of 800 pg/mL. Which of the following laboratory fi ndings should cue the nurse to focus the client history assessment on specifi c drug or alcohol use? ■ 1. Total bilirubin, 0.3 mg/dL. ■ 2. Serum creatinine, 0.5 mg/dL. ■ 3. Hemoglobin, 16 g/dL. ■ 4. Folate, 1.5 ng/mL.

4. The normal range of folic acid is 1.8 to 9 ng/mL, and the normal range of vitamin B12 (cyanocobalamin) is 200 to 900 pg/mL. A low folic acid level in the presence of a normal vitamin B12 level is indicative of a primary folic acid defi ciency anemia. Factors that affect the absorption of folic acid are drugs such as methotrexate, oral contraceptives, antiseizure drugs, and alcohol. The total bilirubin, serum creatinine, and hemoglobin values are within normal limits.

56. Platelets should not be administered under which of the following conditions? ■ 1. The platelet bag is cold. ■ 2. The platelets are 2 days old. ■ 3. The platelet bag is at room temperature. ■ 4. The platelets are 12 hours old.

1. Platelets cannot survive cold temperatures. The platelets should be stored at room temperature and last for no more than 5 days.

45. The client states she does not understand what causes idiopathic thrombocytopenic purpura (ITP). The nurse provides which of the following explanations? ■ 1. It is believed that the platelets are coated with antibodies and the spleen sees them as foreign bodies. ■ 2. It is believed that the liver identifi es the platelets as foreign bodies. ■ 3. It is now believed that the syndrome is related to an underactive immune system. ■ 4. The cause is unknown.

1. Previously the cause was unknown, but recent research suggests that idiopathic thrombocytopenic purpura occurs when antibody-coated platelets are identifi ed as foreign bodies and destroyed by macrophages in the spleen. It is not an idiosyncratic response and is not related to a depressed immune system. CN

92. In providing care to the client with leukemia who has developed thrombocytopenia, the nurse assesses the most common sites for bleeding. Which of the following is not a common site? ■ 1. Biliary system. ■ 2. Gastrointestinal tract. ■ 3. Brain and meninges. ■ 4. Pulmonary system.

1. The biliary system is not especially prone to hemorrhage. Thrombocytopenia (a low platelet count) leaves the client at risk for a potentially life-threatening spontaneous hemorrhage in the gastrointestinal, respiratory, and intracranial cavities.

71. A client with neutropenia has an absolute neutrophil count of 900. What is the client's risk of infection? ■ 1. Normal risk. ■ 2. Moderate risk. ■ 3. High risk. ■ 4. Extremely high risk.

2. A client is at moderate risk when the ANC is less than 1,000. The ANC decreases proportionately to the increased risk for infection. The client is at normal risk for infection if the ANC is 1,500 or greater. The client is at high risk for infection if the ANC is less than 500. An ANC of 100 or less is life-threatening.

53. The client with tuberculosis is to be discharged home with community health nursing follow-up. Of the following nursing interventions, which should have the highest priority? ■ 1. Offering the client emotional support. ■ 2. Teaching the client about the disease and its treatment. ■ 3. Coordinating various agency services. ■ 4. Assessing the client's environment for sanitation.

2. Ensuring that the client is well educated about tuberculosis is the highest priority. Education of the client and family is essential to help the client understand the need for completing the prescribed drug therapy to cure the disease. Offering the client emotional support, coordinating various agency services, and assessing the environment may be part of the care for the client with tuberculosis; however, these interventions are of less importance than education about the disease process and its treatment

76. When teaching a client with chronic obstructive pulmonary disease to conserve energy, the nurse should teach the client to lift objects: ■ 1. While inhaling through an open mouth. ■ 2. While exhaling through pursed lips. ■ 3. After exhaling but before inhaling. ■ 4. While taking a deep breath and holding it.

2. Exhaling requires less energy than inhaling. Therefore, lifting while exhaling saves energy and reduces perceived dyspnea. Pursing the lips prolongs exhalation and provides the client with more control over breathing. Lifting after exhaling but before inhaling is similar to lifting with the breath held. This should not be recommended because it is similar to the Valsalva maneuver, which can stimulate cardiac arrhythmias

74. A client's arterial blood gas values are as follows: pH, 7.31; PaO2, 80 mm Hg; PaCO2, 65 mm Hg; HCO3 −, 36 mEq/L. The nurse should assess the client for? ■ 1. Cyanosis. ■ 2. Flushed skin. ■ 3. Irritability. ■ 4. Anxiety

2. The high PaCO2 level causes fl ushing due to vasodilation. The client also becomes drowsy and lethargic because carbon dioxide has a depressant effect on the central nervous system. Cyanosis is a sign of hypoxia. Irritability and anxiety are not common with a PaCO2 level of 65 mm Hg but are associated with hypoxia.

THE CLIENT WITH PLATELET DISORDERS 39. A healthcare provider orders 0.5 mg of protamine sulfate for a client who is showing signs of bleeding after receiving a 100-unit dose of heparin. The nurse should expect the effects of the protamine sulfate to be noted in which of the following time frames? ■ 1. 5 minutes. ■ 2. 10 minutes. ■ 3. 20 minutes. ■ 4. 30 minutes.

3. A dose of 0.5 mg of protamine sulfate reverses a 100-unit dose of heparin within 20 minutes. The nurse should administer protamine sulfate by I.V. push slowly to avoid adverse effects, such as hypotension, dyspnea, bradycardia, and anaphylaxis.

111. Which of the following should be readily available at the bedside of a client with a chest tube in place? ■ 1. A tracheostomy tray. ■ 2. Another sterile chest tube. ■ 3. A bottle of sterile water. ■ 4. A spirometer.

3. A bottle of sterile water should be readily available and in view when a client has a chest tube so that the tube can be immediately submersed in the water if the chest tube system becomes disconnected. The chest tube should be reconnected to the water-seal system as soon as a sterile functioning system can be re-established. There is no need for a tracheostomy tray, another chest tube, or a spirometer to be placed at the bedside for emergency use.

121. A client's chest tube is to be removed by the physician. Which of the following items should the nurse have ready to be placed directly over the wound when the chest tube is removed? ■ 1. Butterfl y dressing. ■ 2. Montgomery strap. ■ 3. Fine-mesh gauze dressing. ■ 4. Petroleum gauze dressing.

4. Immediately after chest tube removal, a petroleum gauze is placed over the wound and covered with a dry sterile dressing. This serves as an airtight seal to prevent air leakage or air movement in either direction. Bandages are not applied directly over wounds. Montgomery straps are used in place of adhesive tape when a dressing requires very frequent changes and the constant removal of adhesive tape would damage the skin. Montgomery straps are not placed over open wounds. Mesh gauze would allow air movement.

69. Which of the following indicates that the client with chronic obstructive pulmonary disease (COPD) who has been discharged to home understands his care plan? ■ 1. The client promises to do pursed-lip breathing at home. ■ 2. The client states actions to reduce pain. ■ 3. The client says that he will use oxygen via a nasal cannula at 5 L/minute. ■ 4. The client agrees to call the physician if dyspnea on exertion increases

4. Increasing dyspnea on exertion indicates that the client may be experiencing complications of COPD. Therefore, the nurse should notify the physician. Extracting promises from clients is not an outcome criterion. Pain is not a common symptom of COPD. Clients with COPD use low-fl ow oxygen supplementation (1 to 2 L/minute) to avoid suppressing the respiratory drive, which, for these clients, is stimulated by hypoxia.

At 0730 hours, a nurse receives a verbal order for a cardiac catheterization to be completed on a client at 1400 hours. Which action should the nurse initiate first? 1. Initiate NPO (nothing per mouth) status for the client. 2. Teach the client about the procedure. 3. Start an intravenous (IV) infusion of 0.9% NaCl. 4. Ask the client to sign a consent form.

1 A cardiac catheterization is an invasive procedure requiring the client to lie still in a supine position. The client is usually sedated with medication, such as midazolam (Versed®), during the procedure. To avoid aspiration, the client should be NPO 6 to 12 hours prior to the procedure. Because of the time element, NPO status should be initiated first and then teaching should occur. A consent form should be signed after the cardiologist has spoken with the client, and then an IV infusion order would be received.

The nurse is monitoring a client who has received antidysrhythmic therapy for the treatment of premature ventricular contractions (PVCs). The nurse would determine this therapy as being less than optimal if the client's PVCs continued to: 1 Occur in pairs 2 Be unifocal in appearance 3 Be fewer than six per minute 4 Fall after the end of the T wave

1 PVCs are considered dangerous when they are frequent (more than six per minute), occur in pairs or couplets, are multifocal (multiform), or fall on the T wave

Which intervention should a nurse plan to incorporate in the care of a surgical client to decrease the risk of deep venous thrombosis (DVT) and pulmonary embolism (PE)? 1. Use of intermittent compression devices on the lower extremities 2. Administration of heparin intravenously 3. Coughing and deep breathing exercises 4. Isometric leg exercises

1 Recommendations to prevent DVT and PE address the need to improve circulation and counter any states of hypercoagulopathy. Intermittent compression devices improve circulation. While administration of heparin will achieve anticoagulation, a low dose of unfractionated or low-molecular-weight heparin is usually ordered subcutaneous, and not intravenous, administration. Coughing and deep breathing exercises and isometric leg exercises are positive actions but do not decrease the risk for DVT and PE.

A client without history of respiratory disease has experienced sudden onset of chest pain and dyspnea and is diagnosed with pulmonary embolus. The nurse immediately implements which expected prescription for this client? 1 Semi-Fowler's position, oxygen, and morphine sulfate intravenously (IV) 2 Supine position, oxygen, andmeperidine hydrochloride (Demerol) intramuscularly (IM) 3 High Fowler's position, oxygen, and meperidine hydrochloride (Demerol) intravenously (IV) 4 High Fowler's position, oxygen, and two tablets of acetaminophen with codeine (Tylenol #3)

1 Standard therapeutic intervention for the client with pulmonary embolus includes proper positioning, oxygen, and intravenous analgesics. The head of the bed is placed in semi-Fowler's position. High Fowler's is avoided because extreme hip flexure slows venous return from the legs and increases the risk of new thrombi. The supine position will increase the dyspnea that occurs with pulmonary embolism. The usual analgesic of choice is morphine sulfate administered IV. This medication reduces pain, alleviates anxiety, and can diminish congestion of blood in the pulmonary vessels because it causes peripheral venous dilation

126. A client with acute respiratory distress syndrome (ARDS) has fi ne crackles at lung bases and the respirations are shallow at a rate of 28 breaths/minute. The client is restless and anxious. In addition to monitoring the arterial blood gas results, the nurse should do which of the following? Select all that apply. ■ 1. Monitor serum creatinine and blood urea nitrogen levels. ■ 2. Administer a sedative. ■ 3. Keep the head of the bed fl at. ■ 4. Administer humidifi ed oxygen. ■ 5. Auscultate the lungs

1, 4, 5. Acute respiratory distress syndrome (ARDS) may cause renal failure and superinfection, so the nurse should monitor urine output and urine chemistries. Treatment of hypoxemia can be complicated because changes in lung tissue leave less pulmonary tissue available for gas exchange, thereby causing inadequate perfusion. Humidifi ed oxygen may be one means of promoting oxygenation. The client has crackles in the lung bases, so the nurse should continue to assess breath sounds. Sedatives should be used with caution in clients with ARDS. The nurse should try other measures to relieve the client's restlessness and anxiety. The head of the bed should be elevated to 30 degrees to promote chest expansion and prevent atelectasis

A client in labor has a concurrent diagnosis of sickle cell anemia. Which action has priority to assist in preventing a sickling crisis from occurring during labor? 1 Reassuring the client 2 Administering oxygen 3 Preventing bearing down 4 Maintaining strict asepsis

2 During the labor process, the client with sickle cell anemia is at high risk for being unable to meet the oxygen demands of labor. Administering oxygen will prevent sickle cell crisis during labor. Options 1 and 4 are appropriate actions but are unrelated to sickle cell crisis. Option 3 is inappropriate.

68. When developing a discharge plan to manage the care of a client with chronic obstructive pulmonary disease (COPD), the nurse should advise the the client to expect to: ■ 1. Develop respiratory infections easily. ■ 2. Maintain current status. ■ 3. Require less supplemental oxygen. ■ 4. Show permanent improvement.

1. A client with COPD is at high risk for development of respiratory infections. COPD is slowly progressive; therefore, maintaining current status and establishing a goal that the client will require less supplemental oxygen are unrealistic expectations. Treatment may slow progression of the disease, but permanent improvement is highly unlikely.

87. The client with acute lymphocytic leukemia (ALL) is at risk for infection. What should the nurse do? ■ 1. Place the client in a private room. ■ 2. Have the client wear a mask. ■ 3. Have staff wear gowns and gloves. ■ 4. Restrict visitors.

1. Clients with ALL are at risk for infection due to granulocytopenia. The nurse should place the client in a private room. Strict hand-washing procedures should be enforced and will be the most effective way to prevent infection. It is not necessary to have the client wear a mask. The client is not contagious and the staff does not need to wear gloves. The client can have visitors; however, they should be screened for infection and use hand-washing procedures.

137. Which of the following complications is associated with mechanical ventilation? ■ 1. Gastrointestinal hemorrhage. ■ 2. Immunosuppression. ■ 3. Increased cardiac output. ■ 4. Pulmonary emboli.

1. Gastrointestinal hemorrhage occurs in about 25% of clients receiving prolonged mechanical ventilation because of the development of stress ulcers. Clients who are receiving steroid therapy and those with a previous history of ulcers are most likely to be at risk. Other possible complications include incorrect ventilation, oxygen toxicity, fl uid imbalance, decreased cardiac output, pneumothorax, infection, and atelectasis.

98. When assessing the client with Hodgkin's disease, the nurse should observe the client for which of the following fi ndings? ■ 1. Herpes zoster infections. ■ 2. Discolored teeth. ■ 3. Hemorrhage. ■ 4. Hypercellular immunity.

1. Herpes zoster infections are common in clients with Hodgkin's disease. Discoloring of the teeth is not related to Hodgkin's disease but rather to the ingestion of iron supplements or some antibiotics such as tetracycline. Mild anemia is common in Hodgkin's disease, but the platelet count is not affected until the tumor has invaded the bone marrow. A cellular immunity defect occurs in Hodgkin's disease in which there is little or no reaction to skin sensitivity tests. This is called anergy.

140. Which of the following are expected outcomes for a client with pulmonary disease? ■ 1. A relatively matched ventilation-to-perfusion ratio. ■ 2. A low ventilation-to-perfusion ratio. ■ 3. A high ventilation-to-perfusion ratio. ■ 4. An equal PaO2 and PaCO2 ratio.

1. In the normal lung, the volume of blood perfusing the lungs each minute is approximately equal to the amount of fresh gas that reaches the alveoli each minute. Blood gas analysis evaluates respiratory function; the level of dissolved oxygen (PaO2) should be greater than the level of dissolved carbon dioxide (PaCO2).

52. When teaching the client older than age 50 who is receiving long-term prednisone therapy, the nurse should recommend? ■ 1. Take the prednisone with food. ■ 2. Take over-the-counter drugs as needed. ■ 3. Exercise three to four times a week. ■ 4. Eat foods that are low in potassium.

1. Nausea, vomiting, and peptic ulcers are gastrointestinal adverse effects of prednisone, so it is recommended that clients take the prednisone with food. In some instances, the client may be advised to take a prescribed antacid prophylactically. The client should never take over-thecounter drugs without notifying the physician who prescribed the prednisone. The client should ask the physician about the amount and kind of exercise because of the need to establish baseline physical values before starting an exercise program and because of the increased potential for comorbidity with increasing age. The client should eat foods that are high in potassium to prevent hypokalemia.

6. The nurse is preparing to teach a client with microcytic hypochromic anemia about the diet to follow after discharge. Which of the following foods should be included in the diet? ■ 1. Eggs. ■ 2. Lettuce. ■ 3. Citrus fruits. ■ 4. Cheese.

1. One of the microcytic, hypochromic anemias is iron deficiency anemia. A rich source of iron is needed in the diet, and eggs are high in iron. Other foods high in iron include organ and muscle (dark) meats; shellfi sh, shrimp, and tuna; enriched, whole-grain, and fortifi ed cereals and breads; legumes, nuts, dried fruits, and beans; oatmeal; and sweet potatoes. Dark green, leafy vegetables and citrus fruits are good sources of vitamin C. Cheese is a good source of calcium.

130. A client with acute respiratory distress syndrome (ARDS) is on a ventilator. The client's peak inspiratory pressures and spontaneous respiratory rate are increasing, and the PO2 is not improving. Using the SBAR (Situation-Background-Assessment- Recommendation) technique for communication, the nurse calls the physician with the recommendation for: ■ 1. Initiating I.V. sedation. ■ 2. Starting a high-protein diet. ■ 3. Providing pain medication. ■ 4. Increasing the ventilator rate.

1. The client may be fi ghting the ventilator breaths. Sedation is indicated to improve compliance with the ventilator in an attempt to lower peak inspiratory pressures. The workload of breathing does indicate the need for increased protein calories; however, this will not correct the respiratory problems with high pressures and respiratory rate. There is no indication that the client is experiencing pain. Increasing the rate on the ventilator is not indicated with the client's increased spontaneous rate.

134. Which of the following conditions can place a client at risk for acute respiratory distress syndrome (ARDS)? ■ 1. Septic shock. ■ 2. Chronic obstructive pulmonary disease. ■ 3. Asthma. ■ 4. Heart failure.

1. The two risk factors most commonly associated with the development of ARDS are gramnegative septic shock and gastric content aspiration. Nurses should be particularly vigilant in assessing a client for onset of ARDS if the client has experienced direct lung trauma or a systemic infl ammatory response syndrome (which can be caused by any physiologic insult that leads to widespread infl ammation). Chronic obstructive pulmonary disease, asthma, and heart failure are not direct causes of ARDS.

A client had a mastectomy followed by chemotherapy 6 months ago. She reports that she is now "unable to concentrate at her card game" and "it seems harder and harder to fi nish her errands because of exhaustion." Based on this information, the nurse should suggest that the client do which of the following? 1. Take frequent naps. 2. Limit activities. 3. Increase fl uid intake. 4. Avoid contact with others.

1. This client is likely experiencing fatigue and should increase her periods of rest. The fatigue may be caused by anemia from depletion of red blood cells due to the chemotherapy. Asking the client to limit her activities may cause the client to become withdrawn. The information given does not support limiting activity. Increasing fl uid intake will not reduce the fatigue. The information does not indicate that the client is immunosuppressed and should avoid contact with others.

client with symptoms of anemia and a hemoglobin of 7.8 g/dL refuses blood and blood products transfusions for religious reasons. A nurse should anticipate that a health-care provider might prescribe: SELECT ALL THAT APPLY. 1. Epoetin alfa (Procrit®) 2. Folic acid 3. Albumin 4. Platelets 5. Fresh frozen plasma 6. Granulocytes

12 Epoetin alfa (erythropoietin growth factor) and folic acid promote erythropoiesis (production of red blood cells), thus decreasing the need for transfusions. Folic acid also stimulates production of white blood cells and platelets. According to the evidence base, for persons with hemoglobin less than 8 g/dL, the use of either transfusion or erythropoietic growth factor was rated "appropriate." Albumin, platelets, plasma, and granulocytes are all blood products.

A nurse is caring for multiple 25-year-old female clients. For which clients should the nurse plan to obtain a referral for genetic counseling and family planning? SELECT ALL THAT APPLY. 1. Client diagnosed with thalassemia major 2. Client diagnosed with sickle cell disease 3. Client diagnosed with hemophilia A 4. Client diagnosed with autoimmune hemolytic anemia 5. Client diagnosed with hemophilia B

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A nurse is caring for a client following a coronary artery bypass graft. Which assessment finding in the immediate postoperative period should be most concerning to the nurse? 1. No chest tube output for 1 hour when previously it was copious 2. Client temperature of 99.1°F (37.2°C) 3. Arterial blood gas (ABG) results show pH 7.32; Pco2 48; HCO3 28; Po2 80 4. Urine output of 160 mL in the last 4 hours

1\ A copiously draining chest tube that is no longer draining indicates an obstruction. There is an increased risk for cardiac tamponade or pleural effusion. A slight elevation in temperature could be the effects of rewarming after surgery. This should continue to be monitored, but is not immediately concerning. The ABG results show compensated respiratory acidosis. Though the pH is low and the PCO2 is high, the kidneys are compensating by conserving bicarbonate (HCO3). Normal pH is 7.35-7.45, PCO2 32-42 mm Hg, HCO3 20-24 mmol/L, and PO2 75-100 mm Hg. A urine output of 160 mL/4 hr is equivalent to 40 mL/hr; adequate, but it warrants continued monitoring. Less than 30 mL/hr indicates decreased renal function.

A client was admitted to the hospital with a diagnosis of frequent symptomatic premature ventricular contractions (PVCs). After sitting up in a chair for a few minutes, the client complains of feeling lightheaded. On auscultation of the heartbeat, the nurse should anticipate which of the following findings? 1 A regular apical pulse 2 An irregular apical pulse 3 A very slow regular apical pulse 4 A very rapid regular apical pulse

2

A nurse is caring for a client with a left-sided chest tube attached to a wet suction chest tube system. Which observation by the nurse would require immediate intervention? 1. Bubbling in the suction chamber 2. Dependent loop hanging off the edge of the bed 3. Banded connections between tubing sections 4. Occlusive dressing over chest tube insertion site

2 A dependent loop creates pressure back up and prevents fluid from draining; this requires immediate intervention to prevent lung collapse. Bubbling in a wet suction chest tube system indicates that the suction is working and is an expected finding as are banded connections between sections of tubing. An occlusive dressing helps to prevent air from leaking into the subcutaneous space and maintains integrity of the closed drainage system.

client who has no history of immunosuppressive disease and is at low risk for tuberculosis has a Mantoux test. The results indicate an area of induration that is 8 mm in size. The nurse interprets that the client: 1 Has active tuberculosis 2 Has a negative response 3 Has a history of tuberculosis 4 Has been exposed to tuberculosis

2 Induration of 15mmormore is considered positive for clients in low-risk groups. More than 5 mm of induration is considered a positive result for clients with known or suspected human immunodeficiency virus infection, persons with organ transplants, people in close contact with a known case of tuberculosis, and those with a chest x-ray study suggestive of previous tuberculosis.More than 10mmof induration is considered positive in all other high-risk groups, such as intravenous drug users.

128. The nurse interprets which of the following as an early sign of acute respiratory distress syndrome (ARDS) in a client at risk? ■ 1. Elevated carbon dioxide level. ■ 2. Hypoxia not responsive to oxygen therapy. ■ 3. Metabolic acidosis. ■ 4. Severe, unexplained electrolyte imbalance.

2. A hallmark of early ARDS is refractory hypoxemia. The client's PaO2 level continues to fall, despite higher concentrations of administered oxygen. Elevated carbon dioxide and metabolic acidosis occur late in the disorder. Severe electrolyte imbalances are not indicators of ARDS.

67. The nurse reviews an arterial blood gas report for a client with chronic obstructive pulmonary disease (COPD). pH 7.35; PC02 62; PO2 70; HCO3 34 The nurse should: ■ 1. Apply a 100% non-rebreather mask. ■ 2. Assess the vital signs. ■ 3. Reposition the client. ■ 4. Prepare for intubation

2. Clients with chronic COPD have CO2 retention and the respiratory drive is stimulated when the PO2 decreases. The heart rate, respiratory rate, and blood pressure should be evaluated to determine if the client is hemodynamically stable. Symptoms, such as dyspnea, should also be assessed. Oxygen supplementation, if indicated, should be titrated upward in small increments. There is no indication that the client is experiencing respiratory distress requiring intubation

105. The client is a survivor of non-Hodgkin's lymphoma. Which of the following statements indicates the client needs additional information? ■ 1. "Regular screening is very important for me." ■ 2. "The survivor rate is directly proportional to the incidence of second malignancy." ■ 3. "The survivor rate is indirectly proportional to the incidence of second malignancy." ■ 4. "It is important for survivors to know the stage of the disease and their current treatment plan."

2. It is incorrect that the survivor rate is directly proportional to the incidence of second malignancy. The survivor rate is indirectly proportional to the incidence of second malignancy, and regular screening is very important to detect a second malignancy, especially acute myeloid leukemia or myelodysplastic syndrome. Survivors should know the stage of the disease and their current treatment plan so that they can remain active participants in their health care

63. What is the earliest clinical manifestation in a client with acute disseminated intravascular coagulation (DIC)? I 1. Severe shortness of breath. I 2. Bleeding without history or cause. I 3. Orthopnea. I 4. Hematuria.

2. There is no well-defined sequence for acute DIC other than that the client starts bleeding without a history or cause and does not stop bleeding. Later signs may include severe shortness of breath, hypotension, pallor, petechiae, hematoma, orthopnea, hematuria, vision changes, and joint pain.

19. A client is to have a Schilling test? The nurse should: ■ 1. Administer methylcellulose (Citrucel). ■ 2. Start a 24- to 48-hour urine specimen collection. ■ 3. Maintain nothing-by-mouth (NPO) status. ■ 4. Start a 72-hour stool specimen collection.

2. Urinary vitamin B12 levels are measured after the ingestion of radioactive vitamin B12. A 24- to 48-hour urine specimen is collected after administration of an oral dose of radioactively tagged vitamin B12 and an injection of nonradioactive vitamin B12. In a healthy state of absorption, excess vitamin B12 is excreted in the urine; in a malabsorptive state or when the intrinsic factor is missing, vitamin B12 is excreted in the feces. Citrucel is a bulk-forming agent. Laxatives interfere with the absorption of vitamin B12. The client is NPO 8 to 12 hours before the test but is not NPO during the test. A stool collection is not a part of the Schilling test. If stool contaminates the urine collection, the results will be altered.

64. Which of the following is contraindicated for a client diagnosed with disseminated intravascular coagulation (DIC)? ■ 1. Treating the underlying cause. ■ 2. Administering heparin. ■ 3. Administering warfarin sodium (Coumadin). ■ 4. Replacing depleted blood products

3. DIC has not been found to respond to oral anticoagulants such as warfarin sodium (Coumadin). Treatments for DIC are controversial but include treating the underlying cause, administering heparin, and replacing depleted blood products.

A nurse teaches a 55-year-old strict vegetarian that, to decrease the risk of developing megaloblastic anemia, the client should: 1. undergo a Schilling test. 2. increase intake of foods high in iron. 3. supplement the diet with vitamin B12. 4. have a monthly hemoglobin level drawn.

3 Megaloblastic anemia is caused by deficiency of vitamin B12 or folic acid. A vegetarian can prevent a deficiency with oral vitamin supplements or fortified soy milk. The U.S. Department of Agriculture's Dietary Guidelines for Americans 2005 also recommend that people over age 50, whether or not they are vegetarian, consume vitamin B12 in its crystalline form (i.e., fortified foods or supplements). The Schilling test is used to diagnose vitamin B12 deficiency. Consuming foods high in iron will prevent iron-deficiency anemia. Monthly laboratory work is unnecessary and costly.

66. Which of the following is an assessment finding associated with internal bleeding with disseminated intravascular coagulation? I 1. Bradycardia. I 2. Hypertension. I 3. Increasing abdominal girth. I 4. Petechiae.

3. As blood collects in the peritoneal cavity, it causes dilation and distention, which is reflected in increased abdominal girth. The client would be tachycardic and hypotensive. Petechiae reflect bleeding in the skin.

60. When receiving a client from the postanesthesia care unit after a splenectomy, which should the nurse assess after obtaining vital signs? ■ 1. Nasogastric drainage. ■ 2. Urinary catheter. ■ 3. Dressing. ■ 4. Need for pain medication.

3. After a splenectomy, the client is at high risk for hypovolemia and hemorrhage. The dressing should be checked often; if drainage is present, a circle should be drawn around the drainage and the time noted to help determine how fast bleeding is occurring. The nasogastric tube should be connected, but this can wait until the dressing has been checked. A urinary catheter is not needed. The last pain medication administration and the client's current pain level should be communicated in the exchange report. Checking for hemorrhage is a greater priority than assessing pain level.

104. A client with advanced Hodgkin's disease is admitted to hospice because death is imminent. The goal of nursing care is to help relieve the client's: ■ 1. Fear of pain. ■ 2. Fear of further therapy. ■ 3. Feelings of isolation. ■ 4. Feelings of social inadequacy.

3. Terminally ill clients most often describe feelings of isolation because they tend to be ignored; they are often left out of conversations (especially those dealing with the future); and they sense the attitudes of discomfort that many people feel in their presence. Helpful nursing measures include taking the time to be with the client; offering opportunities to talk about feelings; and answering questions honestly.

A child is admitted to the hospital with a suspected diagnosis of idiopathic thrombocytopenic purpura (ITP), and diagnostic studies are performed. Which of the following diagnostic results are indicative of this disorder? 1 An elevated platelet count 2 Elevated hemoglobin and hematocrit levels 3 A bone marrow examination showing an increased number of megakaryocytes 4 A bone marrow examination indicating an increased number of immature white blood cells

33 The laboratory manifestations of ITP include the presence of a low platelet count of usually less than 20,000 cells/mm3. Thrombocytopenia is the only laboratory abnormality expected with ITP. If there has been significant blood loss, there is evidence of anemia in the blood cell count. If a bone marrow examination is performed, the results with ITP show a normal or increased number of megakaryocytes, which are the precursors of platelets. Option 4 indicates the bone marrow result that would be found in a child with leukemia.

The nurse in an ambulatory clinic administers a tuberculin (Mantoux) skin test to a client on a Monday. The nurse tells the client to return to the clinic to have the results read on: 1 Thursday or Friday 2 The following Monday 3 Tuesday or Wednesday 4 Wednesday or Thursday

4 The Mantoux skin test for tuberculosis is read in 48 to 72 hours. Therefore the client should return to the clinic on Wednesday or Thursday

132. A client has the following arterial blood gas values: pH, 7.52; PaO2, 50 mm Hg; PaCO2, 28 mm Hg; HCO3 -, 24 mEq/L. The nurse determines that which of the following is a possible cause for these fi ndings? ■ 1. Chronic obstructive pulmonary disease (COPD). ■ 2. Diabetic ketoacidosis with Kussmaul's respirations. ■ 3. Myocardial infarction. ■ 4. Pulmonary embolus.

4. A PaCO2 of 28 mm Hg and PaO2 of 50 mm Hg are both abnormal; the PaO2 of 50 mm Hg signifi es acute respiratory failure. In evaluating possible causes for this disorder, the nurse should consider conditions that lead to hypoxia and hyperventilation, such as pulmonary embolus. COPD is typically associated with respiratory acidosis and elevated PaCO2. The client with diabetic ketoacidosis most often has metabolic acidosis. A myocardial infarction does not often cause an acid-base imbalance because the primary problem is cardiac in origin.

141. The nurse should place a client being admitted to the hospital with suspected tuberculosis on what type of isolation? ■ 1. Standard precautions. ■ 2. Contact precautions. ■ 3. Droplet precautions. ■ 4. Airborne precautions.

4. Airborne precautions prevent transmission of infectious agents that remain infectious over long distances when suspended in the air (e.g. mycobacterium tuberculosis, measles, varicella virus [chickenpox], and possibly SARS-CoV). The preferred placement is in an isolation single-client room that is equipped with special air handling and ventilation. A negative pressure room, or an area that exhausts room air directly outside or through HEPA fi lters, should be used if recirculation is unavoidable. Standard precautions combine the major features of Universal Precautions and Body Substance Isolation and are based on the principle that the blood, body fl uids, secretions, and excretions of all clients may contain transmissible infectious agents. Standard precautions include: hand hygiene; use of gloves, gown, mask, eye protection, or face shield, depending on the anticipated exposure; and safe injection practices. Contact precautions are for clients with known or suspected infections or evidence of syndromes that represent an increased risk for contact transmission. Droplet precautions are intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions. Because these pathogens do not remain infectious over long distances in a health care facility, special air handling and ventilation are not required to prevent droplet transmission

135. Which one of the following assessments is most appropriate for determining the correct placement of an endotracheal tube in a mechanically ventilated client? ■ 1. Assessing the client's skin color. ■ 2. Monitoring the respiratory rate. ■ 3. Verifying the amount of cuff infl ation. ■ 4. Auscultating breath sounds bilaterally.

4. Auscultation for bilateral breath sounds is the most appropriate method for determining cuff placement. The nurse should also look for the symmetrical rise and fall of the chest and should note the location of the exit mark on the tube. Assessments of skin color, respiratory rate, and the amount of cuff infl ation cannot validate the placement of the endotracheal tube.

91. Which of the following is an appropriate expected outcome for an adult client with wellcontrolled asthma? ■ 1. Chest X-ray demonstrates minimal hyperinfl ation. ■ 2. Temperature remains lower than 100° F (37.8° C). ■ 3. Arterial blood gas analysis demonstrates a decrease in PaO2. ■ 4. Breath sounds are clear.

4. Between attacks, breath sounds should be clear on auscultation with good air fl ow present throughout lung fi elds. Chest X-rays should be normal. The client should remain afebrile. Arterial blood gases should be normal

50. The client with idiopathic thrombocytopenic purpura (ITP) asks the nurse why she has to take steroids. Which is the nurse's best response? ■ 1. Steroids destroy the antibodies and prolong the life of platelets. ■ 2. Steroids neutralize the antigens and prolong the life of platelets. ■ 3. Steroids increase phagocytosis and increase the life of platelets. ■ 4. Steroids alter the spleen's recognition of platelets and increase the life of platelets.

4. ITP is treated with steroids to suppress the splenic macrophages from phagocytizing the antibody-coated platelets, which are recognized as foreign bodies, so that the platelets live longer. The steroids also suppress the binding of the autoimmune antibody to the platelet surface. Steroids do not destroy the antibodies on the platelets, neutralize antigens, or increase phagocytosis

127. Which of the following interventions would be most likely to prevent the development of acute respiratory distress syndrome (ARDS)? ■ 1. Teaching cigarette smoking cessation. ■ 2. Maintaining adequate serum potassium levels. ■ 3. Monitoring clients for signs of hypercapnia. ■ 4. Replacing fl uids adequately during hypovolemic states

4. One of the major risk factors for development of ARDS is hypovolemic shock. Adequate fl uid replacement is essential to minimize the risk of ARDS in these clients. Teaching smoking cessation does not prevent ARDS. An abnormal serum potassium level and hypercapnia are not risk factors for ARDS.

125. The nurse has calculated a low PaO2/FIO2 (P/F) ratio < 150 for a client with acute respiratory distress syndrome (ARDS). The nurse should place the client in which position to improve oxygenation, ventilation distribution, and drainage of secretions? ■ 1. Supine. ■ 2. Semi-fowlers. ■ 3. Lateral side. ■ 4. Prone.

4. Prone positioning is used to improve oxygenation in clients with acute respiratory distress syndrome (ARDS) who are receiving mechanical ventilation. The positioning allows for recruitment of collapsed alveolar units, improvement in ventilation, reduction in shunting, mobilization of secretions, and improvement in functional reserve capacity (FRC). When the client is supine, side-to-side repositioning should be done every 2 hours with the head of the bed elevated at least 30 degrees.

A client seeks medical attention because of pain that develops while walking. An ankle-brachial index (ABI) test is ordered, and the results show that the client has ratios of 1.4 and 1.3 bilaterally. Based on these results, a nurse determines that the client: 1. has severe peripheral arterial disease. 2. would benefit from the medication ticlopidine hydrochloride (Ticlid®). 3. is experiencing pain that is psychological in origin. 4. needs further medical consultation to determine the cause of pain

4\ The client requires further medical consultation because the ABI (comparison of blood pressure in ankle to the brachial blood pressure) is normal in each leg. A result of less than 0.9 is diagnostic of peripheral arterial disease. Based on the results of the ABI, the client has normal arterial circulation and would not benefit from ticlopidine hydrochloride. There is no information relating the pain to a psychological concern.

The nurse is preparing to teach a client with microcytic hypochromic anemia about the diet to follow after discharge. Which of the following foods should be included in the diet? A Eggs B Lettuce C Citrus fruits D Cheese

A One of the microcytic, hypochromic anemias is iron-deficiency anemia. A rich source of iron is needed in the diet, and eggs are high in iron. Other foods high in iron include organ and muscle (dark) meats; shellfish, shrimp, and tuna; enriched, whole-grain, and fortified cereals and breads; legumes, nuts, dried fruits, and beans; oatmeal; and sweet potatoes. Dark green leafy vegetables and citrus fruits are good sources of vitamin C. Cheese is a good source of calcium.

A vegetarian client was referred to a dietitian for nutritional counseling for anemia. Which client outcome indicates that the client does not understand nutritional counseling? The client: A Adds dried fruit to cereal and baked goods B Cooks tomato-based foods in iron pots C Drinks coffee or tea with meals D Adds vitamin C to all meals

C Coffee and tea increase gastrointestinal motility and inhibit the absorption of nonheme iron. Clients are instructed to add dried fruits to dishes at every meal because dried fruits are a nonheme or nonanimal iron source. Cooking in iron cookware, especially acid-based foods such as tomatoes, adds iron to the diet. Clients are instructed to add a rich supply of vitamin C to every meal because the absorption of iron is increased when food with vitamin C or ascorbic acid is consumed.

83. A client uses a metered-dose inhaler (MDI) to aid in management of his asthma. Which action by the client indicates to the nurse that he needs further instruction regarding its use? Select all that apply. ■ 1. Activation of the MDI is not coordinated with inspiration. ■ 2. The client inspires rapidly when using the MDI. ■ 3. The client holds his breath for 3 seconds after inhaling with the MDI. ■ 4. The client shakes the MDI after use. ■ 5. The client performs puffs in rapid succession.

1, 2, 3, 4, 5. Utilization of an MDI requires coordination between activation and inspiration; deep breaths to ensure that medication is distributed into the lungs, holding the breath for 10 seconds or as long as possible to disperse the medication into the lungs, shaking up the medication in the MDI before use, and a suffi cient amount of time between puffs to provide an adequate amount of inhalation medication.

11. A client comes to the health clinic 3 years after undergoing a resection of the terminal ileum and tells the nurse that he has weakness, shortness of breath, and a sore tongue. Which client statement indicates a need for intervention and client teaching? ■ 1. "I have been drinking plenty of fluids." ■ 2. "I have been gargling with warm salt water for my sore tongue." ■ 3. "I have three to four loose stools per day." ■ 4. "I take a vitamin B12 tablet every day."

4. Vitamin B12 combines with intrinsic factor in the stomach and is then carried to the ileum, where it is absorbed into the bloodstream. In this situation, vitamin B12 cannot be absorbed regardless of the amount of oral intake of sources of vitamin B12, such as animal protein or vitamin B12 tablets. Vitamin B12 needs to be injected every month because the ileum has been surgically removed. Replacement of fluids and electrolytes is important when the client has continuous multiple loose stools on a daily basis. Warm salt water is used to soothe sore mucous membranes. Crohn's disease and a small-bowel resection may cause several loose stools a day.

33. A client states that she is afraid of receiving vitamin B12 injections because of potential toxic reactions. Which is the nurse's best response to relieve these fears? ■ 1. "Vitamin B12 will cause ringing in the ears before a toxic level is reached." ■ 2. "Vitamin B12 may cause a very mild rash initially." ■ 3. "Vitamin B12 cause mild nausea but nothing toxic." ■ 4. "Vitamin B12 is generally free of toxicity because it is water-soluble

4. Vitamin B12 is a water-soluble vitamin. When water-soluble vitamins are taken in excess of the body's needs, they are fi ltered through the kidneys and excreted. Vitamin B12 is considered to be nontoxic. Adverse reactions that have occurred are believed to be related to impurities or to the preservative in B12 preparations. Ringing in the ears, rash, and nausea are not considered to be related to vitamin B12 administration.

7. The nurse should instruct the client to eat which of the following foods to obtain the best supply of vitamin B12? ■ 1. Whole grains. ■ 2. Green leafy vegetables. ■ 3. Meats and dairy products. ■ 4. Broccoli and brussels sprouts.

3. Good sources of vitamin B12 include meats and dairy products. Whole grains are a good source of thiamine. Green, leafy vegetables are good sources of niacin, folate, and carotenoids (precursors of vitamin A). Broccoli and brussels sprouts are good sources of ascorbic acid (vitamin C).

88. In assessing a client in the early stage of chronic lymphocytic leukemia (CLL), the nurse should determine if the client has: ■ 1. Enlarged, painless lymph nodes. ■ 2. Headache. ■ 3. Hyperplasia of the gums. ■ 4. Unintentional weight loss.

4. Clients with CLL develop unintentional weight loss; fever and drenching night sweats; enlarged, painful lymph nodes, spleen, and liver; decreased reaction to skin sensitivity tests (anergy); and susceptibility to viral infections. Enlarged, painless lymph nodes are a clinical manifestation of Hodgkin's lymphoma. A headache would not be one of the early signs and symptoms expected in CLL because CLL does not cross the blood-brain barrier and would not irritate the meninges. Hyperplasia of the gums is a clinical manifestation of AML

56. Which of the following family members exposed to tuberculosis would be at highest risk for contracting the disease? ■ 1. 45-year-old mother. ■ 2. 17-year-old daughter. ■ 3. 8-year-old son. ■ 4. 76-year-old grandmother.

4. Elderly persons are believed to be at higher risk for contracting tuberculosis because of decreased immunocompetence. Other high-risk populations in the United States include the urban poor, clients with acquired immunodefi ciency syndrome, and minority groups.

16. A client is admitted from the emergency department after falling down a fl ight of stairs at home. Her vital signs are stable and her history states that she had a gastric stapling 2 years ago and takes neomycin for acne. The client jokes about how she is clumsy lately and trips over things. The nurse should ask the client which of the following questions? Select all that apply. ■ 1. "Are you experiencing numbness in your extremities?" ■ 2. "How much vitamin B12 are you getting?" ■ 3. "Are you feeling depressed?" ■ 4. "Do you feel safe at home?" ■ 5. "Are you getting suffi cient iron in your diet?"

1 2 3 4 The nurse should ask the client about symptoms related to pernicious anemia because she had her stomach stapled 2 years ago and shows no history of supplemental vitamin B12. Numbness and tingling relate to a loss of intrinsic factor from the gastric stapling. Intrinsic factor is necessary for absorption of vitamin B12. The nurse should suspect pernicious anemia if the client is not taking supplemental vitamin B12. Other signs and symptoms of pernicious anemia include cognitive problems and depression. The nurse also should ask about the client's support at home in case the fall was not an accident. Pernicious anemia is not related to dietary intake of iron.

36. Which of the following is a late symptom of polycythemia vera? ■ 1. Headache. ■ 2. Dizziness. ■ 3. Pruritus. ■ 4. Shortness of breath.

3. Pruritus is a late symptom that results from abnormal histamine metabolism. Headache and dizziness are early symptoms from engorged veins. Shortness of breath is an early symptom from congested mucous membranes and ineffective gas exchange.