NCLEX - Adult Health - Hematology

A nurse provides dietary instructions to a client who will be taking warfarin sodium. The nurse should tell the client to avoid which food item? 1.Grapes 2.Spinach 3.Watermelon 4.Cottage cheese

Correct Answer: 2 Rationale: Warfarin sodium is an anticoagulant. Anticoagulant medications act by antagonizing the action of phytonadione, which is needed for clotting. When a client is taking an anticoagulant, foods high in phytonadione often are omitted from the diet. Phytonadione-rich foods include green leafy vegetables, fish, liver, coffee, and tea.

The nurse is preparing to administer phytonadione to the client. Which laboratory value should the nurse monitor in order to evaluate the effectiveness of the medication? 1.Prothrombin time 2.Blood ammonia level 3.Direct serum bilirubin 4.Serum potassium level

Correct Answer: 1 Rationale: Phytonadione is needed for adequate blood clotting. Therefore, checking the prothrombin time is necessary 24 hours after injection of this medication. Blood ammonia levels are assessed to determine the conversion of ammonia to urea that normally occurs in the liver. Bilirubin is a measurement of the ability of the liver to conjugate and excrete bilirubin. Serum potassium is an electrolyte and is not affected by the injection of phytonadione.

The nurse has completed client teaching on use of thrombolytic medications in acute ischemic stroke. The nurse determines that the educational session was effective if the client states that thrombolytics are used for what purpose? 1.To dissolve clots 2.To prevent ischemia 3.To prevent bleeding 4.To decrease anxiety

Correct Answer: 1 Rationale: Thrombolytic medications are used to treat acute thrombolytic disorders. These medications dissolve clots. Because these medications alter the hemostatic capability of the client, any bleeding that does occur can be difficult to control. Options 2, 3, and 4 are not actions of this medication.

A postpartum client with deep vein thrombosis is being treated with anticoagulant therapy. The nurse teaches the client that the health care provider (HCP) should be contacted for which noted side and adverse effects? Select all that apply. 1.Vertigo 2.Dysuria 3.Epistaxis 4.Hematuria 5.Ecchymosis

Correct Answer: 3,4,5 Rationale: The treatment for deep vein thrombosis is anticoagulant therapy. The nurse assesses for bleeding, which is an adverse effect of anticoagulants. This includes hematuria, ecchymosis, and epistaxis. Vertigo and dysuria are not associated specifically with bleeding.

The nurse is preparing to care for a client with chronic kidney disease and anemia. Which describes the relationship between chronic kidney disease and anemia? 1. Lack of angiotensin I may cause anemia. 2. Increased production of aldosterone leads to anemia. 3. Anemia is caused by insufficient production of renin. 4. Decreased production of erythropoietin is causing anemia.

Correct Answer: 4 Rationale: Clients with chronic kidney disease do not manufacture adequate amounts of erythropoietin, which is a glycoprotein needed to synthesize red blood cells. Renin, aldosterone, and angiotensin are substances that assist in maintaining blood pressure.

The nurse provides instructions to a client who has a prescription for ticlopidine. Which statement made by the client indicates a need for further teaching? 1. "I'll take my medicine with meals." 2. "Blood work will be done every 2 weeks for the first 3 months." 3. "I should not stop the medication without talking to my doctor first." 4. "Food will affect the medication, so I need to take the medication on an empty stomach."

Correct Answer: 4 Rationale: Ticlopidine is an antiplatelet agent that is used for the prevention of thrombotic stroke. Ticlopidine is best tolerated when taken with meals. Blood work is monitored closely, particularly in early therapy, because the medication can cause neutropenia. A client should not stop medication without the health care provider's permission.

A client has a prescription to receive enoxaparin. The nurse should plan to administer this medication by which route? 1.Oral 2.Intravenous 3.Intramuscular 4.Subcutaneous

Correct Answer: 4 Rationale: Enoxaparin is an anticoagulant that is administered by the subcutaneous route. It is used in preventing thromboembolism in selected clients at risk. It also may be administered by the client at home after hospital discharge with follow-up assessments by a home health nurse. It is not administered orally or by the intravenous or intramuscular routes.

A client having a myocardial infarction is receiving alteplase therapy. Which action should be carried out by the nurse to monitor for the most frequent side/adverse effect? 1.Check for signs of bleeding. 2.Assess for allergic reaction. 3.Evaluate the client for muscle weakness. 4.Monitor for signs and symptoms of infection.

Correct Answer: 1 Rationale: Alteplase is a thrombolytic medication, which means that it breaks down or dissolves clots; therefore, bleeding is a concern. Allergic reaction is not a frequent response. Muscle weakness is not a side/adverse effect of this medication. Local or systemic infection could occur with poor aseptic technique during medication administration, but it is rare and not specifically associated with this medication.

The nurse has provided instruction to a client with chronic kidney disease who has a prescription for epoetin alfa. Which statement by the client indicates that teaching was effective? 1. "I have to receive this medication subcutaneously." 2. "This medication has to be administered using the Z-track method." 3. "I will take this medication orally with the rest of my morning pills." 4. "I will receive this medication through intramuscular injection."

Correct Answer: 1 Rationale: Epoetin alfa is administered parenterally by the intravenous or subcutaneous route. It cannot be given orally because it is a glycoprotein and would be degraded in the gastrointestinal tract.

The nurse has provided medication instructions to a client with an iron deficiency anemia who will be taking iron supplements. Which statement made by the client indicates an understanding of this medication? 1."I need to increase my fluid intake." 2."I should eliminate fiber foods from my diet." 3."I need to take the medication with water before a meal." 4."I should be sure to chew the tablet thoroughly before swallowing it."

Correct Answer: 1 Rationale: Iron preparations can be very irritating to the stomach and are best taken between meals. Because iron supplements may be associated with constipation, the client should increase fluids and fiber in the diet to counteract this side effect of therapy. Iron preparations should be taken with a substance that is high in vitamin C to increase its absorption. The tablet is swallowed whole and not chewed.

The nurse is reviewing the health care provider's (HCP's) prescriptions for a client recently admitted to the hospital and notes that the HCP has prescribed ticlopidine therapy. Which finding on the client's record would indicate a need to contact the HCP before initiating the medication prescription? 1. Neutropenia 2. Client history of stroke 3. Client history of hypertension 4. Complaints of gastrointestinal disturbances

Correct Answer: 1 Rationale: Neutropenia, or agranulocytosis, is the most serious adverse effect associated with the use of ticlopidine. A baseline complete blood cell (CBC) count with differential will be performed for the client. Neutropenia occurs most often within the first 3 months of therapy; therefore, a CBC with differential is recommended every 2 weeks during the first 3 months. If a diagnosis of neutropenia is determined, the client will be withdrawn from therapy. This medication is used to prevent a stroke and is not contraindicated in hypertension. Gastrointestinal disturbances can occur as a result of taking the medication, and the client is instructed to take the medication with food to minimize these side effects.

The nurse is caring for a client who is receiving heparin sodium intravenously as a continuous infusion. Which laboratory finding requires immediate nursing intervention? 1.Platelet count of 100,000 mm3 (100 × 109/L) 2.Red blood cell count of 4.2 cells (4.2 × 1012/L) 3.International normalized ratio (INR) of 1.2 (1.2) 4.Activated partial thromboplastin time (aPTT) of 60 seconds (60 seconds)

Correct Answer: 1 Rationale: The platelet count indicates that the client receiving heparin sodium is at risk for heparin-induced thrombocytopenia (HIT). HIT should be suspected whenever platelet counts fall below normal. If severe thrombocytopenia develops (platelet count less than 100,000 mm3 [100 × 109/L]), heparin sodium should be discontinued. The aPTT in option 4 represents an expected finding for intravenous heparin sodium therapy. Option 3 is not a value measured for heparin sodium therapy but is used to measure a response to warfarin sodium therapy, and the red blood cell count in option 2 is normal.

The nurse is preparing a plan of care for a client with sickle cell crisis who will be admitted to the nursing unit. The nurse should include which intervention as a priority in the plan of care for the client? 1.Initiate an intravenous (IV) line for the administration of fluids. 2.Consult with the psychiatric department regarding genetic counseling. 3.Call the blood bank and request preparation of a unit of packed red blood cells. 4.Call the respiratory department to prepare for intubation and mechanical ventilation.

Correct Answer: 1 Rationale: The priorities in management of sickle cell crisis are hydration therapy and pain relief. To achieve this, the client is given IV fluids to promote hydration and reverse the agglutination of sickled cells in small blood vessels. Opioid analgesics may be given to relieve the pain that accompanies the crisis. Genetic counseling is recommended but not during the acute phase of illness. Red blood cell transfusion may be done in selected circumstances such as aplastic crisis or when the episode is refractive to other therapy. Oxygen would be administered according to individual need, but the client would not require intubation and mechanical ventilation.

A health care provider prescribed ticlopidine to the client with thrombotic stroke. The nurse provides instructions to the client and spouse regarding the medication. Which statement made by the client indicates that education was effective? 1."I'll take the medicine with meals." 2."If I do not feel well, I should skip the medication." 3."I won't have another stroke if I take this medicine faithfully." 4."If I have any gastrointestinal side effects, I should call the health care provider (HCP)."

Correct Answer: 1 Rationale: Ticlopidine is an antiplatelet agent that is used to assist in preventing a thrombotic stroke. Ticlopidine is best tolerated when taken with meals. The most common side effects are gastrointestinal (GI) disturbances. Taking ticlopidine with meals tends to lessen those effects. It is not necessary to contact the health care provider (HCP) if GI upset occurs. The client should not skip medications. The medication is used to prevent strokes but does not guarantee that a stroke will not occur.

The nurse is preparing to perform an assessment on a client being admitted to the hospital with a diagnosis of sickle cell crisis, vaso-occlusive crisis. Which findings should the nurse expect to note on assessment of the client? Select all that apply. 1.Pallor 2.Fever 3.Joint swelling 4.Blurred vision 5.Abdominal pain

Correct Answer: 1,2,3,5 Rationale: Sickle cell crises are acute exacerbations of the disease. Vaso-occlusive crisis is caused by stasis of blood with clumping of cells in the microcirculation, ischemia, and infarction. Manifestations include pallor; fever; painful swelling of hands, feet, and joints; and abdominal pain. Blurred vision is not a manifestation of vaso-occlusive crisis.

The nurse is reviewing the health care provider's prescriptions for a client admitted to the hospital with a diagnosis of idiopathic autoimmune hemolytic anemia. The nurse prepares the client for treatment of this disorder, understanding that which may be recommended? Select all that apply. 1.Transfusions 2.Splenectomy 3.Radiation therapy 4.Corticosteroid medication 5.Immunosuppressive agents

Correct Answer: 1,2,4,5 Rationale: Idiopathic autoimmune hemolytic anemia is a decrease in the number of red blood cells due to increased destruction by the body's defense (immune) system. It is an acquired disease that occurs when antibodies form against a person's own red blood cells. In the idiopathic form of this disease, the cause is unknown. Idiopathic autoimmune hemolytic anemia is treated with corticosteroids. Other treatments that may be prescribed as necessary include transfusions, splenectomy, and, occasionally,

A client is being discharged to home with enoxaparin for short-term therapy. What should the nurse explain to the family about the medication action? 1. Relieves joint pain 2. Dissolves urinary calculi 3. Stops progression of multiple sclerosis 4. Reduces the risk of deep vein thrombosis

Correct Answer: 4 Rationale: Enoxaparin is an anticoagulant that is administered to prevent deep vein thrombosis and thromboembolism in clients at risk. It is not used to treat the conditions listed in options 1, 2, or 3.

The nurse is preparing a client with thrombocytopenia for discharge. Which statement by the client about measures minimizing injury indicates that discharge teaching was effective? Select all that apply. 1."I may continue to use an electric shaver." 2."I will not blow my nose if I get a cold." 3."I should use an enema instead of laxatives for constipation." 4."I definitely will play football with my friends this weekend." 5."I should use a soft-bristled toothbrush to avoid mouth trauma."

Correct Answer: 1,2,5 Rationale: Bleeding precautions are used to protect the client with thrombocytopenia from bleeding. The client with thrombocytopenia may experience internal and external bleeding. Bleeding is frequently provoked by trauma, but it also may be spontaneous. The client with thrombocytopenia should be educated about activities that increase the risk for bleeding, such as contact sports and trauma to oral, nasal, and rectal mucosa. This will help to eliminate options 3 and 4.

The nurse has a prescription to administer a dose of iron by the intramuscular route to the client. What are the most appropriate nursing actions? Select all that apply. 1.Use a Z-track method. 2.Administer the medication only in the deltoid. 3.Aspirate for blood after the needle is inserted. 4.Use an air lock when drawing up the medication. 5.Change the needle after drawing up the dose and before injection. 6.Massage the injection site well after injection to hasten absorption.

Correct Answer: 1,4,5 Rationale: An air lock and a Z-track method should both be used when administering iron by the intramuscular route. Proper technique includes changing the needle after drawing up the medication but before giving it to prevent staining of skin. Only the dorsogluteal site should be used, and proper identification of appropriate landmarks is essential. The site should not be massaged after injection because massaging could cause staining of the skin.

The nurse is preparing to administer filgrastim to the client. Which route of administration should the nurse determine is the most appropriate for this medication? 1.Oral 2.Subcutaneous 3.Intramuscular 4.Intravenous bolus

Correct Answer: 2 Rationale: Filgrastim is a granulocyte colony-stimulating factor produced by human recombinant DNA technology. It is given by subcutaneous injection or continuous intravenous infusion.

When obtaining assessment data from a client with a microcytic normochromic anemia, which should the nurse question the client about? 1.Folic acid intake 2.Dietary intake of iron 3.A history of gastric surgery 4.A history of sickle cell anemia

Correct Answer: 2 Rationale: Microcytic normochromic anemias involve the presence of small, pale-colored red blood cells. Causes are iron deficiency anemia, thalassemia, and lead poisoning. The only choice that fits this description is option 2. Folic acid deficiency is caused by macrocytic normochromic cells; these are large red blood cells. Gastric surgery can result in vitamin B12 deficiency. Sickle cell anemia results in sickled cells and erythrocyte destruction.

A client is receiving heparin sodium by continuous intravenous (IV) infusion. The nurse should notify the health care provider if ongoing nursing assessment reveals which finding? 1.Tinnitus 2.Ecchymosis 3.Increased pulse rate 4.Increased blood pressure

Correct Answer: 2 Rationale: The client who receives a continuous IV infusion of heparin sodium is at risk for bleeding. The nurse assesses for signs/symptoms of bleeding, which include bleeding from the gums, ecchymosis on the skin, cloudy or pink-tinged urine, tarry stools, and body fluids that test positive for occult blood. The other options are not side or adverse effects related to this medication.

The nurse is providing discharge instructions to a client taking warfarin sodium. Which statement, based on health care provider (HCP) permission, is appropriate to include in client teaching for this medication? 1."Alcohol can be consumed as long as it is in small amounts." 2."You need to check with your doctor about what can be taken for headache." 3."It doesn't matter what time the daily dose is taken as long as it is taken each day." 4."It is all right to take over-the-counter medications as long as they do not contain vitamin K."

Correct Answer: 2 Rationale: Warfarin sodium is an anticoagulant that prevents further extension of formed existing clots and also prevents new clot formation and secondary thromboembolic complications. Because the medication places the client at risk for bleeding, the client is instructed to avoid salicylates (acetylsalicylic acid, or aspirin) and alcohol. The medication should be taken exactly as prescribed and at the same time daily. The client needs to avoid all over-the-counter medications and needs to consult with the HCP before taking any other medications because of the risk for medication interactions.

A nurse has provided discharge instructions to a client being placed on long-term anticoagulant therapy with warfarin sodium. Adequate learning would be evident if the client makes which statements? Select all that apply. 1."I may take over-the-counter medications as needed." 2."I will inform my dentist that I am taking this medication." 3."I should alternate the timing of my daily dose of this medication." 4."I should use a firm-bristled toothbrush to prevent the side effects of this medication." 5."I will have my blood levels checked as prescribed by my health care provider (HCP)." 6."I will report any signs of blood in my urine or stool to my health care provider (HCP)."

Correct Answer: 2,5,6 Rationale: Clients need to notify all health care providers (HCPs) that they are on warfarin sodium therapy. Dental procedures may put the client at risk for increased bleeding, so this should direct you to option 2. Knowing that the effectiveness of warfarin sodium is based on maintaining a therapeutic blood level will direct you to select option 5. Awareness of bleeding as a primary complication will direct you to option 6.

A client is admitted to the hospital with a diagnosis of myocardial infarction (MI). The client is started on alteplase therapy. The nurse determines that teaching has been effective when the client's significant other states that the purpose of the medication is to perform which action? 1.Thin the blood. 2.Slow the clotting of the blood. 3.Dissolve any clots in the coronary arteries. 4.Prevent further clots from forming in the coronary arteries.

Correct Answer: 3 Rationale: Alteplase converts plasminogen in the blood to plasmin. Plasmin is an enzyme that digests or dissolves fibrin clots wherever they exist. Heparin sodium and warfarin sodium thin the blood, slow clotting, and prevent further clots from forming.

The nurse has provided instructions to a client who will receive alteplase for the treatment of acute myocardial infarction. The nurse determines that teaching was effective if the client states that the main action of alteplase is what? 1."It will slow the clotting of my blood." 2."It will keep my blood thin to prevent clotting." 3."It will dissolve any clots that are obstructing the coronary arteries." 4."It will prevent any further clots from forming anywhere in the body."

Correct Answer: 3 Rationale: Alteplase is a thrombolytic medication that is used to manage acute myocardial infarction. It lyses thrombi that are obstructing the coronary arteries, decreases infarct size, improves ventricular function, decreases the risk of heart failure, and limits the risk of death associated with myocardial infarction. Options 1, 2, and 4 are not actions of this medication.

Enoxaparin sodium is prescribed for a client after hip replacement surgery. Which medication should the nurse anticipate to administer in the event of enoxaparin sodium overdose? 1.Epinephrine 2.Phytonadione 3.Protamine sulfate 4.Diphenhydramine

Correct Answer: 3 Rationale: Enoxaparin sodium is an anticoagulant. Accidental overdose of this medication may lead to bleeding complications. The antidote is protamine sulfate. Epinephrine is used to treat hypersensitivity reactions or acute bronchial asthma attacks and bronchospasms. Phytonadione is the antidote for warfarin sodium. Diphenhydramine is an antihistamine.

Epoetin alfa by the subcutaneous route is prescribed for a client. What is the most appropriate nursing action? 1.Shake the vial before use. 2.Freeze the medication before use. 3.Refrigerate the medication until used. 4.Obtain syringes with 1½-inch (3.8 cm) needles for administration.

Correct Answer: 3 Rationale: Epoetin alfa should be refrigerated at all times. The bottle should not be shaken, and the medication should not be frozen because this will affect the chemical composition. Syringes with a ⅚-inch (1.5 cm) needle are used for subcutaneous injection. A 1½-inch (3.8cm) needle may be used for intramuscular injection.

The nurse is evaluating the results of laboratory studies for a client receiving epoetin alfa. When should the nurse expect to note a therapeutic effect of this medication? 1.Immediately 2.After 3 days of therapy 3.After 2 weeks of therapy 4.After 1 week of therapy

Correct Answer: 3 Rationale: Epoetin alfa stimulates erythropoiesis. It takes 2 to 6 weeks after initiation of therapy before a clinically significant increase in hematocrit is observed. Therefore, this medication is not intended for clients who require immediate correction of severe anemia, and it is not a substitute for emergency blood transfusions.

A client with chronic kidney disease is receiving epoetin alfa for the past 2 months. What should the nurse determine is an indicator that this therapy is effective? 1.A decrease in blood pressure 2.An increase in white blood cells 3.An increase in serum hematocrit 4.A decrease in serum creatinine level

Correct Answer: 3 Rationale: Epoetin alfa stimulates red blood cell production. Initial effects should be seen within 1 to 2 weeks, and the hematocrit reaches normal levels in 2 to 3 months.

A client is diagnosed with iron deficiency anemia, and ferrous sulfate is prescribed. The nurse should tell the client that it would be best to take the medication with which food? .1.Milk 2.Boiled egg 3.Tomato juice 4.Pineapple juice

Correct Answer: 3 Rationale: Ferrous sulfate is an iron preparation, and the client is instructed to take the medication with orange juice or another vitamin C-containing product or a product high in ascorbic acid to increase the absorption of the iron. Among the options presented, tomato juice is highest in vitamin C and ascorbic acid. Milk and eggs inhibit absorption of iron.

A client receiving heparin sodium by continuous intravenous (IV) infusion removes the tubing from the pump to change his hospital gown. The nurse is concerned that the client received a bolus of medication. After requesting a prescription for a stat partial thromboplastin time (PTT), the nurse should check for the availability of which medication in the medication cart? 1.Enoxaparin 2.Phytonadione 3.Protamine sulfate 4.Aminocaproic acid

Correct Answer: 3 Rationale: If the tubing is removed from an IV pump and the tubing is not clamped, the client will receive a bolus of the solution and the medication contained in the solution. The client who receives a bolus dose of heparin sodium is at risk for bleeding. If the results of the next PTT are extremely high, a dose of protamine sulfate, the antidote for heparin sodium, may be prescribed. Enoxaparin is an anticoagulant. Phytonadione is the antidote for warfarin sodium. Aminocaproic acid is an antifibrinolytic agent (inhibits clot breakdown).

A client is admitted to the hospital emergency department with an acute anterior wall myocardial infarction. The nurse discusses thrombolytic therapy with the client and spouse. The spouse is concerned about the dangers of this treatment. Which statement by the nurse is appropriate? 1."There is no reason to worry. We use this medication all the time." 2."I'm certain you made the correct decision to use this medication." 3."You have concerns about whether this treatment is the best option." 4."Your loved one is very ill. The health care provider has made the best decision for you."

Correct Answer: 3 Rationale: Paraphrasing is restating the client's or family members' own words. This allows the client and family members to express their concerns and talk through the decisions that have been made. Option 1 offers false reassurance. In option 2, the nurse is expressing approval, which can be harmful to the client-nurse or family-nurse relationship. Option 4 represents a communication block that denies the family member's right to an opinion.

The nurse is preparing to administer heparin sodium subcutaneously. Which nursing action is the most appropriate? 1.Apply heat after the injection. 2.Use a 21- to 23-gauge, 1-inch (2.5 cm) needle. 3.Use a 25- to 26-gauge, ⅝-inch (1.5 cm) needle. 4.Aspirate before injection of the medication.

Correct Answer: 3 Rationale:For subcutaneous heparin sodium injection, a 25- to 26-gauge, ⅝-inch (1.5 cm) needle is used to prevent tissue trauma and inadvertent intramuscular injection. The application of heat may affect the absorption of the heparin sodium and cause bleeding. A 1-inch (2.5 cm) needle would inject the heparin sodium into the muscle. Aspiration before injection is an incorrect technique with heparin sodium administration because it could cause bleeding in the tissues.

A client is scheduled to have alteplase. Which item should the nurse obtain to monitor side/adverse effects of the medication therapy? 1.Flashlight 2.Pulse oximeter 3.Suction equipment 4.Occult blood test strips

Correct Answer: 4 Rationale: Alteplase is a thrombolytic medication that dissolves thrombi or emboli. Bleeding is a frequent and potentially severe adverse effect of therapy. The nurse assesses for signs of bleeding in clients receiving this therapy using occult blood test strips to test urine, stool, or nasogastric drainage. A flashlight is used for pupil assessment as part of the neurological examination in the client who is neurologically impaired. Pulse oximeter and suction equipment would be needed if the client had evidence of oxygenation or respiratory problems.

A client with a subarachnoid hemorrhage needs to have surgery delayed until a stable clinical condition is achieved. The nurse prepares to administer which medication as prescribed to prevent clot breakdown and dissolution? 1.Alteplase 2.Heparin sodium 3.Warfarin sodium 4.Aminocaproic acid

Correct Answer: 4 Rationale: Aminocaproic acid is an antifibrinolytic agent that prevents clot breakdown or dissolution. It is commonly prescribed after subarachnoid hemorrhage if surgery is delayed or contraindicated, to prevent further hemorrhage. Alteplase is a fibrinolytic that actively breaks down clots. Warfarin sodium and heparin sodium are anticoagulants that interfere with propagation or growth of a clot.

The nurse is providing instructions to the parent of a child with iron deficiency anemia about the administration of a liquid oral iron supplement. Which statement, if made by the parent, indicates an understanding of the administration of this medication? 1."I should give the iron with food." 2."I can mix the iron with cereal to give it." 3."I should add the iron to the formula in the baby's bottle." 4."I should use a medicine dropper and place the iron near the back of the throat."

Correct Answer: 4 Rationale: An oral iron supplement should be administered through a straw or medicine dropper placed at the back of the mouth because it will stain the teeth. The parents should be instructed to brush or wipe the teeth after administration. Iron is administered between meals because absorption is decreased if there is food in the stomach. Iron requires an acidic environment to facilitate its absorption in the duodenum.

The nurse is caring for a postpartum client with a diagnosis of deep vein thrombosis who is receiving a continuous intravenous infusion of heparin sodium. Review of which laboratory result is the most important by the nurse? 1.Platelet count 2.Prothrombin time (PT) 3.International normalized ratio (INR) 4.Activated partial thromboplastin time (aPTT)

Correct Answer: 4 Rationale: Anticoagulation therapy may be used to prevent the extension of thrombus by delaying the clotting time of the blood. The aPTT time should be monitored, and the heparin sodium dose should be adjusted to maintain a therapeutic level of 1.5 to 2.5 times the control value in seconds. The platelet count cannot be used to determine an adequate dosage for the heparin sodium infusion. The PT and the INR are used to monitor coagulation time when warfarin sodium is used.

A client is scheduled to have heparin sodium 5000 units subcutaneously. What is the most appropriate nursing intervention? 1. Inject via an infusion device. 2. Inject ½ inch (1.25 cm) from the umbilicus. 3. Massage the injection site after administration. 4. Avoid aspirating prior to injecting the medication.

Correct Answer: 4 Rationale: Aspiration should be avoided before injecting the heparin because it can cause hematoma at the administration site. Heparin sodium administered subcutaneously does not require an infusion device and is injected at least 2 inches (5 cm) from the umbilicus or any scar tissue. The needle is withdrawn rapidly, and the site is not massaged (although pressure is applied).

The nurse has given the client with atrial fibrillation instructions to take one 1 aspirin daily. The client says to the nurse, "Why do I need to take this? I don't get any pain with my heart rhythm."Which response by the nurse is the most appropriate? 1."This will keep you from experiencing chest pain." 2."This will most likely keep you from ever having a heart attack." 3."This will prevent any inflammation from occurring on the walls of your heart." 4."This will help prevent clot formation in your heart as a result of your heart's rhythm."

Correct Answer: 4 Rationale: Atrial fibrillation puts the client at risk for mural thrombi because of the sluggish blood flow through the atria that occurs as a result of loss of the atrial kick. In atrial fibrillation, the health care provider may prescribe a daily aspirin. This will prevent clot formation along the walls of the atria and resultant embolus. Aspirin will not prevent chest pain or keep a client from ever having a heart attack. Although aspirin does have antiinflammatory properties, it cannot prevent any inflammation from occurring, as stated in option 3.

The nurse is performing an assessment on a client with a diagnosis of pernicious anemia. Which finding would the nurse expect to note in this client? 1.Dyspnea 2.Dusky mucous membranes 3.Shortness of breath on exertion 4.Red tongue that is smooth and sore

Correct Answer: 4 Rationale: Classic signs of pernicious anemia include weakness, mild diarrhea, and a smooth red tongue that is sore. The client also may have nervous system signs and symptoms such as paresthesias, difficulty with balance, and occasional confusion. The client does not exhibit dyspnea, the mucous membranes do not become dusky, and the client does not exhibit shortness of breath.

The home care nurse is making a monthly visit to a client with a diagnosis of pernicious anemia who has been receiving a monthly injection of cyanocobalamin. Before administering the injection, the nurse evaluates the effects of the medication and determines that a therapeutic effect is occurring if the client makes which statement? 1. "I feel really lightheaded." 2. "I no longer have any nausea." 3. "I have not had any pain in a month." 4. "I feel stronger and have a much better appetite."

Correct Answer: 4 Rationale: Cyanocobalamin is essential for DNA synthesis. It can take up to 3 years for the vitamin B12 stores to be depleted and for symptoms of pernicious anemia to appear. Symptoms can include weakness, fatigue, anorexia, loss of taste, and diarrhea. To correct deficiencies, a crystalline form of vitamin B12, cyanocobalamin, can be given intramuscularly. The client statements in options 1, 2, and 3 do not identify a therapeutic effect of the medication.

The nurse is caring for a client who was just admitted to the hospital for the treatment of iron overload. The nurse anticipates that the health care provider will prescribe which medication to treat the iron overload? 1.Terbinafine 2.Granisetron 3.Ketoconazole 4.Deferoxamine

Correct Answer: 4 Rationale: Deferoxamine is a medication used to treat iron overload. Granisetron is an antiemetic. Ketoconazole and terbinafine are antifungal medications.

A home care nurse is visiting a client who was discharged to home with a prescription for continued administration of enoxaparin subcutaneously. What is the nurse's priority assessment for this client? 1.Constipation 2.Fear of needles 3.Nausea or vomiting 4.Bleeding gums or bruising

Correct Answer: 4 Rationale: Enoxaparin is an anticoagulant. An adverse effect of anticoagulant therapy is bleeding. Accordingly, the nurse questions the client about signs and symptoms that could indicate bleeding, such as bleeding gums, bruising, hematuria, or dark, tarry stools.

The nurse is monitoring a client who is receiving epoetin alfa for adverse effects of the medication. Which finding indicates a side/adverse effect? 1.Diarrhea 2.Depression 3.Bradycardia 4.Hypertension

Correct Answer: 4 Rationale: Epoetin alfa generally is well tolerated. The most significant adverse effect is hypertension, and its use is contraindicated in uncontrolled hypertension. Occasionally a tachycardia may occur as a side effect. This medication also may cause an improved sense of well-being.

The client in chronic kidney disease is receiving epoetin alfa. The nurse should monitor this client for which side/adverse effect of this medication? 1.Fever 2.Depression 3.Bradycardia 4.Hypertension

Correct Answer: 4 Rationale: Epoetin alfa is generally well tolerated, although hypertension can occur and is the most significant adverse effect. Occasionally, tachycardia may also occur. It may also cause an improved sense of well-being. Fever, depression, and bradycardia are not adverse effects of this medication.

A client with chronic kidney disease is receiving ferrous sulfate. The nurse instructs the client that which finding is a common side/adverse effect associated with this medication? 1.Fatigue 2.Headache 3.Weakness 4.Constipation

Correct Answer: 4 Rationale: Ferrous sulfate is an iron supplement used to treat anemia. Constipation is a frequent and uncomfortable side effect associated with the administration of oral iron supplements. Stool softeners often are prescribed to prevent constipation. Options 1, 2, and 3 are not side or adverse effects associated with this medication.

The nurse is preparing to administer filgrastim to a client with a diagnosis of agranulocytosis. The client asks the nurse about the purpose of the medication. Which information should the nurse include in the response regarding action of this medication? 1.It prevents bleeding. 2.It prolongs the clotting time. 3.It increases the red blood cell count. 4.It promotes the growth of neutrophils.

Correct Answer: 4 Rationale: Filgrastim is a granulocyte colony-stimulating factor produced by human recombinant DNA. It is administered to clients with agranulocytosis to promote the growth of neutrophils and enhance the function of mature neutrophils. Options 1, 2, and 3 are not actions of this medication.

The nurse is reviewing the laboratory test results for a client who is receiving filgrastim. Which reported value would indicate an effective response to this medication? 1. Hematocrit of 42% (0.42) 2. Blood glucose level of 110 mg/dL (6 mmol/L) 3. Platelet count of 150,000 mm3 (150 × 109/L) 4. Neutrophil count of 10,000 mm3 (10 × 109/L)

Correct Answer: 4 Rationale: Filgrastim is used to promote the growth of neutrophils and enhance the function of mature neutrophils. Treatment is continued until the absolute neutrophil count reaches 10,000 cells/mm3. Options 1, 2, and 3 are unrelated to the action of this medication.

A client is prescribed a liquid iron preparation that has the potential to stain the teeth. The nurse should instruct the client to take which action to prevent staining of the teeth? 1.Brush the teeth before drinking the iron. 2.Drink the iron undiluted for maximal effect. 3.Dilute more than the amount prescribed to obtain the correct dosage. 4.Dilute the iron in juice, drink it through a straw, and rinse the mouth afterward.

Correct Answer: 4 Rationale: Liquid iron preparations will stain the teeth. The best advice for the client who needs liquid iron is to dilute the iron in juice or water, drink it through a straw, and rinse the mouth well afterward. Brushing before taking the liquid iron would not be of any benefit. The nurse would not instruct a client to take more than the prescribed amount.

The nurse is providing dietary instructions to the client with anemia. The client tells the nurse that the iron pills are very expensive and it will be difficult to pay for the pills and buy the proper food. What is the most appropriate nursing response? 1."You will have to find a way to afford both." 2."You will be fine as long as you take the iron pills." 3."Why don't you ask your family to help you out financially?" 4."Would you like for me to check into some other options for you?"

Correct Answer: 4 Rationale: Option 4 is correct because it validates the client's issue with cost. The nurse offers help in a nonthreatening manner that will allow the client to accept or decline. Option 2 is incorrect because the client needs to consume a proper diet. Options 1 and 3 block the communication process and are nontherapeutic and nonhelpful statements.

A client who was diagnosed with toxic shock syndrome (TSS) now exhibits petechiae, oozing from puncture sites, and coolness of the digits of the hands and feet. Clotting times determined for this client are prolonged. The nurse interprets these clinical signs as being most compatible with which condition? 1.Heparin overdose 2.Vitamin K deficiency 3.Factor VIII deficiency 4.Disseminated intravascular coagulopathy (DIC)

Correct Answer: 4 Rationale: TSS is caused by infection and often is associated with tampon use. The client's clinical signs in this question are compatible with DIC, which is a complication of TSS. The nurse assesses the client at risk and notifies the health care provider promptly when signs and symptoms of DIC are noted. Although signs of bleeding may be seen with each of the conditions listed in the incorrect options, the initial diagnosis of TSS makes DIC the logical correct option.

A client who is scheduled to have warfarin sodium therapy has a prothrombin time (PT) of 28 seconds (28 seconds). What is the most appropriate nursing intervention at this time? 1. Give double the dose. 2. Administer the next dose. 3. Give half of the next dose. 4. Call the health care provider (HCP).

Correct Answer: 4 Rationale: The PT is one test that may be used to monitor warfarin sodium therapy. The international normalized ratio is another laboratory test used to monitor warfarin therapy. The normal PT is 11 to 12.5 seconds (11 to 12.5 seconds). A PT of 28 seconds represents an elevated value. The nurse should withhold the next dose and notify the HCP. A medication dose should not be changed without a specific prescription (options 1 and 3).

The nurse has provided instructions to a client with sickle cell disease regarding measures that will prevent a sickle cell crisis. Which client statement indicates an understanding of these measures? 1."I need to avoid any exercise." 2."I need to avoid increasing my fluid intake." 3."I need to avoid going outdoors in warm weather." 4."I need to avoid situations that may lead to an infection."

Correct Answer: 4 Rationale: The client should avoid infections, which can increase metabolic demands and cause dehydration, precipitating a sickle cell crisis. Fluids are important to prevent dehydration, which could lead to sickle cell crisis. Warm weather and mild exercise do not need to be avoided, but the client should take measures to avoid dehydration during these conditions.

The nurse is performing an assessment on a client with a diagnosis of anemia that developed as a result of blood loss after a traumatic injury. The nurse should expect to find which sign or symptom in the client as a result of the anemia? 1.Bradycardia 2.Muscle cramps 3.Increased respiratory rate 4.Shortness of breath with activity

Correct Answer: 4 Rationale: The client with anemia is likely to experience shortness of breath and complain of fatigue because of the decreased ability of the blood to carry oxygen to the tissues to meet metabolic demands. The client is likely to have tachycardia, not bradycardia, as a result of efforts by the body to compensate for the effects of anemia. Muscle cramps are an unrelated finding. Increased respiratory rate is not an associated finding.

A client enters the hospital emergency department with a nosebleed. On assessment the client tells the nurse that the nosebleed just suddenly began. The nurse notes no obvious facial injury. Which is the initial nursing action? 1.Insert nasal packing. 2.Prepare a nasal balloon for insertion. 3.Place the client in a semi Fowler's position, and apply ice packs to the nose. 4.Sit the client down, ask the client to lean forward slightly, and apply pressure to the nose for 5 to 10 minutes.

Correct Answer: 4 Rationale: The initial nursing action for a client with a nosebleed is to sit the client down, ask the client to lean forward slightly, and apply pressure to the nose for 5 to 10 minutes. Inserting nasal packing or preparing a nasal balloon is not an appropriate initial intervention. These interventions are used when conservative measures fail. Placing the client in a semi Fowler's position would promote swallowing blood, which is not helpful because of the risk of vomiting and resultant aspiration.

The nurse is monitoring the laboratory test results for a client who is taking warfarin sodium after mechanical heart valve replacement. The nurse should expect the international normalized ratio (INR) for this client to be at what value in order to be therapeutic? 1.0.2 2.0.5 3.1.0 4.3.0

Correct Answer: 4 Rationale: The normal value for INR is 0.81 to 1.2 (0.81 to 1.2). The target INR or therapeutic level for a client receiving warfarin sodium is 2.5 to 3.5 (2.5 to 3.5).

The nurse is reviewing the laboratory results for a client who arrives at the health care clinic for follow-up assessment after being diagnosed with atrial fibrillation. The international normalized ratio (INR) is analyzed because the client has been taking warfarin sodium since discharge from the hospital. The nurse determines that the INR range is at an appropriate level if what value is noted on the laboratory report? 1.0.6 2.0.75 3.1.0 4.2.3

Correct Answer: 4 Rationale: The recommended INR range for warfarin sodium therapy for atrial fibrillation is 2.0 to 3.0 (2.0 to 3.0). Subtherapeutic INRs increase the client's risk for thrombus formation. The normal range for INR is 0.81 to 1.2 (0.81 to 1.2), so option 4 is therapeutic for this client.

A client is taking ticlopidine hydrochloride. The nurse should tell the client to avoid which substance while taking this medication? 1.Vitamin C 2.Vitamin D 3.Acetaminophen 4.Acetylsalicylic acid

Correct Answer: 4 Rationale: Ticlopidine hydrochloride is a platelet aggregation inhibitor. It is used to decrease the risk of thrombotic stroke in clients with precursor symptoms. Because it is an antiplatelet agent, other medications that precipitate or aggravate bleeding should be avoided during its use. Therefore, aspirin or any aspirin-containing product should be avoided. The substances in options 1, 2, and 3 are safe to consume.

A client is scheduled to take ticlopidine. The nurse plans to take which action before implementing this medication therapy? 1. Take the client's blood pressure. 2. Obtain a prothrombin time (PT). 3. Take the client's apical heart rate. 4. Review the results of the complete blood cell (CBC) count.

Correct Answer: 4 Rationale: Ticlopidine is an antiplatelet agent that is used for the prevention of thrombotic stroke. Ticlopidine's effects last for the life of the platelet, 7 to 10 days. Ticlopidine also can cause neutropenia, which is an abnormally small number of mature white blood cells (WBCs). Baseline data from a CBC count are necessary before implementation of therapy, and the nurse should monitor for neutropenia during this medication therapy. If this adverse effect does occur, the health care provider is notified and therapy should be stopped. The effects of neutropenia are reversible within 1 to 3 weeks. Options 1, 2, and 3 are actions that are not specific to this medication therapy.