Saunders NCLEX review

A client with iron deficiency anemia complains of feeling fatigued almost all of the time. The nurse should respond with which statement? 1."The work of breathing is increased when the client is anemic." 2."Blood flows more slowly when the hemoglobin or hematocrit is low." 3."The body has to work harder to fight infection in the presence of anemia." 4."Adequate amounts of hemoglobin are needed to carry oxygen for tissue metabolism."

"Adequate amounts of hemoglobin are needed to carry oxygen for tissue metabolism." Rationale:Oxygen is required to meet the metabolic needs of the body. With decreased hemoglobin, such as in iron deficiency anemia, the oxygen-carrying capacity of the blood is less than normal. The client feels the effects of this change as fatigue. The statements in the remaining options are incorrect.

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."

"I feel stronger and have a much better appetite." 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 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."

"I need to increase my fluid intake." 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 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."

"I should use a medicine dropper and place the iron near the back of the throat." 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 provides home care instructions to a client with sickle cell anemia. Which statement by the client indicates a need for further instruction? 1."I'm going to take a painting class." 2."I've learned to knit and sew my own clothes." 3."When I'm feeling better, I'm returning to the soccer team." 4."I'm using a schedule to maintain my increased fluid intake."

"When I'm feeling better, I'm returning to the soccer team." Rationale:Clients with sickle cell anemia are advised to avoid strenuous activities. Quiet activities as tolerated are recommended when the client is feeling well. Increasing fluid intake is encouraged to assist in preventing sickle cell crisis.

The nurse is instructing a client with iron deficiency anemia regarding the administration of a liquid oral iron supplement. Which instruction should the nurse tell the client? 1.Administer the iron at mealtimes. 2.Administer the iron through a straw. 3.Mix the iron with cereal to administer. 4.Add the iron to apple juice for easy administration.

Administer the iron through a straw. Rationale:In iron deficiency anemia, iron stores are depleted, resulting in a decreased supply of iron for the manufacture of hemoglobin in red blood cells. An oral iron supplement should be administered through a straw or medicine dropper placed at the back of the mouth, because the iron stains the teeth. The client should be instructed to brush or wipe their teeth after administration. Iron is administered between meals, because absorption is decreased if there is food in the stomach. Iron requires an acid environment to facilitate its absorption in the duodenum. Iron is not mixed with cereal or other food items.

The nurse has conducted dietary teaching with a client diagnosed with iron deficiency anemia. The nurse instructs the client that which food item is a good dietary source of iron? 1.Oranges 2.Apricots 3.Egg whites 4.Refined white bread

Apricots Rationale:The client with iron deficiency anemia should increase intake of foods that are naturally high in iron. The best sources of dietary iron are red meat, liver and other organ meats, blackstrap molasses, and oysters. Other good sources of iron are kidney beans, whole-wheat bread, egg yolks, spinach, kale, turnip tops, beet greens, carrots, raisins, and apricots.

A prescription reads heparin sodium, 1300 units/hr by continuous intravenous (IV) infusion. The pharmacy prepares the medication and delivers an IV bag labeled heparin sodium 20,000 units/250 mL D5W. An infusion pump must be used to administer the medication. The nurse sets the infusion pump at how many milliliters (mL) per hour to deliver 1300 units/hour? Fill in the blank. Record your answer to the nearest whole number.

Calculation of this problem can be done using a 2-step process. First, you need to determine the amount of heparin sodium in 1 mL. The next step is to determine the infusion rate, or milliliters per hour.Step 1: Determine the amount of heparin sodium in 1 mL.Known amount of medication-------------------------- = Medication/mLTotal volume of diluent20,000 units------------ = 80 units/mL250 mLStep 2: Calculate mL per hour.Dose per hour desired--------------------- = Milliliters per hourConcentration per mL1300 units---------- = 16.25 mL/hour80 units= 16 mL/hour (rounded

A client with a clot in the right atrium is receiving a heparin sodium infusion at 1000 units/hour and warfarin sodium 7.5 mg at 5:00 p.m. daily. The morning laboratory results are as follows: activated partial thromboplastin time (aPTT), 32 seconds; international normalized ratio (INR), 1.3. The nurse should take which action based on the client's laboratory results?

Collaborate with the PHCP to obtain a prescription to increase the heparin infusion and administer the warfarin sodium as prescribed. Rationale:When a client is receiving warfarin for clot prevention due to atrial fibrillation, an INR of 2 to 3 is appropriate for most clients. Until the INR has achieved a therapeutic range, the client should be maintained on a continuous heparin infusion with the aPTT ranging between 60 and 80 seconds. Therefore, the nurse should collaborate with the PHCP to obtain a prescription to increase the heparin infusion and to administer the warfarin as prescribed.

The nurse overhears a primary health care provider (PHCP) stating that a client diagnosed with disseminated intravascular coagulation (DIC) requires a transfusion. Which blood product should the nurse anticipate that the PHCP will write a prescription for? 1.Albumin 2.Platelets 3.Cryoprecipitate 4.Packed red blood cells

Cryoprecipitate Rationale:Cryoprecipitate is useful in treating bleeding from hemophilia or DIC because it is rich in clotting factors. Albumin may be used as a plasma expander in hypovolemia with or without shock. Platelets are used when the client's platelet count is low. Packed red blood cells replace erythrocytes, not fibrinogen

The nurse is reviewing the laboratory test results for a client seen in the health care clinic and notes that the hematocrit value is 30% (0.30). The nurse determines that this hematocrit value is most likely to be associated with which condition? 1.Dehydration 2.Pernicious anemia 3.Polycythemia vera 4.Iron deficiency anemia

Iron deficiency anemia Rationale:A hematocrit of 30% (0.30) or less indicates iron deficiency anemia. Decreased values occur in leukemia, acute hemorrhage, iron deficiency anemia, and hemolytic anemia. The conditions in the remaining options represent conditions in which an elevated hematocrit would be noted.

The nurse is reviewing the laboratory test results for a client with a diagnosis of thrombocytopenia purpura. The nurse should expect the results for platelet aggregation to be at which level? 1.Normal 2.Increased 3.Decreased 4.Insignificant

Decreased Rationale:The adherence of platelets to one another is defined as platelet aggregation. Platelets usually aggregate in less than 5 minutes. This test determines abnormalities in the rate and percentages of platelet aggregation. Decreased platelet aggregation may occur in persons with infectious mononucleosis, idiopathic thrombocytopenia purpura, acute leukemia, or von Willebrand's disease.

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.

Dilute the iron in juice, drink it through a straw, and rinse the mouth afterward. 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

A client who has undergone preadmission testing has had blood drawn for serum laboratory studies, including a complete blood count, coagulation studies, and electrolytes and creatinine levels. Which laboratory result should be reported to the surgeon's office by the nurse, knowing that it could cause surgery to be postponed? 1.Hemoglobin, 8.0 g/dL (80 mmol/L) 2.Sodium, 145 mEq/L (145 mmol/L) 3.Serum creatinine, 0.8 mg/dL (70.6 mcmol/L) 4.Platelets, 210,000 cells/mm3 (210 × 109/L)

Hemoglobin, 8.0 g/dL (80 mmol/L) Rationale:Routine screening tests include a complete blood count, serum electrolyte analysis, coagulation studies, and a serum creatinine test. The complete blood count includes the hemoglobin analysis. All of these values are within normal range except for hemoglobin. If a client has a low hemoglobin level, the surgery likely could be postponed by the surgeon

The nurse is preparing a plan of care for a child 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 child? 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.

Initiate an intravenous (IV) line for the administration of fluids. Rationale:The priorities in management of sickle cell crisis are hydration therapy and pain relief. To achieve this, the child 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.

The nurse reviews the plan of care for a woman at 37 weeks' gestation who has sickle cell anemia. The nurse determines that which problem listed on the nursing care plan will receive the highest priority? 1.Pain 2.Disturbed body image 3.Insufficient fluid volume 4.Inability to tolerate activity

Insufficient fluid volume Rationale:In a client with sickle cell anemia, dehydration will precipitate sickling of the red blood cells. Sickling can lead to life-threatening consequences for the pregnant woman and for the fetus, such as an interruption of blood flow to the placenta. Although the remaining options may also be appropriate problems for the client with sickle cell anemia, they are not the priority.

The nurse is reviewing the laboratory test results for a client seen in the health care clinic and notes that the red blood cell (RBC) count is decreased. The nurse determines that this finding occurs in which condition? 1.Dehydration 2.Iron deficiency 3.Severe diarrhea 4.Polycythemia vera

Iron deficiency Rationale:Decreased RBC counts occur in clients with vitamin B6 and B12 deficiencies, iron deficiency, chronic infection, bone marrow depression, multiple myeloma, leukemia, hemolytic anemia, and pernicious anemia. A decrease in the RBC count also may be noted in the older client. Increased RBC counts are noted in clients with the disorders in the remaining options.

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.

It promotes the growth of neutrophils. 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 teaching a client who has iron deficiency anemia about foods she should include in the diet. The nurse determines that the client understands the dietary modifications if which items are selected from the menu? 1. Nuts and milk 2. Coffee and tea 3. Cooked rolled oats and fish 4. Oranges and dark green leafy vegetables

Oranges and dark green leafy vegetables Rationale:Dark green leafy vegetables are a good source of iron, and oranges are a good source of vitamin C, which enhances iron absorption. All other options are not food sources that are high in iron and vitamin C.

The nurse is reviewing the laboratory test results for a client and notes that the differential white blood cell (WBC) count indicates a shift to the right. The nurse suspects that the client's diagnosis is most likely to be which one? 1.Sepsis 2.Pneumonia 3.Pernicious anemia 4.Coronary artery disease

Pernicious anemia Rationale: A differential WBC count is the leukocyte count broken down (differentiated) according to the cell type. A right shift represents an increased number of mature neutrophils, which is seen with pernicious anemia and after tissue breakdown. The conditions in the remaining options are not associated with this finding

The ambulatory care nurse is reviewing an adult client's laboratory test results and notes that the hematocrit level is 60% (0.60). The nurse recognizes that this level is most likely to be found in clients with which diagnosis? 1.Leukemia 2.Hemolytic anemia 3.Pernicious anemia 4.Iron deficiency anemia

Pernicious anemia Rationale:The normal hematocrit level is approximately 42% to 52% (0.42 to 0.52) in a male and 37% to 47% (0.37 to 0.47) in a female. The hematocrit level measures the percentage of red blood cells in whole blood. Elevated hematocrit levels are seen in persons with dehydration, pernicious anemia, or polycythemia. Therefore, the conditions in the remaining options are incorrect.

After undergoing Billroth I gastric surgery, the client experiences fatigue and complains of numbness and tingling in the feet and difficulties with balance. On the basis of these symptoms, the nurse suspects which postoperative complication? 1.Stroke 2.Pernicious anemia 3.Bacterial meningitis 4.Peripheral arterial disease

Pernicious anemia llroth I surgery involves removing one half to two thirds of the stomach and reanastomosing the remaining segment of the stomach to the duodenum. With the loss of this much of the stomach, development of pernicious anemia is not uncommon. Pernicious anemia is a macrocytic anemia that most commonly is caused by the lack of intrinsic factor. During a Billroth I procedure, a large portion of the parietal cells, which are responsible for producing intrinsic factor (a necessary component for vitamin B12 absorption), are removed. In this anemia, the red blood cell is larger than usual and hence does not last as long in the circulation as normal red blood cells do, causing the client to have anemia with resultant fatigue. Vitamin B12 also is necessary for normal nerve function. Because of the lack of the necessary intrinsic factor, persons with pernicious anemia also experience paresthesias, impaired gait, and impaired balance. Although the symptoms could possibly indicate the other options listed, pernicious anemia is the most logical based on the surgery the client underwent.

During the intrapartum period, the nurse is caring for a client with sickle cell disease. The nurse ensures that the client receives adequate intravenous fluid intake and oxygen consumption to achieve which outcome? 1.Stimulate the labor process. 2.Prevent dehydration and hypoxemia. 3.Avoid the necessity of a cesarean section. 4.Eliminate the need for analgesic administration.

Prevent dehydration and hypoxemia. HomeHelpCalculator Study Mode Question 23 of 32 ID: 4174 | Maternity_Intrapartum_final.htm #4319 PreviousGoNext StopBookmark Rationale Strategy Reference Labs Submit During the intrapartum period, the nurse is caring for a client with sickle cell disease. The nurse ensures that the client receives adequate intravenous fluid intake and oxygen consumption to achieve which outcome? Rationale:A variety of conditions, including dehydration, hypoxemia, infection, and exertion, can stimulate the sickling process during the intrapartum period. Maintaining adequate intravenous fluid intake and the administration of oxygen via face mask will help to ensure a safe environment for maternal and fetal health during labor. These measures will not stimulate the labor process, avoid the necessity of a cesarean section, or eliminate the need for analgesic administration

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

Red tongue that is smooth and sore 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.

A clinic nurse is reviewing the record of a client with a suspected diagnosis of pernicious anemia. The nurse anticipates that which diagnostic test will be prescribed by the client's primary health care provider? 1.Schilling test 2.Clotting time 3.Bone marrow biopsy 4.White blood cell differential

Schilling test Rationale:The Schilling test is used to determine the cause of vitamin B12 deficiency, which leads to pernicious anemia. This test involves the use of a small oral dose of radioactive B12, followed by a large nonradioactive intramuscular (IM) dose. The IM dose helps flush the oral dose into the urine if it was absorbed. A 24-hour urine collection is performed to measure the amount of radioactivity in the urine. Clotting time and a white blood cell differential count are not significantly related to pernicious anemia and would not be helpful in determining the diagnosis. A bone marrow biopsy is indicated in a client suspected of having leukemia.

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

Shortness of breath with activity 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.

An older client is seen in the clinic for a physical examination. Laboratory studies reveal that the hemoglobin and hematocrit levels are low, indicating the need for further diagnostic studies and a blood transfusion. The client is a Jehovah's Witness and refuses to have a blood transfusion. The nurse should take which most appropriate action? 1. Try to convince the client of the need for the transfusion. 2. Speak to the family regarding the need for a blood transfusion. 3. Support the client's decision not to receive a blood transfusion. 4. Discuss with the client the results of the hemoglobin and hematocrit levels compared with normal levels.

Support the client's decision not to receive a blood transfusion. Rationale:A client's cultural and ethnic background influences the response to health, illness, surgery, and death. Awareness of cultural differences enhances the nurse's knowledge of how a health care experience may be perceived by the client or family. In the Jehovah's Witness religion, the administration of blood and blood products is forbidden; therefore, the nurse would support the client's decision. Trying to convince the client of the need for the blood transfusion is inappropriate and does not respect the client's cultural beliefs. Speaking to the family is a violation of the client's right to confidentiality; in addition, it does not respect the client's cultural beliefs. Discussing the results of laboratory values is an indirect way of trying to convince the client of the need for a blood transfusion, which again is inappropriate and does not respect the client's cultural beliefs.

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

Tomato juice 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.

The nurse is caring for a client with pernicious anemia. Which prescription by the primary health care provider (PHCP) should the nurse anticipate? 1.Iron 2.Folic acid 3.Vitamin B6 4.Vitamin B12

Vitamin B12 Rationale:Pernicious anemia is caused by a deficiency of vitamin B12. Treatment consists of administration of high doses of oral vitamin B12. Monthly injections of vitamin B12 can also be administered but are less comfortable when compared to oral administration. Thiamine is most often prescribed for the client with alcoholism, folic acid is prescribed for folic acid deficiency, and vitamin B6 is ordered when there is pyridoxine deficiency.

The nurse should anticipate that the primary health care provider (PHCP) will prescribe which treatment for a client with pernicious anemia? 1.Oral iron tablets 2.Blood transfusions 3.Gastric tube feedings 4.Vitamin B12 injections

Vitamin B12 injections Rationale:A lack of the intrinsic factor needed to absorb vitamin B12 occurs in pernicious anemia. Vitamin B12 is needed for the maturation of red blood cells. Iron is used for anemia that results from a lack of iron. Blood transfusions are not needed for pernicious anemia because a lack of red blood cells is not the problem. Gastric tube feedings will not replace vitamin B12. Vitamin B12 needs to be given by injection to ensure absorption.

The nurse is providing dietary teaching for a client with a diagnosis of chronic gastritis. The nurse instructs the client to include which foods rich in vitamin B12 in the diet? Select all that apply. 1.Nuts 2.Corn 3.Liver 4.Apples 5.Lentils 6.Bananas

nuts liver lentils Rationale:Chronic gastritis causes deterioration and atrophy of the lining of the stomach, leading to the loss of function of the parietal cells. The source of intrinsic factor is lost, which results in an inability to absorb vitamin B12, leading to development of pernicious anemia. Clients must increase their intake of vitamin B12 by increasing consumption of foods rich in this vitamin, such as nuts, organ meats, dried beans, citrus fruits, green leafy vegetables, and yeast.

During a routine prenatal visit, a client complains of gums that bleed easily with brushing. The nurse performs an assessment and teaches the client about proper nutrition to minimize this problem. Which client statement indicates an understanding of the proper nutrition to minimize this problem? 1."I will drink 8 oz of water with each meal." 2."I will eat 3 servings of cracked wheat bread each day." 3."I will eat 2 saltine crackers before I get up each morning." 4."I will eat fresh fruits and vegetables for snacks and for dessert each day."

"I will eat fresh fruits and vegetables for snacks and for dessert each day." Rationale:Fresh fruits and vegetables provide vitamins and minerals needed for healthy gums. Drinking water with meals has no direct effect on gums. Cracked wheat bread may abrade the tender gums. Eating saltine crackers can also abrade the tender gums.

The nurse provides discharge instructions to a client who is taking warfarin sodium. Which statement, by the client, reflects the need for further teaching? 1."I will avoid alcohol consumption." 2."I will take my pills every day at the same time." 3."I have already called my family to pick up a MedicAlert bracelet." 4."I will take coated aspirin for my headaches because it will coat my stomach."

"I will take coated aspirin for my headaches because it will coat my stomach." Rationale:Aspirin-containing products need to be avoided when a client is taking this medication. Alcohol consumption should be avoided by a client taking warfarin sodium. Taking the prescribed medication at the same time each day increases client compliance. The MedicAlert bracelet provides health care personnel with emergency information.

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?"

"Would you like for me to check into some other options for you?" 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

The nurse is assessing a dark-skinned client for signs of anemia. The nurse should focus the assessment on which structures? Select all that apply. 1.Lips 2.Tongue 3.Earlobes 4.Conjunctiva 5.Mucous membranes

1.Lips 4.Conjunctiva 5.Mucous membranes Changes in skin color can be difficult to assess in the dark-skinned client. Color changes are most easily seen in areas of the body where the epidermis is thin and in areas where pigmentation is not influenced by exposure to sunlight. The nurse should assess the lips, conjunctiva, and oral mucous membranes for signs of anemia in the dark-skinned client. Signs of anemia are less easily observed in the tongue and earlobes.

The nurse is reviewing the laboratory test results and notes that the prothrombin time (PT) is 7.0 seconds. The nurse understands that this PT value would be noted in which condition? 1.Hepatic disease 2.Cirrhosis of the liver 3.Factor VII deficiency 4.Deep vein thrombosis

Deep vein thrombosis Rationale:The normal PT for an adult ranges from 11 to 12.5 seconds. A decreased PT may be noted in many conditions, including arterial occlusion, deep vein thrombosis, edema, myocardial infarction, peripheral vascular disease, and pulmonary embolism. An increased PT would be noted in the conditions identified in the remaining options

Packed red blood cells have been prescribed for a female client with anemia who has a hemoglobin level of 7.6 g/dL (76 mmol/L) and a hematocrit level of 30% (0.30). The nurse takes the client's temperature before hanging the blood transfu¬sion and records 100.6° F (38.1° C) orally. Which action should the nurse take? 1.Begin the transfusion as prescribed. 2.Administer an antihistamine and begin the transfusion. 3.Administer 2 tablets of acetaminophen and begin the transfusion. 4.Delay hanging the blood and notify the primary health care provider (PHCP).

Delay hanging the blood and notify the primary health care provider (PHCP). Rationale:If the client has a temperature higher than 100° F (37.8° C), the unit of blood should not be hung until the primary PHCP is notified and has the opportunity to give further prescriptions. The PHCP likely will prescribe that the blood be administered regardless of the temperature, or may instruct the nurse to administer prescribed acetaminophen and wait until the temperature has decreased before administration, but the decision is not within the nurse's scope of practice to make. The nurse needs a PHCP's prescription to administer medications to the client

A unit of packed red blood cells has been prescribed for a client with low hemoglobin and hematocrit typing and crossmatching. The nurse receives a telephone call from the blood bank and is informed that the unit of blood is ready for administration. In order of priority, how should the nurse plan the actions to take? Arrange the actions in the order that they should be performed. All options must be used Hang the bag of blood. Obtain the unit of blood from the blood bank. Ensure that an informed consent has been signed. Insert an 18- or 19-gauge intravenous catheter into the client. Verify the primary health care provider's (PHCP's) prescription for the blood transfusion. Ask a licensed nurse to assist in confirming vital signs and blood compatibility and verifying client identity.

The nurse would first verify the PHCP's prescription for the blood transfusion and ensure that the client has been informed about the procedure and has signed an informed consent. Once this has been done, the nurse would ensure that at least an 18- or 19-gauge intravenous needle is inserted into the client. Blood has a thicker and stickier consistency than intravenous solutions, and using an 18- or 19-gauge catheter ensures that the bore of the catheter is large enough to prevent damage to the blood cells. Next, the blood is obtained from the blood bank once the nurse is sure that the client has been informed and has an adequate access for administering the blood. Once the blood has been obtained, 2 registered nurses or 1 registered nurse and 1 licensed practical nurse (depending on agency policy) must together check the label on the blood product against the client's identification number, blood group, and complete name. This minimizes the risk of error in checking information on the blood bag and thereby minimizes the risk of harm or injury to the client. The nurse should measure vital signs and assess lung sounds and then hang the transfusion.

As part of chemotherapy education, the nurse teaches a female client about the risk for bleeding and self-care during the period of greatest bone marrow suppression (the nadir). The nurse understands that further teaching is needed if the client makes which statement? 1."I should avoid blowing my nose." 2."I may need a platelet transfusion if my platelet count is too low." 3."I'm going to take aspirin for my headache as soon as I get home." 4."I will count the number of pads and tampons I use when menstruating."

"I'm going to take aspirin for my headache as soon as I get home." uring the period of greatest bone marrow suppression (the nadir), the platelet count may be low, less than 20,000 cells mm3 (20.0 × 109/L). The correct option describes an incorrect statement by the client. Aspirin and nonsteroidal antiinflammatory drugs and products that contain aspirin should be avoided because of their antiplatelet activity. Options 1, 2, and 4 are correct statements by the client to prevent and monitor bleeding.

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

"My child needs to avoid situations that may lead to an infection." Rationale:The child 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 measures need to be taken to avoid dehydration during these conditions.

The nurse is preparing to perform an assessment on a child 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 child? Select all that apply. 1.Pallor 2.Fever 3.Joint swelling 4.Blurred vision 5.Abdominal pain

1.Pallor 2.Fever 3.Joint swelling 5.Abdominal pain 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.

An adult female client has a hemoglobin level of 10.8 g/dL (108 mmol/L). The nurse interprets that this result is most likely caused by which condition noted in the client's history? 1.Dehydration 2.Heart failure 3.Iron deficiency anemia 4.Chronic obstructive pulmonary disease

3.Iron deficiency anemia The normal hemoglobin level for an adult female client is 12 to 16 g/dL (120 to 160 mmol/L). Iron deficiency anemia can result in lower hemoglobin levels. Dehydration may increase the hemoglobin level by hemoconcentration. Heart failure and chronic obstructive pulmonary disease may increase the hemoglobin level as a result of the body's need for more oxygen-carrying capacity.

The nurse is monitoring the laboratory results of a client receiving an antineoplastic medication by the intravenous route. The nurse plans to initiate bleeding precautions if which laboratory result is noted? 1.A clotting time of 10 minutes 2.An ammonia level of 10 mcg/dL (6 mcmol/L). 3.A platelet count of 50,000 mm3 (50 × 109/L) 4.A white blood cell count of 5000 mm3 (5.0 × 109/L)

A platelet count of 50,000 mm3 (50 × 109/L) Rationale:Bleeding precautions need to be initiated when the platelet count decreases. The normal platelet count is 150,000 to 450,000 mm3 (150 to 400 × 109/L). When the platelet count decreases, the client is at risk for bleeding. The normal white blood cell count is 5000 to 10,000 mm3 (5.0 to 10.0 × 109/L). When the white blood cell count drops, neutropenic precautions need to be implemented. The normal clotting time is 8 to 15 minutes. The normal ammonia value is 10 to 80 mcg/dL (6 to 47 mcmol/L).

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

Dietary intake of iron 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

One unit of packed red blood cells has been prescribed for a client with severe anemia. The client has received multiple transfusions in the past, and it is documented that the client has experienced urticaria-type reactions from the transfusions. The nurse anticipates that which medication will be prescribed before administration of the red blood cells to prevent this type of reaction? 1.Ibuprofen 2.Acetaminophen 3.Diphenhydramine 4.Acetylsalicylic acid

Diphenhydramine Rationale:An urticaria-type reaction is characterized by a rash accompanied by pruritus. This type of transfusion reaction is prevented by pretreating the client with an antihistamine such as diphenhydramine. The remaining medications would not prevent an urticaria-type reaction. Acetaminophen may be prescribed before the administration to assist in preventing an elevated temperature.

The nurse is reviewing the laboratory test results for a client who takes 325 mg of acetylsalicylic acid, or aspirin, daily and has been having frequent nosebleed episodes. What blood level should the nurse review? 1.Hemoglobin (Hgb) 2.Prothrombin time (PT) 3.Red blood cell (RBC) level 4.Partial thromboplastin time (PTT)

Prothrombin time (PT) Rationale:PT is used to evaluate the adequacy of the extrinsic system and common pathway in the clotting mechanism. When clotting factors exist in deficient quantities, the PT is prolonged. Many diseases and medications such as salicylates are associated with decreased PTs. PT is also used to monitor the adequacy of warfarin therapy. The Hgb level is related to oxygen and carbon dioxide transport. Hgb concentration serves as the oxygen-carrying capacity of the blood and also acts as an important acid-base buffer system. The RBC level is helpful in identifying the cause of anemia and the presence of other diseases. The PTT is used to evaluate the intrinsic system and the common pathway of clot formation and is most commonly used to monitor heparin therapy.

The community health nurse has instructed a group of parents of preschoolers about home safety measures for children. Which statement by 1 of the parents should the nurse identify as something that requires the need for reinforcement of the instructions? 1.Refers to medication as "candy for when you are sick" 2.Says he or she will store medications in child-proof containers 3.Keeps the poison control center telephone number readily available 4.States the intention to label all toxic substances and place them in a locked area

Refers to medication as "candy for when you are sick" Rationale:Medicine should not be referred to as candy. Home safety measures are simple but important. Medications should be stored in child-proof containers. The number of tablets in a container should be limited. The poison control center telephone number should be visible near all telephones. Toxic substances should be labeled with poison stickers and placed in a locked area out of reach of children

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."

1."I may continue to use an electric shaver." 2."I will not blow my nose if I get a 3."I should use an enema instead of laxatives for constipation." he 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 monitors the client for which condition as a complication of polycythemia vera? 1.Thrombosis 2.Hypotension 3.Cardiomyopathy 4.Pulmonary edema

1.Thrombosis Rationale:Polycythemia vera is a disorder of the bone marrow. It results in excessive production of white blood cells, red blood cells, and platelets. Clients with polycythemia vera are also more likely to form blood clots that can cause thrombi, strokes, myocardial infarctions, and abnormal bleeding. Clients with polycythemia vera are hypertensive; therefore, hypotension is incorrect. Cardiomyopathy and pulmonary edema are not concerns with this disorder.

Which interventions are the most appropriate for a client who is experiencing thrombocytopenia? Select all that apply. 1.Use a straight-edge razor for shaving. 2.Obtain a rectal temperature every 8 hours. 3. Check secretions for frank or occult blood. 4.Give vitamin K by the intramuscular route. 5.Encourage fluid intake to avoid constipation. 6.Provide oral sponges or a soft toothbrush for oral care.

3. Check secretions for frank or occult blood. 5.Encourage fluid intake to avoid constipation. 6.Provide oral sponges or a soft toothbrush for oral care. HomeHelpCalculator Study Mode Question 15 of 47 ID: 2096 | Adult Health_Oncology Questions_final.htm #2576 PreviousGoNext StopBookmark Rationale Strategy Reference Labs Submit Which interventions are the most appropriate for a client who is experiencing thrombocytopenia? Select all that apply. Rationale:Thrombocytopenia is a condition in which the platelets fall below the number needed for normal coagulation. When a client has thrombocytopenia, the risk of bleeding is greatly increased. To monitor for bleeding, the nurse should check all secretions for frank or occult blood. Valsalva maneuvers (as in straining to have a stool, vomiting, or sneezing) could cause intracerebral bleeding when the platelet count is low. To avoid constipation, the nurse would encourage the client to take more fluids and increase his or her dietary fiber. The nurse should encourage the client to use a soft toothbrush or oral sponges to decrease irritation to the mouth and bleeding from the gums. An electric razor is recommended for shaving during times when the client is thrombocytopenic. The nurse should not take rectal temperatures or use any rectal suppositories because of the risk for injury to the rectal membranes with resultant bleeding. Medications should not be given subcutaneously or intramuscularly because use of these routes carries a risk for hemorrhage into the tissues.

A client's laboratory test results reveal an increased transferrin level and a decreased iron-binding capacity. The nurse interprets that these laboratory results are compatible with anemia because of which problem? 1.Infection 2.Malnutrition 3.Iron deficiency 4.Sickle cell disease

3.Iron deficiency Rationale:Iron deficiency anemia usually is characterized by decreased iron-binding capacity and increased transferrin saturation. Infection is not associated with these laboratory values. Malnutrition can cause reductions in both iron-binding capacity and transferrin saturation. Sickle cell anemia is diagnosed by determining that the client has hemoglobin S.

The registered nurse is precepting a new nurse who is caring for a client with pernicious anemia as a result of a gastrectomy. Which statement made by the new nurse indicates understanding of this diagnosis? 1."It's due to insufficient production of vitamin B12 in the colon." 2."Increased production of intrinsic factor in the stomach leads to this type of anemia." 3."Overproduction of vitamin B12 in the large intestine can result in pernicious anemia." 4."Decreased production of intrinsic factor by the stomach affects absorption of vitamin B12 in the small intestine."

4."Decreased production of intrinsic factor by the stomach affects absorption of vitamin B12 in the small intestine." Rationale:Intrinsic factor is produced in the stomach but is used to aid in the absorption of vitamin B12 in the small intestine. This vitamin is not produced or absorbed in the large intestine.

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.

4.Decreased production of erythropoietin is causing anemia. 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 is reviewing the 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 agent

1.Transfusions 2.Splenectomy 4.Corticosteroid medication 5.Immunosuppressive agent 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, immunosuppressive medications. Radiation therapy is not used to treat this disorder.

Laboratory studies are performed for a client suspected to have iron deficiency anemia. The nurse reviews the laboratory results, knowing that which result indicates this type of anemia? 1.Elevated hemoglobin level 2.Decreased reticulocyte count 3.Elevated red blood cell count 4.Red blood cells that are microcytic and hypochromic

4.Red blood cells that are microcytic and hypochromic Rationale:In iron deficiency anemia, iron stores are depleted, resulting in a decreased supply of iron for the manufacture of hemoglobin in red blood cells. The results of a complete blood cell count in clients with iron deficiency anemia show decreased hemoglobin levels and microcytic and hypochromic red blood cells. The red blood cell count is decreased. The reticulocyte count is usually normal or slightly elevated.

A home care nurse is visiting a client with a diagnosis of pernicious anemia that developed as a result of gastric surgery. The nurse instructs the client that in this disorder, because the stomach lining produces a decreased amount of a substance known as the intrinsic factor, the client will need which medication? 1.An antacid .An antibiotic 3.Vitamin B6 injections 4.Vitamin B12 injections

4.Vitamin B12 injections Rationale:A lack of the intrinsic factor needed to absorb vitamin B12 is a feature of pernicious anemia. Vitamin B12 is needed for the maturation of red blood cells. Vitamin B6 is not specifically lacking in pernicious anemia and can be taken orally. An antibiotic and antacids may be prescribed for certain types of gastric ulcers

A client is at risk for developing disseminated intravascular coagulopathy (DIC). The nurse determines that which fibrinogen level is normal? 1.170 mg/dL (1.7 g/L) 2.400 mg/dL (4.0 g/L) 3.480 mg/dL (4.8 g/L) 4.500 mg/dL (5.0 g/L

400 mg/dL (4.0 g/L) (Normal fibrinogen is 2.0-4.0) Rationale:The normal fibrinogen level is 200 to 400 mg/dL (2 to 4 g/L). With DIC, the fibrinogen level drops because fibrinogen is used up in the clotting process. The correct option is the only one that identifies a normal level.

A client in the postpartum care unit who is recovering from disseminated intravascular coagulopathy is to be discharged on low dosages of an anticoagulant medication. In developing home care instructions for this client, the nurse should include which priority safety instruction regarding this medication? 1.Avoid brushing the teeth. 2.Avoid taking acetylsalicylic acid (aspirin). 3.Avoid walking long distances and climbing stairs. 4.Avoid all activities because bruising injuries can occur.

Avoid taking acetylsalicylic acid (aspirin). Rationale:Aspirin can interact with the anticoagulant medication to increase clotting time beyond therapeutic ranges. Avoiding aspirin is a priority. The client does not need to avoid brushing the teeth; however, the client should be instructed to use a soft toothbrush. Walking and climbing stairs are acceptable activities. Not all activities need to be avoided.

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)

Disseminated intravascular coagulopathy (DIC) HomeHelpCalculator Study Mode Question 11 of 16 ID: 1492 | Adult Health_Hematological Questions_final.htm #1712 PreviousGoNext StopBookmark Rationale Strategy Reference Labs Submit 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? 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 primary 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.

The nurse is caring for a client in the early stages of disseminated intravascular coagulation (DIC). At this stage, what medication would the nurse expect to be prescribed? 1.Heparin 2.Platelets 3.Antibiotic 4.Clotting factors

Heparin Rationale:During the early phase of DIC, anticoagulants (especially heparin) are given to limit clotting and prevent the rapid consumption of circulating clotting factors and platelets. Antibiotics are given when sepsis is suspected in an attempt to prevent DIC from occurring

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.

Sit the client down, ask the client to lean forward slightly, and apply pressure to the nose for 5 to 10 minutes. 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.