131 Practice Questions NCLEX blood disorders
The client is being admitted with folic acid deficiency anemia. Which would be most appropriate referral? 1. Alcoholics Anonymous. 2. Leukemia Society of America. 3. A hematologist. 4. A social worker
1. Alcoholics Anonymous
The paraplegic client is being admitted to a medical unit from home with a stage IV pressure ulcer over the right ischium. which assessment tool should be completed on admission to the hospital. 1. Complete the Braden scale. 2. Monitor the client on a Glasgow Coma Scale. 3. Assess for babinski sign. 4. Initiate a Brudzinski flow sheet.
1. Complete the Braden scale.
The nurse caring for clients in a long term care facility. Which is a modifiable risk factor for the development of pressure ulcers? 1. Constant perineal moisture. 2. Ability of the clients to reposition themselves. 3. Decreased elasticity of the skin. 4. impaired cardiovascular perfusion of the periphery.
1. Constant perineal moisture.
The nurse is admitting a person who has had a sudden loss of eyesight. On assessing this client, the nurse finds that the client is disoriented. The nurse will most suspect which of the following about the disorientation? 1. Disorientation is a normal reaction to sudden blindness. 2. Compensatory behavior to eyesight loss includes disorientation. 3. Client will compensate for the eyesight loss within 48 hours. 4. Disorientation is a symptom of the cause of sudden eyesight loss.
1. Disorientation is a normal reaction to sudden blindness.
The nurse is developing a plan of care for a client diagnosed with left-sided paralysis secondary to a right-sided cerebrovascular accident (stroke). Which should be included in the interventions? 1. Use a pillow to keep the heels off the bed when supine. 2. Order a low air-loss therapy bed immediately. 3. Prepare to insert nasogastric feeding tube. 4. Order an occupational therapy consult for strength training.
1. Use a pillow to keep the heels off the bed when supine.
The nurse is admitting a 24 year old African American female client with a diagnosis of rule-out anemia. The client has a history of gastric bypass surgery for obesity four years ago. Current assessment findings include height: 5'5", weight 75kg, P 110, R 27, and BP 104/66, Pale mucous membranes and dyspnea on exertion. Which type of anemia would the nurse suspect the client has developed? 1. Vitamin B12 deficiency 2. Folic Acid deficiency 3. Iron deficiency 4. Sickle Cell anemia
1. Vitamin B12 deficiency
When gathering data to assist with assessments of clients, you will find which of the following clients most at risk for sensory overload? [Hint] 1. a client in pain 2. a homebound client 3. a client on bed rest 4. a client in isolation
1. a client in pain
A client, who lives alone in the country, was admitted to the hospital two days ago. The client begins to show signs of confusion and disorientation. You would most suspect which of the following problems as most contributing to the confusion and disorientation? 1. changes in quantity and quality of sensory stimuli 2. changes in the amount or type of medication 3. excessive worry about a variety of things 4. a mental condition that has previously gone undetected
1. changes in quantity and quality of sensory stimuli
A 70-kg woman with 50% TBSA burn arrived at 11am & was burned at 9am, according to her family. Q.How much fluid is required for the 24 hours
14,000mL
The nurse is caring for a client who has developed a stage IV pressure ulcer on the left trochanter and coccyx. Which collaborative problem has the highest priority? 1. Impaired cognition 2. Altered nutrition 3. Self-care deficit 4. Altered Coping
2. Altered nutrition
The client who is debilitated and has developed multiple pressure ulcers complains to the nurse during a dressing change that he is "tired of it all". Which is the nurses best therapeutic response? 1. These wounds can heal if we get enough protein in you. 2. Are you tired of the treatments and needing to be cared for? 3. why would you say that? we are doing our best. 4. Have you made out an advance directive to let the HCP know your wishes?
2. Are you tired of the treatments and needing to be cared for?
The nurse writes the problem " impaired skin integrity" for a client with a stage IV pressure ulcer. Which interventions should be included in the plan of care? select all that apply. 1. Turn the client every three to four hours 2. Ask the dietitian to consult. 3. Have the client sign a consent for pictures of the wounds. 4. Obtain an order for a low air-loss bed. 5. Elevate the head of the bed at all times.
2. Ask the dietitian to consult. 4. Obtain an order for a low air-loss bed.
The client has some equipment that is noisy, and the roommate also has equipment that makes noise, and the room is close to a noisy nursing station, where they can be watched a little closer. Which of the following interventions by the nurse would be best for the client as well as reduce the risk of sensory overload? 1. Move the client away from the nurses' station area. 2. Explain the sounds in the environment. 3. Tell the client to ignore the sounds. 4. Play the client's favorite music louder than the sounds.
2. Explain the sounds in the environment.
The culturally sensitive nurse will realize which of the following about a client from a large active Latino family who is put into isolation for a communicable disease? 1.The number of visitors greatly needs to be restricted. 2. may be accustomed to, and need, high stimulation level 3. is a likely candidate for sensory overload 4. will need more personal space than other clients
2. may be accustomed to, and need, high stimulation level
The nurse and the LNA on a medical floor are caring for clients whoa re elderly and immobile. Which action by the LNA warrants immediate intervention by the nurse? 1. The LNA elevates the head of the bed of a client who can feed himself with minimal assistance. 2. the LNA asked to take a meal break before turning the clients at the 2 hour time limit. 3. the LNA restocks the rooms that need unsterile gloves before clocking out for the shift. 4. The LNA mixes the Thick-it into the glass of water for a client who has difficulty swallowing.
2. the LNA asked to take a meal break before turning the clients at the 2 hour time limit.
Your assigned first day post-operative client, who has a new colostomy, seems to worry a lot and has symptoms of sensory overload. Which of the following client goals, if met, would most contribute to reducing sensory overload for this client? 1.Will not sleep or nap during the day. 2.Will report pain at 4 or less on a 10-point scale. 3. Will attend classes on colostomy care. 4. Will look at colostomy during colostomy care.
2.Will report pain at 4 or less on a 10-point scale.
The charge nurse is making assignments on a medical floor. Which client should be assigned to the most experienced nurse? 1. Client diagnosed with iron-deficiency anemia who is prescribed iron supplements. 2. Client diagnosed with pernicious anemia who is receiving vitamin B12 intramuscularly. 3. Client diagnosed with aplastic anemia who has developed pancytopenia. 4. The client diagnosed with renal disease wo has a deficiency of erythropoietin.
3. Client diagnosed with aplastic anemia who has developed pancytopenia.
You are about to bathe an unconscious client. Which of the following interventions are most important on your part? 1. Vary the schedule of bathing and care from day to day. 2. Tune the radio to client's favorite music during bath time. 3. Explain procedures to client, and talk as if client can hear. 4. Speak louder to the client than to other clients.
3. Explain procedures to client, and talk as if client can hear.
The nurse is caring for clients on a medical unit. After the shift report, which client should be assessed first? 1. the 34-year old client who is quadriplegic and cannot move his arms. 2. the elderly client diagnosed with a CVA who is weak on the right side. 3. The 78 year old client with pressure ulcers who has a temperature of 102.3 4. The young adult who is unhappy with the care that was provided last shift.
3. The 78 year old client with pressure ulcers who has a temperature of 102.3
The client diagnosed with a iron-deficiency anemia is prescribed ferrous gluconate orally. Which should the nurse teach the client? 1. Take Imodium, an antidiarrheal, OTC for diarrhea. 2. Limit exercise for several weeks until a tolerance is achieved 3. The stools may be very dark, and this can mask blood. 4. Eat only red meats and organ meats for protein.
3. The stools may be very dark, and this can mask blood.
The nurse in a long term care facility is teaching a group of new unlicensed assistive personnel. Which information regarding skin care should the nurse emphasize? 1. Keep the skin moist by leaving the skin damp after the bath. 2. Do not rub any lotion into the skin. 3. Turn the clients who are immobile at least every two hours. 4. Only the licensed nursing staff may care for the clients skin.
3. Turn the clients who are immobile at least every two hours.
the nurse advises a woman considering pregnancy of the importance of being tested for syphilis and rubella. What is most likely the reason the nurse is offering this advice? 1. suspicion that a client has high risk of sexual and drug behaviors 2. assess factors that mainly cause visual impairments in baby 3. assess factors that mainly cause hearing impairments in baby 4. the health history assessment findings
3. assess factors that mainly cause hearing impairments in baby
The client diagnosed with menorrhagia complains to the nurse of feeling listless and tired all the time. Which scientific rationale would explain why these symptoms occur? 1. The pain is associated with the menorrhagia does not allow the client to rest. 2. The client's symptoms are unrelated to the diagnosis of menorrhagia. 3. The client probably has been exposed to a virus that causes chronic fatigue. 4. Menorrhagia has caused the client to have decrease levels of hemoglobin.
4. Menorrhagia has caused the client to have decreased levels of hemoglobin.
The client diagnosed with stage IV infected pressure ulcer on the coccyx is scheduled for a fecal diversion operation. The nurse knows that client teaching has been effective when the client makes which statement? 1. This surgery will create a skin flap to cover my wounds. 2. This surgery will get all the old black tissue out of the wound so it can heal. 3. the surgery is important to allow oxygen to get the tissue healing to occur. 4. Stool will come out an opening in my abdomen so it won't get in the sore.
4. Stool will come out an opening in my abdomen so it won't get in the sore.
What is the scientific rationale for placing lift pads under an immobile client? 1. The pads will absorb any urinary incontinence and contain stool. 2. The pads will prevent the client from being diaphoretic. 3. The pads will keep the staff from workplace injuries such as a pulled muscle. 4. The pads will help prevent friction shearing when repositioning the client.
4. The pads will help prevent friction shearing when repositioning the client.
Using Parkland (4mL/kg),what vol of fluid should be admin in 1st 8hr to an 80kg client w/30% total body surface burn?
4800 mL
The client is in the acute phase of burn injury. In which situation does the nurse decide to coordinate with the nutritionist? A) To discourage having food brought in from the client's favorite restaurant B) To provide more palatable choices for the client C) To help the client lose weight D) To plan additions to the standard nutritional pattern
???
15. On admission to the emergency department the burned client's blood pressure is 90/60, with an apical pulse rate of 122. These findings are an expected result of what thermal injury-related response? A. Fluid shift B. Intense pain C. Hemorrhage D. Carbon monoxide poisoning
A
17. Which clinical manifestation indicates that the burned client is moving into the fluid remobilization phase of recovery? A. Increased urine output, decreased urine specific gravity B. Increased peripheral edema, decreased blood pressure C. Decreased peripheral pulses, slow capillary refill D. Decreased serum sodium level, increased hematocrit
A
A patient with partial-thickness wounds of the face and chest caused by a campfire is admitted to the burn unit. All of these actions have been prescribed by the physician. Which one should the nurse accomplish first? A) Give oxygen per non-rebreather mask at 100% FiO2. B) Infuse lactated Ringer's solution at 150 mL/hr. C) Give morphine sulfate 4 to 10 mg IV for pain control. D) Insert a 14-Fr retention catheter.
A
On admission to the emergency department the burned client's blood pressure is 90/60, with an apical pulse rate of 122. These findings are an expected result of what thermal injury-related response? A. Fluid shift B. Intense pain C. Hemorrhage D. Carbon monoxide poisoning
A
The client is in the emergent phase of burn injury. Which route does the nurse use to administer pain medication to the client? A) Intramuscular B) Intravenous C) Sublingual D) Topical
A
Which clinical manifestation is indicative of wound healing for the client in the acute phase of burn injury? A) Pale, boggy, dry, or crusted granulation tissue B) Increasing wound drainage C) Scar tissue formation D) Sloughing of grafts
A
Which intervention is most important for the nurse to use to prevent infection by cross-contamination in the client who has open burn wounds? A. Handwashing on entering the client's room B. Encouraging the client to cough and deep breathe C. Administering the prescribed tetanus toxoid vaccine D. Changing gloves between cleansing different burn areas
A
Which intervention is most important to use to prevent infection by autocontamination in the burned client during the acute phase of recovery? A. Changing gloves between wound care on different parts of the client's body. B. Avoiding sharing equipment such as blood pressure cuffs between clients. C. Using the closed method of burn wound management. D. Using proper and consistent handwashing.
A
Which newly admitted patient should the nurse assign as a roommate for a patient who has aplastic anemia? a. A patient with severe heart failure b. A patient who has viral pneumonia c. A patient who has right leg cellulitis d. A patient with multiple abdominal drains
A
Whichmanifestation in cient w/suspected inhalation burn would require immediate intervention by RN? A.Audible wheezing B.Blistering in area of burn C.^ respiratory rate D.Thick, tan-colored sputum
A
Which menu choice indicates that the patient understands the nurse's teaching about best dietary choices for iron-deficiency anemia? a. Omelet and whole wheat toast b. Cantaloupe and cottage cheese c. Strawberry and banana fruit plate d. Cornmeal muffin and orange juice
A Eggs and whole grain breads are high in iron. The other choices are appropriate for other nutritional deficiencies, but are not the best choice for a patient with iron-deficiency anemia.
The nurse is teaching the client with polycythemia vera about prevention of complications of the disease. Which of the following statements by the client indicates a need for further teaching? a. "I will drink 500mL of fluid or less each day." b. "I will wear support hose when I am up." c. "I will use an electric razor for shaving." d. "I will eat foods low in iron.
A The client with polycythemia vera is at risk for thrombus formation. Hydrating the client with at least 3L of fluid per day is important in preventing clot formation, so the statement to drink less than 500mL is incorrect. Answers B, C, and D are incorrect because they all contribute to the prevention of complications. Support hose promotes venous return, the electric razor prevents bleeding due to injury, and a diet low in iron is essential to preventing further red cell formation.
1. The nurse is caring for a client with an electrical burn. Which structures have the greatest risk for soft tissue injury? A. Fat, tendons, and bones B. Skin and hair C. Nerves, muscle, and blood vessels D. Skin, fat, and muscle
A Fat, tendon, and bone have the most resistance. The higher the resistance, the greater the heat generated by the current, thereby increasing the risk for soft tissue injury.
Which clinical manifestation indicates that the burned client is moving into the fluid remobilization phase of recovery? A. Increased urine output, decreased urine specific gravity B. Increased peripheral edema, decreased blood pressure C. Decreased peripheral pulses, slow capillary refill D. Decreased serum sodium level, increased hematocrit
A fluid mobilization improves renal blood flow and icnreases diuresis
After the nurse has finished teaching a patient about taking oral ferrous sulfate, which patient statement indicates that additional instruction is needed? a. "I will call the doctor if my stools start to turn black." b. "I will take a stool softener if I feel constipated occasionally." c. "I should take the iron with orange juice about an hour before eating."
A it is normal for the stools to appear black when a pt is taking iron
32. Which statements by the mother of a toddler would lead the nurse to suspect that the child has iron-deficiency anemia? Select all that apply. "He drinks over 3 cups of milk per day." "I can't keep enough apple juice in the house; he must drink over 10 ounces per day." "He refuses to eat more than 2 different kinds of vegetables." "He doesn't like meat, but he will eat small amounts of it." "He sleeps 12 hours every night and take a 2-hour nap."
A and B Toddlers should have between 2 and 3 cups of milk per day and 8 ounces of juice per day. If they have more than that, then they are probably not eating enough other foods, including iron-rich foods that have the needed nutrients.
A client was admitted with iron deficiency anemia and blood-streaked emesis. Which question is most appropriate for the nurse to ask in determining the extent of the client's activity intolerance? A. "What activities were you able to do 6 months ago compared with the present?" B. "How long have you had this problem?" C. "Have you been able to keep up with all your usual activities?" D. "Are you more tired now than you used to be?"
A. It is difficult to determine activity intolerance without objectively comparing activities from one time frame to another. Because iron deficiency anemia can occur gradually and individual endurance varies, the nurse can best assess the client's activity tolerance by asking the client to compare activities 6 months ago and at the present. Asking a clie
The newly admitted client has deep partial-thickness burns. The nurse expects to see which clinical manifestations? A) Painful red and white blisters B) Painless, brownish-yellow eschar C) Painful reddened blisters D) Painless black skin with eschar
A: there wouldn't be any eschar becuae he is newly admitted. Eschar forms after a few days
The primary purpose of the Schilling test is to measure the client's ability to: Store vitamin B12 Digest vitamin B12 Absorb vitamin B12 Produce vitamin B12
Absorb vitamin b12 Pernicious anemia is caused by the body's inability to absorb vitamin B12. This results in a lack of intrinsic factor in the gastric juices. Schilling's test helps diagnose pernicious anemia by determining the client's ability to absorb vitamin B12.
11. Which type of fluid should the nurse expect to prepare and administer as fluid resuscitation during the emergent phase of burn recovery? A. Colloids B. Crystalloids C. Fresh-frozen plasma D. Packed red blood cells
B
12. The client with a dressing covering the neck is experiencing some respiratory difficulty. What is the nurse's best first action? A. Administer oxygen. B. Loosen the dressing. C. Notify the emergency team. D. Document the observation as the only action.
B
13. The client who experienced an inhalation injury 6 hours ago has been wheezing. When the client is assessed, wheezes are no longer heard. What is the nurse's best action? A. Raise the head of the bed. B. Notify the emergency team. C. Loosen the dressings on the chest. D. Document the findings as the only action
B
14. Ten hours after the client with 50% burns is admitted, her blood glucose level is 90 mg/dL. What is the nurse's best action? A. Notify the emergency team. B. Document the finding as the only action. C. Ask the client if anyone in her family has diabetes mellitus. D. Slow the intravenous infusion of dextrose 5% in Ringer's lactate.
B
16. Twelve hours after the client was initially burned, bowel sounds are absent in all four abdominal quadrants. What is the nurse's best action? A. Reposition the client onto the right side. B. Document the finding as the only action. C. Notify the emergency team. D. Increase the IV flow rate.
B
2. The newly admitted client has a large burned area on the right arm. The burned area appears red, has blisters, and is very painful. How should this injury be categorized? A. Superficial B. Partial-thickness superficial C. Partial-thickness deep D. Full thickness
B
The client has experienced an electrical injury, with the entrance site on the left hand and the exit site on the left foot. What are the priority assessment data to obtain from this client on admission? A. Airway patency B. Heart rate and rhythm C. Orientation to time, place, and person D. Current range of motion in all extremities
B
The client who experienced an inhalation injury 6 hours ago has been wheezing. When the client is assessed, wheezes are no longer heard. What is the nurse's best action? A. Raise the head of the bed. B. Notify the emergency team. C. Loosen the dressings on the chest. D. Document the findings as the only action.
B
The newly admitted client has a large burned area on the right arm. The burned area appears red, has blisters, and is very painful. How should this injury be categorized? A. Superficial B. Partial-thickness superficial C. Partial-thickness deep D. Full thickness
B
Twelve hours after the client was initially burned, bowel sounds are absent in all four abdominal quadrants. What is the nurse's best action? A. Reposition the client onto the right side. B. Document the finding as the only action. C. Notify the emergency team. D. Increase the IV flow rate.
B
What is the priority nursing diagnosis for a client in the rehabilitative phase of recovery from a burn injury? A. Acute Pain B. Impaired Adjustment C. Deficient Diversional Activity D. Imbalanced Nutrition: Less than Body Requirements
B
What statement by the client indicates the need for further discussion regarding the outcome of skin grafting (allografting) procedures? A. "For the first few days after surgery, the donor sites will be painful." B. "Because the graft is my own skin, there is no chance it won't 'take'." C. "I will have some scarring in the area when the skin is removed for grafting." D. "Once all grafting is completed, my risk for infection is the same as it was before I was burned."
B
What type of wound is created in the typical donor site? A.Stage 1 B.Partial thicknessC.Full thickness D.Stage 4
B
Which action will be included in the care plan for a hospitalized patient who is neutropenic? a. Avoid any IM or subcutaneous injections. b. Check the oral temperature every 4 hours. c. Omit all fruits or vegetables from the diet. d. Place a "No Visitors" sign on the patient door.
B
Which nursing action should the nurse delegate to nursing assistive personnel (NAP) when administering a transfusion of packed red blood cells (PRBCs) to a patient with blood loss? a. Verify the patient identification (ID) according to hospital policy. b. Obtain the temperature, blood pressure, and pulse before the transfusion. c. Double-check the product numbers on the PRBCs with the patient ID band. d. Monitor the patient for shortness of breath or chest pain during the transfusion
B
he burned client's family ask at what point the client will no longer be at increased risk for infection. What is the nurse's best response? A. "When fluid remobilization has started." B. "When the burn wounds are closed." C. "When IV fluids are discontinued." D. "When body weight is normal."
B
A patient who is receiving methotrexate develops a megaloblastic anemia. The nurse will anticipate teaching the patient about increasing oral intake of a. iron. b. folic acid. c. cobalamin (vitamin B12). d. ascorbic acid (vitamin C)
B methotrexate use can lead to folic acid deficiency
A patient who has been receiving a heparin infusion and warfarin (Coumadin) for a deep vein thrombosis (DVT) is diagnosed with heparin-induced thrombocytopenia (HIT). Which action will the nurse include in the plan of care? a. Use low-molecular-weight heparin (LMWH) only. b. Flush all intermittent IV lines using normal saline. c. Administer the warfarin (Coumadin) at the scheduled time. d. Teach the patient about the purpose of platelet transfusions.
B All heparin is discontinued when the HIT is diagnosed. The patient should be instructed to never receive heparin or LMWH. Warfarin is usually not given until the platelet count has returned to 150,000/μl. The platelet count does not drop low enough in HIT for a platelet transfusion, and platelet transfusions increase the risk for thrombosis.
All of the following laboratory test results on a burned client's blood are present during the emergent phase. Which result should the nurse report to the physician immediately? A. Serum sodium elevated to 131 mmol/L (mEq/L) B. Serum potassium 7.5 mmol/L (mEq/L) C. Arterial pH is 7.32 D. Hematocrit is 52%
B All these findings are abnormal; however, only the serum potassium level is changed to the degree that serious, life-threatening responses could result. With such a rapid rise in the potassium level, the client is at high risk for experiencing severe cardiac dysrhythmias and death
25. Which of the following diagnostic findings are most likely for a client with aplastic anemia? A. Decreased production of T-helper cells B. Decreased levels of white blood cells, red blood cells, and platelets C. Increased levels of WBCs, RBCs, and platelets D. Reed-Sternberg cells and lymph node enlargement
B In aplastic anemia, the most likely diagnostic findings are decreased levels of all the cellular elements of the blood (pancytopenia). T-helper cell production doesn't decrease in aplastic anemia. Reed-Sternberg cells and lymph node enlargement occur with Hodgkin's disease.
33. Which of the following foods would the nurse encourage the mother to offer to her child with iron deficiency anemia? A. Rice cereal, whole milk, and yellow vegetables B. Potato, peas, and chicken C. Macaroni, cheese, and ham D. Pudding, green vegetables, and rice
B Potato, peas, chicken, green vegetables, and rice cereal contain significant amounts of iron and therefore would be recommended. Milk and yellow vegetables are not good iron sources. Rice by itself also is not a good source of iron.
A patient who has a history of a transfusion-related acute lung injury (TRALI) is to receive a transfusion of packed red blood cells (PRBCs). Which action will the nurse take to decrease the risk for TRALI for this patient? a. Infuse the PRBCs slowly over 4 hours. b. Transfuse only leukocyte-reduced PRBCs. c. Administer the scheduled oral diuretic before the transfusion. d. Give the PRN dose of antihistamine before starting the transfusion
B TRALI is caused by a reaction between the donor and the patient leukocytes that causes pulmonary inflammation and capillary leaking. The other actions may help prevent respiratory problems caused by circulatory overload or by allergic reactions, but they will not prevent TRALI
The nurse is conducting a physical assessment on a client with anemia. Which of the following clinical manifestations would be most indicative of the anemia? a. BP 146/88 b. Respirations 28 shallow c. Weight gain of 10 pounds in 6 months d. Pink complexion
B When there are fewer red blood cells, there is less hemoglobin and less oxygen. Therefore, the client is often short of breath, as indicated in answer B. The client with anemia is often pale in color, has weight loss, and may be hypotensive
. Which type of fluid should the nurse expect to prepare and administer as fluid resuscitation during the emergent phase of burn recovery? A. Colloids B. Crystalloids C. Fresh-frozen plasma D. Packed red blood cells
B examples are NS and LR
During the admission assessment of a patient with hemolytic anemia, the nurse notes jaundice of the sclerae. The nurse will plan to check the laboratory results for a. the Schilling test. b. the bilirubin level. c. the stool occult blood test. d. the gastric analysis testing
B jaundice is caused by the elevation of bilirubin level associated with RBC hemolysis
The client with a dressing covering the neck is experiencing some respiratory difficulty. What is the nurse's best first action? A. Administer oxygen. B. Loosen the dressing. C. Notify the emergency team. D. Document the observation as the only action.
B the first action is to loosen the dressing and then reassess the RR
A patient is admitted to the hospital with idiopathic aplastic anemia. Which of these collaborative problems will the nurse include when developing the care plan? a. Potential complication: seizures b. Potential complication: infection c. Potential complication: neurogenic shock d. Potential complication: pulmonary edema
B the pt is at risk for infection and bleeding from aplastic anemia
Ten hours after the client with 50% burns is admitted, her blood glucose level is 90 mg/dL. What is the nurse's best action? A. Notify the emergency team. B. Document the finding as the only action. C. Ask the client if anyone in her family has diabetes mellitus. D. Slow the intravenous infusion of dextrose 5% in Ringer's lactate.
B Neural and hormonal compensation to the stress of the burn injury in the emergent phase increases liver glucose production and release. An acute rise in the blood glucose level is an expected client response and is helpful in the generation of energy needed for the increased metabolism that accompanies this trauma.
The nurse on a burn unit has just received change-of-shift report about these patients. Which patient should be assessed first? A) A 20-year-old patient admitted a week ago with deep partial-thickness burns over 35% of the body who is complaining of pain at a level 7 (0-to-10 scale) B) A 26-year-old firefighter with smoke inhalation and facial burns who has just arrived on the unit and whispers "I can't catch my breath!" C) A 50-year-old electrician who suffered external burn injuries a month ago and is requesting that you call the doctor immediately about discharge plans D) A 60-year-old patient admitted yesterday with partial- and full-thickness burns over 40% of the body who is receiving IV fluids at 250 mL/hr
B Smoke inhalation and facial burns are associated with airway inflamation and obstruction.
31. A mother asks the nurse if her child's iron deficiency anemia is related to the child's frequent infections. The nurse responds based on the understanding of which of the following? A. Little is known about iron-deficiency anemia and its relationship to infection in children. B. Children with iron deficiency anemia are more susceptible to infection than are other children. C. Children with iron-deficiency anemia are less susceptible to infection than are other children. D. Children with iron-deficient anemia are equally as susceptible to infection as are other children.
B. Children with iron-deficiency anemia are more susceptible to infection because of marked decreases in bone marrow functioning with microcytosis.
The nurse devises a teaching plan for the patient with aplastic anemia. Which of the following is the most important concept to teach for health maintenance? A. Eat animal protein and dark leafy vegetables each day B. Avoid exposure to others with acute infection C. Practice yoga and meditation to decrease stress and anxiety D. Get 8 hours of sleep at night and take naps during the day
B. avoid exposure to infection Clients with aplastic anemia are severely immunocompromised and at risk for infection and possible death related to bone marrow suppression and pancytopenia. Strict aseptic technique and reverse isolation are important measures to prevent infection
In acute phase of injury, priority nutritional need is? A.Electrolyte replacement B.Protein intake C.CHO consumption D.Vitamin supplementation
B. protein intake
When a client is diagnosed with aplastic anemia, the nurse monitors for changes in which of the following physiological functions? Bleeding tendencies Intake and output Peripheral sensation Bowel function
Bleeding tendancis Aplastic anemia decreases the bone marrow production of RBCs, WBCs, and platelets. The client is at risk for bruising and bleeding tendencies. A change in the intake and output is important, but assessment for the potential for bleeding takes priority. Change in the peripheral nervous system is a priority problem specific to clients with vitamin B12 deficiency. Change in bowel function is not associated with aplastic anemia.
Age-related changes that affect the hematologic system include: (Select all that apply.) Bone marrow in the long bones decline. The number of stem cells in the marrow increases. Lymphocyte function, especially cellular immunity, decreases. Platelet adhesiveness decreases.
Bone marrow in the long bones decline
3. The burned client newly arrived from an accident scene is prescribed to receive 4 mg of morphine sulfate by IV push. What is the most important reason to administer the opioid analgesic to this client by the intravenous route? A. The medication will be effective more quickly than if given intramuscularly. B. It is less likely to interfere with the client's breathing and oxygenation. C. The danger of an overdose during fluid remobilization is reduced. D. The client delayed gastric emptying
C
5. Which client factors should alert the nurse to potential increased complications with a burn injury? A. The client is a 26-year-old male. B. The client has had a burn injury in the past. C. The burned areas include the hands and perineum. D. The burn took place in an open field and ignited the client's clothing.
C
6. The burned client is ordered to receive intravenous cimetidine, an H2 histamine blocking agent, during the emergent phase. When the client's family asks why this drug is being given, what is the nurse's best response? A. "To increase the urine output and prevent kidney damage." B. "To stimulate intestinal movement and prevent abdominal bloating." C. "To decrease hydrochloric acid production in the stomach and prevent ulcers." D. "To inhibit loss of fluid from the circulatory system and prevent hypovolemic shock."
C
7. At what point after a burn injury should the nurse be most alert for the complication of hypokalemia? A. Immediately following the injury B. During the fluid shift C. During fluid remobilization D. During the late acute phase
C
8. What clinical manifestation should alert the nurse to possible carbon monoxide poisoning in a client who experienced a burn injury during a house fire? A. Pulse oximetry reading of 80% B. Expiratory stridor and nasal flaring C. Cherry red color to the mucous membranes D. Presence of carbonaceous particles in the sputum
C
9. What clinical manifestation indicates that an escharotomy is needed on a circumferential extremity burn? A. The burn is full thickness rather than partial thickness. B. The client is unable to fully pronate and supinate the extremity. C. Capillary refill is slow in the digits and the distal pulse is absent. D. The client cannot distinguish the sensation of sharp versus dull in the extremity.
C
In reviewing the burned client's laboratory report of white blood cell count with differential, all the following results are listed. Which laboratory finding indicates the possibility of sepsis? A. The total white blood cell count is 9000/mm3. B. The lymphocytes outnumber the basophils. C. The "bands" outnumber the "segs." D. The monocyte count is 1,800/mm3
C
Nurse recognizes which description as MOST appropriate for deep part thick burns? A.Painless,reddened blisters B.Pink blistersw/minimal local edema C.Painful red,white blisters D.painless brownish-yellow eschar
C
The RN is teamed with a nursing assistant to provide care to patients on the burn unit. Which of these tasks can be safely delegated to the nursing assistant? A) Educating a patient in the rehabilitation phase of burn injury about how to apply ointment to partial-thickness burns B) Changing a routine sterile dressing for a patient with a circumferential partial-thickness burn on the chest and back C) Measuring and documenting hourly urine outputs for a catheterized patient who was admitted yesterday with burns over 35% of TBSA D) Assessing the pain level using a 0-to-10 scale for a burn patient who is using a fentanyl (Duramorph) patch for pain control
C
The burned client on admission is drooling and having difficulty swallowing. What is the nurse's best first action? A. Assess level of consciousness and pupillary reactions. B. Ask the client at what time food or liquid was last consumed. C. Auscultate breath sounds over the trachea and mainstem bronchi. D. Measure abdominal girth and auscultate bowel sounds in all four quadrants.
C
The burned client relates the following history of previous health problems. Which one should alert the nurse to the need for alteration of the fluid resuscitation plan? A. Seasonal asthma B. Hepatitis B 10 years ago C. Myocardial infarction 1 year ago D. Kidney stones within the last 6 month
C
The client is being admitted with burn injuries. Which priority does the nurse anticipate within the first 24 hours? A) Body temperature assessment B) Emotional support C) Fluid resuscitation D) Urine output monitoring
C
The nurse administering a blood transfusion suspects a reaction has occurred. Which signs and symptoms would the nurse expect with an allergic reaction to blood? A. Fever and chills B. Hypotension and tachycardia C. Rash and hives D. Decreased urinary output and hypertension
C
What clinical manifestation indicates that an escharotomy is needed on a circumferential extremity burn? A. The burn is full thickness rather than partial thickness. B. The client is unable to fully pronate and supinate the extremity. C. Capillary refill is slow in the digits and the distal pulse is absent. D. The client cannot distinguish the sensation of sharp versus dull in the extremity.
C
What clinical manifestation should alert the nurse to possible carbon monoxide poisoning in a client who experienced a burn injury during a house fire? A. Pulse oximetry reading of 80% B. Expiratory stridor and nasal flaring C. Cherry red color to the mucous membranes D. Presence of carbonaceous particles in the sputum
C
What is the priority nursing diagnosis during the first 24 hours for a client with full-thickness chemical burns on the anterior neck, chest, and all surfaces of the left arm? A. Risk for Ineffective Breathing Pattern B. Decreased Tissue Perfusion C. Risk for Disuse Syndrome D. Disturbed Body Image
C
Which assessment does the nurse prioritize for the client in the acute phase of burn injury? A) Bowel sounds B) Muscle strength C) Signs of infection D) Urine output
C
Which information obtained by assessment ensures that the client's respiratory efforts are currently adequate? A. The client is able to talk. B. The client is alert and oriented. C. The client's oxygen saturation is 97%. D. The client's chest movements are uninhibited
C
The burned client newly arrived from an accident scene is prescribed to receive 4 mg of morphine sulfate by IV push. What is the most important reason to administer the opioid analgesic to this client by the intravenous route? A. The medication will be effective more quickly than if given intramuscularly. B. It is less likely to interfere with the client's breathing and oxygenation. C. The danger of an overdose during fluid remobilization is reduced. D. The client delayed gastric emptying.
C Although providing some pain relief has a high priority, and giving the drug by the IV route instead of IM, SC, or orally does increase the rate of effect, the most important reason is to prevent an overdose from accumulation of drug in the interstitial space during the fluid shift of the emergent phase. When edema is present, cumulative doses are rapidly absorbed when the fluid shift is resolving. This delayed absorption can result in lethal blood levels of analgesics.
The nurse is instructing a client with iron-deficiency anemia. Which of the following meal plans would the nurse expect the client to select? a. Roast beef, gelatin salad, green beans, and peach pie b. Chicken salad sandwich, coleslaw, French fries, ice cream c. Egg salad on wheat bread, carrot sticks, lettuce salad, raisin pie d. Pork chop, creamed potatoes, corn, and coconut cake
C Egg yolks, wheat bread, carrots, raisins, and green, leafy vegetables are all high in iron, which is an important mineral for this client. Roast beef, cabbage, and pork chops are also high in iron, but the side dishes accompanying these choices are not
At what point after a burn injury should the nurse be most alert for the complication of hypokalemia? A. Immediately following the injury B. During the fluid shift C. During fluid remobilization D. During the late acute phase
C Hypokalemia is most likely to occur during the fluid remobilization period as a result of dilution, potassium movement back into the cells, and increased potassium excreted into the urine with the greatly increased urine output.
A patient is hospitalized for treatment of severe hemolytic anemia. An appropriate nursing action for the patient is to a. provide a diet high in vitamin K. b. place the patient on protective isolation. c. alternate periods of rest and activity. d. teach the patient how to avoid injury.
C Nursing care for patients with anemia should alternate periods of rest and activity to encourage activity without causing undue fatigue. There is no indication that the patient has a bleeding disorder, so a high vitamin K diet or teaching about how to avoid injury is not needed. Protective isolation might be used for a patient with aplastic anemia, but it is not indicated for hemolytic anemia.
10. The nurse has just completed the dressing change for a client with burns to the lower legs and ankles. The nurse should place the client's ankles in which position? A. Internal rotation B. Abduction C. Dorsiflexion D. Hyperextension
C Placing the ankles in dorsiflexed position helps prevent contractures
7. During the rehabilitative phase, the client's burns become infected with pseudomonas. The topical dressing most likely to be ordered for the client is: A. Silver sulfadiazine (Silvadene) B. Poviodine (Betadine) C. Mafenide acetate (Sulfamylon) D. Silver nitrate
C Sulfamylon is effective in treating wounds infected with pseudomonas. The client should receive pain medication prior to dressing changes because the medication produces a burning sensation when applied to the wound.
Which client factors should alert the nurse to potential increased complications with a burn injury? A. The client is a 26-year-old male. B. The client has had a burn injury in the past. C. The burned areas include the hands and perineum. D. The burn took place in an open field and ignited the client's clothing.
C burns on perineum increase risk for sepsis
. When planning discharge teaching for the patient who was admitted with a sickle cell crisis, which instruction will the nurse include? a. Limit fluids to 2 to 3 quarts a day. b. Take a daily multivitamin with iron. c. Avoid exposure to crowds as much as possible. d. Drink only one or two caffeinated beverages daily
C exposure to crowds increases pts risk of infection
The burned client is ordered to receive intravenous cimetidine, an H2 histamine blocking agent, during the emergent phase. When the client's family asks why this drug is being given, what is the nurse's best response? A. "To increase the urine output and prevent kidney damage." B. "To stimulate intestinal movement and prevent abdominal bloating." C. "To decrease hydrochloric acid production in the stomach and prevent ulcers." D. "To inhibit loss of fluid from the circulatory system and prevent hypovolemic shock."
C ulcerative gi disease can develop within 24 hours after a severe burn. cimetadine inhibits the production and release of hydrochloric acid
Which of the following foods would the nurse encourage the client in sickle cell crisis to eat? a. Peaches b. Cottage cheese c. Popsicle d. Lima beans
C ydration is important in the client with sickle cell disease to prevent thrombus formation. Popsicles, gelatin, juice, and pudding have high fluid content. The foods in answers A, B, and D do not aid in hydration and are, therefore, incorrect.
A patient with anemia is experiencing increased fatigue and occasional palpitations at rest. The nurse would expect the patient's laboratory findings to include a. normal red blood cell (RBC) indices. b. a hematocrit (Hct) of 38%. c. a hemoglobin (Hb) of 8.6 g/dL (86 g/L). d. an RBC count of 4,500,000/L.
C. The patient's clinical manifestations indicate moderate anemia, which is consistent with an Hb of 6 to 10 g/dL. The other values are all within the range of normal.
A 76-kg client admitted at 0600 w/a TBSA burn 40%. Using Parkland fromula,client's 24hr IV fluid relacement should be: A. 6,080 ml B. 9,120 ml C. 12,160 ml D. 15,180 ml
C. The Parkland Formula is 4 ml x kg x TBSA=24hr fluid req, or 4 x 76 x 40 = 12160 ml
A vegetarian client was referred to a dietician for nutritional counseling for anemia. Which client outcome indicates that the client does not understand nutritional counseling? The client: A. Adds dried fruit to cereal and baked goods B. Cooks tomato-based foods in iron pots C. Drinks coffee or tea with meals D. Adds vitamin C to all meal
C. coffe and tea increase GI mobility and inhibit the absorption of iron. clients should not add this
A client with macrocytic anemia has a burn on her foot and states that she had been watching television while lying on a heating pad. What is the nurse's first response? Assess for potential abuse Check for diminished sensations Document the findings Clean and dress the area
Check for diminished sensations The nurse should assess for peripheral neuropathy and instruct the client in self-care activities for her diminished sensation to heat and pain. The burn could be related to abuse, but this conclusion would require more supporting data. The findings should be documented, but the nurse would want to address the client's sensations first. The decision of how to treat the burn should be determined by the physician.
When comparing the hematocrit levels of a post-op client, the nurse notes that the hematocrit decreased from 36% to 34% on the third day even though the RBC and hemoglobin values remained stable at 4.5 million and 11.9 g/dL, respectively. Which nursing intervention is most appropriate? Check the dressing and drains for frank bleeding Call the physician Continue to monitor vital signs Start oxygen at 2L/min per NC
Continue to monitor The nurse should continue to monitor the client, because this value reflects a normal physiologic response. The physician does not need to be called, and oxygen does not need to be started based on these laboratory findings. Immediately after surgery, the client's hematocrit reflects a falsely high value related to the body's compensatory response to the stress of sudden loss of fluids and blood
. Fifteen minutes after a transfusion of packed red blood cells is started, a patient complains of back pain and dyspnea. The pulse rate is 124. The nurse's first action should be to a. administer oxygen therapy at a high flow rate. b. obtain a urine specimen to send to the laboratory. c. notify the health care provider about the symptoms. d. disconnect the transfusion and infuse normal saline.
D
1. The newly admitted client has burns on both legs. The burned areas appear white and leather-like. No blisters or bleeding are present, and the client states that he or she has little pain. How should this injury be categorized? A. Superficial B. Partial-thickness superficial C. Partial-thickness deep D. Full thickness
D
37. Which of the following nursing actions included in the care plan for a patient with neutropenia is appropriate for the RN to delegate to an LPN/LVN who is assisting with patient care? a. Assessing the patient for signs and symptoms of infection b. Teaching the patient the purpose of neutropenic precautions c. Developing a discharge teaching plan for the patient and family d. Administering the ordered subcutaneous filgrastim (Neupogen) injection
D
4. Which vitamin deficiency is most likely to be a long-term consequence of a full-thickness burn injury? A. Vitamin A B. Vitamin B C. Vitamin C D. Vitamin D
D
In assessing the client's potential for an inhalation injury as a result of a flame burn, what is the most important question to ask the client on admission? A. "Are you a smoker?" B. "When was your last chest x-ray?" C. "Have you ever had asthma or any other lung problem?" D. "In what exact place or space were you when you were burned?"
D
The newly admitted client has burns on both legs. The burned areas appear white and leather-like. No blisters or bleeding are present, and the client states that he or she has little pain. How should this injury be categorized? A. Superficial B. Partial-thickness superficial C. Partial-thickness deep D. Full thickness
D
When should ambulation be initiated in the client who has sustained a major burn? A. When all full-thickness areas have been closed with skin grafts B. When the client's temperature has remained normal for 24 hours C. As soon as possible after wound debridement is complete D. As soon as possible after resolution of the fluid shift
D
Which statement by the client indicates correct understanding of rehabilitation after burn injury? A. "I will never be fully recovered from the burn." B. "I am considered fully recovered when all the wounds are closed." C. "I will be fully recovered when I am able to perform all the activities I did before my injury." D. "I will be fully recovered when I achieve the highest possible level of functioning that I can."
D
Which statement made by the client with facial burns who has been prescribed to wear a facial mask pressure garment indicates correct understanding of the purpose of this treatment? A. "After this treatment, my ears will not stick out." B. "The mask will help protect my skin from sun damage." C. "Using this mask will prevent scars from being permanent." D. "My facial scars should be less severe with the use of this mask."
D
Which vitamin deficiency is most likely to be a long-term consequence of a full-thickness burn injury? A. Vitamin A B. Vitamin B C. Vitamin C D. Vitamin D
D
Which laboratory information will the nurse monitor to detect heparin-induced thrombocytopenia (HIT) in a patient who is receiving a continuous heparin infusion? a. Prothrombin time b. Erythrocyte count c. Fibrinogen degradation products d. Activated partial thromboplastin time
D platelet aggregation in HIT causes neutralization of heparin, so the aPTT time will be shorter and more heparin will be needed
During the acute phase, the nurse applied gentamicin sulfate (topical antibiotic) to the burn before dressing the wound. The client has all the following manifestations. Which manifestation indicates that the client is having an adverse reaction to this topical agent? A. Increased wound pain 30 to 40 minutes after drug application B. Presence of small, pale pink bumps in the wound beds C. Decreased white blood cell count D. Increased serum creatinine level
D Gentamicin does not stimulate pain in the wound. The small, pale pink bumps in the wound bed are areas of re-epithelialization and not an adverse reaction. Gentamicin is nephrotoxic and sufficient amounts can be absorbed through burn wounds to affect kidney function. Any client receiving gentamicin by any route should have kidney function monitored
A 43-year-old African American male is admitted with sickle cell anemia. The nurse plans to assess circulation in the lower extremities every 2 hours. Which of the following outcome criteria would the nurse use? a. Body temperature of 99°F or less b. Toes moved in active range of motion c. Sensation reported when soles of feet are touched d. Capillary refill of < 3 seconds
D It is important to assess the extremities for blood vessel occlusion in the client with sickle cell anemia because a change in capillary refill would indicate a change in circulation. Body temperature, motion, and sensation would not give information regarding peripheral circulation; therefore, answers A, B, and C are incorrect.
During treatment of the patient with an acute exacerbation of polycythemia vera, a critical action by the nurse is to a. place the patient on bed rest. b. administer iron supplements. c. avoid use of aspirin products. d. monitor fluid intake and output
D Monitoring hydration status is important during an acute exacerbation because the patient is at risk for fluid overload or underhydration. Aspirin therapy is used to decrease risk for thrombosis. The patient should be encouraged to ambulate to prevent deep vein thrombosis (DVT). Iron is contraindicated in patients with polycythemia vera.
A 30-year-old male from Haiti is brought to the emergency department in sickle cell crisis. What is the best position for this client? a. Side-lying with knees flexed b. Knee-chest c. High Fowler's with knees flexed d. Semi-Fowler's with legs extended on the bed
D Placing the client in semi-Fowler's position provides the best oxygenation for this client. Flexion of the hips and knees, which includes the knee-chest position, impedes circulation and is not correct positioning for this client
. A 52-year-old patient has a new diagnosis of pernicious anemia. After teaching the patient about pernicious anemia, the nurse determines that the patient understands the disorder when the patient states, a. "I need to start eating more red meat or liver." b. "I will stop having a glass of wine with dinner." c. "I will need to take a proton pump inhibitor like omeprazole (Prilosec)." d. "I would rather use the nasal spray than have to get injections of vitamin B12
D Since pernicious anemia prevents the absorption of vitamin B12, this patient requires injections or intranasal administration of cobalamin. Alcohol use does not cause cobalamin deficiency. Proton pump inhibitors decrease the absorption of vitamin B12. Eating more foods rich in vitamin B12 is not helpful because the lack of intrinsic factor prevents absorption of the vitami
Clients with sickle cell anemia are taught to avoid activities that cause hypoxia and hypoxemia. Which of the following activities would the nurse recommend? a. A family vacation in the Rocky Mountains b. Chaperoning the local boys club on a snow-skiing trip c. Traveling by airplane for business trips d. A bus trip to the Museum of Natural History
D Taking a trip to the museum is the only answer that does not pose a threat. A family vacation in the Rocky Mountains at high altitudes, cold temperatures, and airplane travel can cause sickling episodes and should be avoided
The nurse is conducting an admission assessment of a client with vitamin B12 deficiency. Which of the following would the nurse include in the physical assessment? a. Palpate the spleen b. Take the blood pressure c. Examine the feet for petechiae d. Examine the tongue
D The tongue is smooth and beefy red in the client with vitamin B12 deficiency, so examining the tongue should be included in the physical assessment. Bleeding, splenomegaly, and blood pressure changes do not occur
What additional laboratory test should be performed on any African American client who sustains a serious burn injury? A. Total protein B. Tissue type antigens C. Prostate specific antigen D. Hemoglobin S electrophoresi
D sickle cell disease are common among african americans
A patient receiving a transfusion of packed red blood cells develops chills, fever, headache, and anxiety 30 minutes after the transfusion is started. After stopping the transfusion, what is the first action that the nurse should take? a. Draw blood for a new crossmatch. b. Send a urine specimen to the laboratory. c. Give the PRN diphenhydramine (Benadryl). d. Administer the PRN acetaminophen (Tylenol
D these are clinical manifestations of a febrile nonhemolytic reaction stop infusion and give antipyretics for fever
The client, who is 2 weeks postburn with a 40% deep partial-thickness injury, still has open wounds. On taking the morning vital signs, the client is found to have a below-normal temperature, is hypotensive, and has diarrhea. What is the nurse's best action? A. Nothing, because the findings are normal for clients during the acute phase of recovery. B. Increase the temperature in the room and increase the IV infusion rate. C. Assess the client's airway and oxygen saturation. D. Notify the burn emergency team.
D these are similar to gram negative infection and sepsis = Er
39. Laboratory studies are performed for a child suspected of having iron deficiency anemia. The nurse reviews the laboratory results, knowing that which of the following results would indicate this type of anemia? An elevated hemoglobin level A decreased reticulocyte count An elevated RBC count Red blood cells that are microcytic and hypochromic
D. The results of a CBC in children with iron deficiency anemia will 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.
In positioning client burns upper extremities, RN positions elbow? A.In position of comfort B.Slightly hyperextended C.Slightly flexed D.In neutral position
D. in neutral position
The nurse is preparing to teach a client with microcytic hypochromic anemia about the diet to follow after discharge. Which of the following foods should be included in the diet? Eggs Lettuce Citrus fruits Cheese
Eggs microcytic hypochromic anemia is iron deficiency anemai a rich source of iron is neded in the diet foods high in iron are: eggs, orgnas, dark meats, shellfish, shrip, tuna, legumes, beans,
A client is to receive epoetin (Epogen) injections. What laboratory value should the nurse assess before giving the injection? Hematocrit Partial thromboplastin time Hemoglobin concentration Prothrombin time
Hematocrit Epogen is a recombinant DNA form of erythropoietin, which stimulates the production of RBCs and therefore causes the hematocrit to rise. The elevation in hematocrit causes an elevation in blood pressure; therefore, the blood pressure is a vital sign that should be checked. The PTT, hemoglobin level, and PT are not monitored for this drug.
During emergent phase of burn injury,what route is used to admin pain meds? A.IV B.Topical C.SQ D.IM
IV
Anemia or insufficient hemoglobin content is common in older persons. The client's body compensates for the deficiency by: Decreasing the respiratory and heart rates. Increasing the heart and respiratory rates. Shunting blood away from vital organs and skin. Decreasing blood viscosity in order to supply oxygen to hypoxic tissues.
Increase the Heart & RR all anemias result in loss of Oxygen carrying capacity of the blood and generalized hypoxia. The body compensates for this by raising HR and RR
The nurse has provided nutritional teaching on foods high in folate to a client with folate deficiency related to malabsorption syndromes and poor nutrition. Which of the following foods, if chosen by the client, indicates that the client understands the teaching? Liver and dark green leafy vegetables Whole milk and eggs Potatoes and carrots Bread and fish
Liver & dark green leafy veggies
The nurse would instruct the client to eat which of the following foods to obtain the best supply of vitamin B12? Whole grains Green leafy vegetables Meats and dairy products Broccoli and Brussels sprouts
Meats and dairy products whole grains=thiamine
Which of the following nursing assessments is a late symptom of polycythemia vera? Headache Dizziness Pruritus Shortness of breath
Pruritis Pruritus is a late symptom that results from abnormal histamine metabolism. Headache and dizziness are early symptoms from engorged veins. Shortness of breath is an early symptom from congested mucous membrane and ineffective gas exchange.
When caring for a client with a diagnosis of thrombocytopenia, the nurse should plan to: Discourage the use of stool softeners. Assess temperature readings every six hours. Avoid invasive procedures. Encourage the use of a hard, brittle toothbrush.
avoid invassive proceedures they are at an increased risk for thrombosis!
An African American female comes to the outpatient clinic. The physician suspects vitamin B12 deficiency anemia. Because jaundice is often a clinical manifestation of this type of anemia, what body part would be the best indicator? a. Conjunctiva of the eye b. Soles of the feet c. Roof of the mouth d. Shins
c The oral mucosa and hard palate (roof of the mouth) are the best indicators of jaundice in dark-skinned persons. The conjunctiva can have normal deposits of fat, which give a yellowish hue; thus, answer A is incorrect. The soles of the feet can be yellow if they are calloused, making answer B incorrect; the shins would be an area of darker pigment
Erythropoietin sometimes is administered subcutaneously to treat which of the following? (Select all that apply.) Clients with marrow suppression Clients with chronic liver disease Clients with Hodgkin's disease and non-Hodgkin's lymphoma Clients with anemia and fatigue related to non-myeloid cancers
clients w/ anemia & fatigue r/t non-myeloid cancer
) A client with chronic renal failure is receiving ferrous sulfate (Feosol). The nurse monitors the client for which common side effect associated with this medication? 1. Diarrhea 2. Weakness 3. Headache 4. Constipation
constipation it is used to treat anemia constipation is a frequent & uncomfortable side effect associated with this
The nurse prioritizes which in emergent phase? A.Assessing body temp B.Monitoring urine output C.Emotional support D.Fluid resuscitation
fluid resuscitation
The nurse has just admitted a 35-year-old female client who has a serum B12 concentration of 800 pg/ml. Which of the following laboratory findings would cue the nurse to focus the client history on specific drug or alcohol abuse? Total bilirubin, 0.3 mg/dL Serum creatinine, 0.5 mg/dL Hemoglobin, 16 g/dL Folate, 1.5 ng/mL
folate, 1.5 the normal folic acid is 1.8-9 normal b12 is 200-900 low folic acid level in presence of a normal vitamin b12 level is indicative of folic acid deficiency anemia
The nurse understands that the client with pernicious anemia will have which distinguishing laboratory findings? Schilling's test, elevated Intrinsic factor, absent. Sedimentation rate, 16 mm/hour RBCs 5.0 million
intrinsic factor absent The defining characteristic of pernicious anemia, a megaloblastic anemia, is lack of the intrinsic factor, which results from atrophy of the stomach wall. Without the intrinsic factor, vitamin B12 cannot be absorbed in the small intestines, and folic acid needs vitamin B12 for DNA synthesis of RBCs.
The usual treatment for iron-deficiency anemia includes: Vitamin B12 injection. Non-enteric-coated ferrous sulfate. Enteric-coated or sustained-release ferrous sulfate. Whole blood transfusion.
non-enteric coated ferrous sulfat
24. Which of the following symptoms is expected with hemoglobin of 10 g/dl? None Pallor Palpitations Shortness of breath
none
2.) Oral iron supplements are prescribed for a 6-year-old child with iron deficiency anemia. The nurse instructs the mother to administer the iron with which best food item? 1. Milk 2. Water 3. Apple juice 4. Orange juice
orange juice it has vitamin C to help increase absorption of iron in the body
A client with anemia may be tired due to a tissue deficiency of which of the following substances? Carbon dioxide Factor VIII Oxygen T-cell antibodies
oxygen
Because older persons can have severe anemia for a long period of time without detection, when diagnosed, quick reversal is warranted. Which of the following orders most likely would be prescribed at this time? Platelet transfusion and osmotic diuretic Ferrous sulfate 325 mg orally three times a day Packed red blood cells followed by oral furosemide (Lasix) Erythropoietin (Procrit) injection twice per week
packed RBCs follow by oral furosemide (Lasix)
Nurse correlates which clinical manifestation as indicative of wound healing in acute phase? A.^ wound drainage B.Dry,light pink wound bed C.Scar tissue formation D.Sloughing of eschar
scar tissue formation
Which of the following cells is the precursor to the red blood cell (RBC)? B cell Macrophage Stem cell T cell
stem cell
26. A client with iron deficiency anemia is scheduled for discharge. Which instruction about prescribed ferrous gluconate therapy should the nurse include in the teaching plan? "Take the medication with an antacid." "Take the medication with a glass of milk." "Take the medication with cereal." "Take the medication on an empty stomach."
take on an empty stomach In aplastic anemia, the most likely diagnostic findings are decreased levels of all the cellular elements of the blood (pancytopenia). T-helper cell production doesn't decrease in aplastic anemia. Reed-Sternberg cells and lymph node enlargement occur with Hodgkin's disease.
The most common cause of macrocytic anemia in the older person is B12 or folate deficiency. Failure to absorb vitamin B12 from the G.I. tract is called: Macrocytic anemia. Aplastic anemia. Pernicious anemia. Thalassemia anemia
thalassemia anemia
Jewish client requires grafting to promote burn healing.Which graft is most likely to be unacceptable to client? A.Isograft B.Autograft C.Homograft D.Xenograft
xenograpt
