Adults II Mod 1: Hemo, Ch. 28, 29, 30

A patient will need a blood transfusion for the replacement of blood loss from the gastrointestinal tract. The patient states, "That stuff isn't safe!" What is the best response from the nurse? "I agree that you should be concerned with the safety of the blood, but it is important that you have this transfusion." "The blood is carefully screened, so there is no possibility of you contracting any illness or disease from the blood." "I understand your concern. The blood is carefully screened but is not completely risk free." "You will have to decide if refusing the blood transfusion is worth the risk to your health."

"I understand your concern. The blood is carefully screened but is not completely risk free."

A client is returning home after having a bone marrow aspiration and biopsy. Which statement indicates that teaching by the nurse has been effective? "I can resume my normal activities." "The area might ache for 1 to 2 days." "I should take aspirin if I have any pain." "I can go to the gym to lift weights later."

"The area might ache for 1 to 2 days." Potential complications of either bone marrow aspiration or biopsy include bleeding and infection. After the marrow sample is obtained, pressure is applied to the site for several minutes. The site is then covered with a sterile dressing. Most clients have no discomfort after a bone marrow aspiration, but the site of a biopsy may ache for 1 or 2 days. The client should be instructed to perform no rigorous activity for 1 to 2 days. Aspirin-containing analgesics should be avoided immediately after the procedure as this might cause or aggravate bleeding. Rigorous exercise should be avoided for 1 to 2 days.

The nurse in the oncology clinic is caring for a 42-year-old female client receiving chemotherapy with fludarabine for acute myeloid leukemia who has developed petechiae, epistaxis, and ecchymosis. Complete the following sentence by choosing from the lists of options. The nurse anticipates that the client has developed (1) and that the laboratory results will reveal (2). 1: hemorrhage thrombocytopenia infection leukocytosis 2: deep vein thrombosis electrolyte imbalances hyperkalemia abnormal renal function tests

1. hemorrhage 2. thrombocytopenia This client has manifestations of hemorrhage, including petechiae (pinpoint bleeding in the skin), epistaxis (nosebleeds), and ecchymosis (bruises) due to a low platelet count (thrombocytopenia) secondary to chemotherapy. Chemotherapy with fludarabine may cause bone marrow suppression with neutropenia (low neutrophil count) and thrombocytopenia (low platelet count). When the platelet count is low, the client is at risk for hemorrhage as evidenced by petechiae, epistaxis, and ecchymosis. Chemotherapy with fludarabine may cause bone marrow suppression, leading to thrombocytopenia (low platelet count) and hemorrhage. Although the client is at risk for infection, the assessment findings of petechiae, epistaxis, and ecchymoses are indicators of a low platelet count. The assessment findings do not support a diagnosis of deep vein thrombosis (DVT). Manifestations of DVT include calf pain, leg swelling, and warmth, and pain over the thrombosis. Hyperkalemia does not cause signs and symptoms of hemorrhage. Leukocytosis (a low white count) may occur following treatment with fludarabine, but it does not cause petechiae, epistaxis, and ecchymosis. Electrolyte imbalances and abnormal renal function also do not cause petechiae, epistaxis, and ecchymosis.

Which client is not a candidate to be a blood donor according to the American Red Cross? 86-year-old male with blood pressure 110/70 mm Hg 50-year-old female with pulse 95 beats/minute 26-year-old female with hemoglobin 11.0 g/dL 18-year-old male weighing 52 kg

26-year-old female with hemoglobin 11.0 g/dL Clients must meet a number of criteria to be eligible as blood donors, including the following: body weight at least 50 kg; pulse rate regular between 50 and 100 bpm; systolic BP 90-100 to 180 mm Hg and diastolic 50 to 100 mm Hg; hemoglobin level at least 12.5 g/dL. There is no upper age limit to donation.

The nurse is caring for a client with type 2 diabetes who take metformin to manage glucose levels. The nurse recognizes the client may be most at risk for which vitamin deficiency? B12 C A Folate

B12 The medication metformin (Glucophage) increases the client's risk for developing B12 deficiency because the medication inhibits the absorption of B12.

The nurse suspects that a client has multiple myeloma based on the client's major presenting symptom and the analysis of laboratory results. What classic symptom for multiple myeloma does the nurse assess for? Debilitating fatigue Bone pain in the back of the ribs Gradual muscle paralysis Severe thrombocytopenia

Bone pain in the back of the ribs Although patients can have asymptomatic bone involvement, the most common presenting symptom of multiple myeloma is bone pain, usually in the back or ribs. Unlike arthritic pain, the bone pain associated with myeloma increases with movement and decreases with rest; clients may report that they have less pain on awakening but the pain intensity increases during the day.

Which is a symptom of hemochromatosis? Bronzing of the skin Inflammation of the mouth Inflammation of the tongue Weight gain

Bronzing of the skin Clients with hemochromatosis exhibit symptoms of weakness, lethargy, arthralgia, weight loss, and loss of libido early in the illness trajectory. The skin may appear hyperpigmented from melanin deposits or appear bronze in color.

The nurse is educating a client about iron supplements. The nurse teaches that what vitamin enhances the absorption of iron? C A D E

C Vitamin C facilitates the absorption of iron. Therefore, iron supplements should be taken with a glass of orange juice or a vitamin C tablet to maximize absorption.

A client with a history of sickle cell anemia has developed iron overload from repeated blood transfusions. What treatment does the nurse anticipate will be prescribed? White blood cell filter Hepatitis B immunization Red blood cell phenotyping Chelation therapy

Chelation therapy Chelation therapy is prescribed to treat iron overload. Hepatitis B immunization helps immunize against hepatitis B. Red blood cell phenotyping helps decreased sensitization. A white blood cell filter protects against cytomegalovirus and some sensitization and febrile reactions.

The nurse expects which assessment finding when caring for a client with a decreased hemoglobin level? Bright red venous blood. Elevated temperature. Decreased oxygen level. Increased bruising.

Decreased oxygen level Hemoglobin carries oxygen; a decreased hemoglobin level results in decreased oxygen. An elevated temperature is a sign of infection and can result from decreased white blood cells. Arterial blood is more oxygen saturated and brighter red in color than venous blood. Increased bruising results from a decreased platelet level, not decreased hemoglobin.

The nurse is caring for a client with external bleeding. What is the nurse's priority intervention? Elevation of the extremity Pressure point control Direct pressure Application of a tourniquet

Direct pressure Applying direct pressure to an injury is the initial step in controlling bleeding. Elevation reduces the force of flow, but direct pressure is the first step. The nurse may use pressure point control for severe or arterial bleeding. Pressure points (those areas where large blood vessels can be compressed against bone) include femoral, brachial, facial, carotid, and temporal artery sites. The nurse should avoid applying a tourniquet unless all other measures have failed, because it may further damage the injured extremity.

A client receiving a blood transfusion reports shortness of breath, appears anxious, and has a pulse of 125 beats/minute. What is the best action for the nurse to take after stopping the transfusion and awaiting further instruction from the health care provider? Place the client in a recumbent position with legs elevated. Remove the intravenous line. Ensure there is an oxygen delivery device at the bedside. Administer prescribed PRN anti-anxiety agent.

Ensure there is an oxygen delivery device at the bedside. The client is exhibiting signs of circulatory overload. After stopping the transfusion and notifying the healthcare provider, the nurse should place the client in a more upright position with the legs dependent to decrease workload on the heart. The IV line is kept patent in case emergency medications are needed. Oxygen and morphine may be needed to treat severe dyspnea. Administering an anti-anxiety agent is not a priority action over ensuring oxygen is available.

The nurse is performing an assessment for a client with anemia admitted to the hospital to have blood transfusions administered. Why would the nurse need to include a nutritional assessment for this patient? It is part of the required assessment information. It is important for the nurse to determine what type of foods the patient will eat. It may indicate deficiencies in essential nutrients. It will determine what type of anemia the patient has.

It may indicate deficiencies in essential nutrients. A nutritional assessment is important, because it may indicate deficiencies in essential nutrients such as iron, vitamin B12, and folate.

A client in acute renal failure has been prescribed 2 units of packed red blood cells (PRBCs). The nurse explains to the client that the blood transfusion is most likely needed for which reason? Preparation for likely nephrectomy Increases the effectiveness of dialysis Hypervolemia Lack of erythropoietin

Lack of erythropoietin The kidneys produce erythropoietin, a hormone that stimulates red blood cell production. A lack of this hormone is the most likely reason for blood transfusion due to the acute kidney failure. There is no indication for a nephrectomy in this question. A blood transfusion will not necessarily increase the effectiveness of dialysis. Transfusing a client with hypervolemia could lead to circulatory overload.

Which iron-rich foods should a nurse encourage an anemic client requiring iron therapy to eat? Shrimp and tomatoes Lobster and squash Cheese and bananas Lamb and peaches

Lamb and peaches

Albumin is important for the maintenance of fluid balance within the vascular system. Albumin is produced by which of the following? Liver Pancreas Kidney Large intestine

Liver

Which term refers to a form of white blood cell involved in immune response? Granulocyte Lymphocyte Spherocyte Thrombocyte

Lymphocyte Both B and T lymphocytes respond to exposure to antigens. Granulocytes include basophils, neutrophils, and eosinophils. A spherocyte is a red blood cell without central pallor, seen with hemolysis. A thrombocyte is a platelet.

Which is a symptom of severe thrombocytopenia? Petechiae Inflammation of the mouth Inflammation of the tongue Dyspnea

Petechiae Clients with severe thrombocytopenia have petechiae, which are pinpoint hemorrhagic lesions, usually more prominent on the trunk or anterior aspects of the lower extremities.

A client is diagnosed with extreme thrombocytosis. The nurse knows this condition is a result of which elevated blood cell count? Neutrophils Platelets Erythocytes Eosinophils

Platelets Extreme thrombocytosis is an elevation in platelets.

A client is awaiting test results to diagnose Hodgkin lymphoma. The nurse knows that which result is the hallmark for the diagnosis of this condition? Increased basophils Reed-Sternberg cells Elevated platelet count Misshaped red blood cells

Reed-Sternberg cells The malignant cell of Hodgkin lymphoma is the Reed-Sternberg cell, a gigantic tumor cell that is morphologically unique and thought to be of immature lymphoid origin. These cells arise from the B lymphocyte. They may have more than one nucleus and often have an owl-like appearance. The presence of Reed-Sternberg cells is the pathologic hallmark and essential diagnostic criterion. Basophils, platelets, or red blood cells are not used to diagnose Hodgkin lymphoma.

Which type of lymphocyte is responsible for cellular immunity? B lymphocyte Plasma cell T lymphocyte Basophil

T lymphocyte T lymphocytes are responsible for delayed allergic reactions, rejection of foreign tissue (e.g., transplanted organs), and destruction of tumor cells. This process is known as cellular immunity. B lymphocytes are responsible for humoral immunity. A plasma cell secretes immunoglobulin. A basophil contains histamine and is an integral part of hypersensitivity reactions.

A client admitted to the hospital with abdominal pain, anemia, and bloody stools reports feeling weak and dizzy. The client has rectal pressure and needs to urinate and move their bowels. The nurse should help them: to the bathroom. to the bedside commode. onto the bedpan. to a standing position so he can urinate.

onto the bedpan A client who's dizzy and anemic is at risk for injury because of his weakened state. Assisting him with the bedpan would best meet his needs at this time without risking his safety. The client may fall if walking to the bathroom, left alone to urinate, or trying to stand up.

The clinic nurse is caring for a client diagnosed with leukopenia. What does the nurse know this client has? Too many erythrocytes A decrease in granulocytes A general reduction in all white blood cells A general reduction in neutrophils and basophils

A general reduction in all white blood cells Leukopenia is a general reduction in all WBCs. Leukopenia does not have anything to do with erythrocytes.

Which of the following are assessment findings associated with thrombocytopenia? Select all that apply. Bleeding gums Epistaxis Hematemesis Bradypnea Hypertension

Bleeding gums Epistaxis Hematemesis Pertinent findings of thrombocytopenia include: bleeding gums, epistaxis, hematemesis, hypotension, and tachypnea. Epistaxis = nosebleed

A client's electronic health record states that the client receives regular transfusions of factor IX. The nurse would be justified in suspecting that this client has what diagnosis? Leukemia Hemophilia Hypoproliferative anemia Hodgkin lymphoma

Hemophilia Administration of clotting factors is used to treat diseases where these factors are absent or insufficient; hemophilia is among the most common of these diseases. Factor IX is not used in the treatment of leukemia, lymphoma, or anemia.

A client has completed induction therapy and has diarrhea and severe mucositis. What is the appropriate nursing goal? Address issues of negative body image. Place the client in reverse isolation. Administer pain medication. Maintain nutrition.

Maintain nutrition Maintaining nutrition is the most important goal after induction therapy because the client experiences severe diarrhea and can easily become nutritionally deficient and develop fluid and electrolyte imbalance. The client is most likely not in pain at this point, and this is an intervention, not a goal.

The nurse is assessing a patient who is a strict vegetarian. What type of anemia is the nurse aware that this patient is at risk for? Iron deficiency anemia Aplastic anemia Megaloblastic anemia Sickle cell anemia

Megaloblastic anemia Strict vegetarians are at risk for megaloblastic anemias, which are characterized by the presence of abnormally large, nucleated RBCs, if they do not supplement their diet with vitamin B12.

The nurse cares for an older adult client with unprovoked back pain and increased serum protein. Which hematologic neoplasm does the nurse suspect the client has? Chronic myeloid leukemia Multiple myeloma Hodgkin lymphoma Non-Hodgkin lymphoma

Multiple myeloma Any older adult with unprovoked or unexplained back pain and increased protein in the serum should be assessed for multiple myeloma. Bone pain occurs because of bone breakdown and the malignant cells of multiple myeloma increase the serum protein levels.

The body responds to infection by increasing the production of white blood cells (WBCs). The nurse should evaluate the differential count for what type of WBCs, which are the first WBCs to respond to an inflammatory event? Basophils Neutrophils Eosinophils Monocytes

Neutrophils Neutrophils, the most abundant type of white blood cell, are the first of the WBCs to respond to infection or inflammation. The normal value is 3,000 to 7,000/cmm (males) and 1,800 to 7,700/cmm (females).

A nurse is caring for a client with multiple myeloma. Which nursing intervention is most appropriate for this client? Monitoring respiratory status Balancing rest and activity Restricting fluid intake Preventing bone injury

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

The nurse is assisting the client with multiple myeloma to ambulate. What is the most important nursing intervention to help prevent fractures in the client? Increase mobility. Provide adequate hydration. Promote safety. Encourage adequate nutrition.

Promote safety Safety is paramount because any injury, no matter how slight, can result in a fracture. Mobility, hydration, and nutrition are important, but will not prevent fractures.

The nurse is assessing several clients. Which client does the nurse determine is most likely to have Hodgkin lymphoma? The client with painful lymph nodes under the arm. The client with painful lymph nodes in the groin. The client with enlarged lymph nodes in the neck. The client with a painful sore throat.

The client with enlarged lymph nodes in the neck. Lymph node enlargement in Hodgkin lymphoma is not painful. The client with enlarged lymph nodes in the neck is most likely to have Hodgkin lymphoma if the enlarged nodes are painless. Sore throat is not a sign for this disorder.

A nurse is assigned to care for a patient with ascites, secondary to cirrhosis. The nurse understands that the fluid accumulation in the peritoneal cavity results from a combination of factors including an alteration in oncotic pressure gradients and increased capillary permeability. Therefore, the nurse monitors the serum level of the plasma protein responsible for maintaining oncotic pressure, which is: Albumin. Globulin. Fibrinogen. Prothrombin.

Albumin Albumin, only produced in the liver, is essential for maintaining oncotic pressure in the vascular system. A decrease in oncotic pressure due to low albumin causes fluid to leak into the peritoneal cavity.

A nurse caring for a client who has hemophilia is getting ready to take the client's vital signs. What should the nurse do before taking a blood pressure? Ask if taking a blood pressure has ever produced bleeding under the skin or in the arm joints. Ask if taking a blood pressure has ever produced pain in the upper arm. Ask if taking a blood pressure has ever caused bruising in the hand and wrist. Ask if taking a blood pressure has ever produced the need for medication.

Ask if taking a blood pressure has ever produced bleeding under the skin or in the arm joints. Due to the client's enhanced risk for bleeding, before taking a blood pressure, the nurse asks the client if the use of a blood-pressure cuff has ever produced bleeding under the skin or in the arm joints.

A client presents with peripheral neuropathy and hypoesthesia of the feet. What is the best nursing intervention? Elevate the client's legs. Encourage ambulation. Assess for signs of injury. Keep the feet cool.

Assess for signs of injury. A client with hypoesthesia of the feet will have decreased sensation and numbness. The nurse should assess for signs of injury. If the client is injured, he or she will not be able to feel it; this could lead to the development of infection. Ambulation will not help the client, and elevating the legs may make the problem worse, as blood flow to the feet would be decreased. Keeping the feet cold will also decrease blood flow.

The nurse is instructing a client about taking a liquid iron preparation for the treatment of iron-deficiency anemia. What should the nurse include in the instructions? Do not take medication with orange juice because it will delay absorption of the iron. Iron may cause indigestion and should be taken with an antacid such as Mylanta. Dilute the liquid preparation with another liquid such as juice and drink with a straw. Discontinue the use of iron if your stool turns black.

Dilute the liquid preparation with another liquid such as juice and drink with a straw. Dilute liquid preparations of iron with another liquid such as juice and drink with a straw to avoid staining the teeth. Avoid taking iron simultaneously with an antacid, which interferes with iron absorption. Drink orange juice or take other forms of vitamin C with iron to promote its absorption. Expect iron to color stool dark green or black.

Which blood cell type is matched correctly with its function? T lymphocyte: Humoral immunity Plasma cell: Cell-mediated immunity Leukocyte: Fights infection B lymphocyte: Secretes immunoglobulin

Leukocyte: Fights infection Leukocytes fight infection, T lymphocytes are integral in cell-mediated immunity, plasma cells secrete immunoglobulin, and B lymphocytes are integral in humoral immunity.

The nurse is completing a physical assessment on a client's lymphatic system. The nurse should palpate for enlarged nodes in which areas? Select all that apply. Popliteal Inguinal Spinal Submental Neck

Popliteal Inguinal Submental Neck Palpable lymph node areas include: popliteal, inguinal, submental, and neck. The spinal region does not contain palpable lymph nodes.

A nurse cares for clients with hematological disorders and notes that women are diagnosed with hemochromatosis at a much lower rate than men. What is the primary reason for this? Women lose iron through menstrual cycles Women rarely manifest the gene expression Women have lower hemoglobin levels Women require grater folic acid supplementation

Women lose iron through menstrual cycles Hemochromatosis is a genetic condition where excess iron is absorbed in the GI tract and deposited in various organs, making them dysfunctional. Women are often less affected than men because women lose excess iron through their menstrual cycles. The other answer choices are not correct reasons why women are impacted less than men with hemochromatosis.

A few minutes after beginning a blood transfusion, a nurse notes that a client has chills, dyspnea, and urticaria. The nurse reports this to the health care provider immediately because the client probably is experiencing which problem? A hemolytic reaction to mismatched blood A hemolytic reaction to Rh-incompatible blood A hemolytic allergic reaction caused by an antigen reaction A hemolytic reaction caused by bacterial contamination of donor blood

A hemolytic allergic reaction caused by an antigen reaction Hemolytic allergic reactions are fairly common and may cause chills, fever, urticaria, tachycardia, dyspnea, chest pain, hypotension, and other signs of anaphylaxis a few minutes after blood transfusion begins. Although rare, a hemolytic reaction to mismatched blood can occur, triggering a more severe reaction and, possibly, leading to disseminated intravascular coagulation. A hemolytic reaction to Rh-incompatible blood is less severe and occurs several days to 2 weeks after the transfusion. Bacterial contamination of donor blood causes a high fever, nausea, vomiting, diarrhea, abdominal cramps and, possibly, shock.

A client with sickle cell crisis is admitted to the hospital in severe pain. While caring for the client during the crisis, which is the priority nursing intervention? Limiting the client's intake of oral and IV fluids Administering and evaluating the effectiveness of opioid analgesics Encouraging the client to ambulate immediately Limit foods that contain folic acid

Administering and evaluating the effectiveness of opioid analgesics The priority nursing intervention is to manage the acute pain. Client-controlled analgesia is frequently used in the acute care setting. A patient with sickle cell crisis experiences severe extreme pain, the use of IV fluids and oral intake is need to hydrate the patient, the patient is initially placed on bed rest during the crisis due to extreme fatigue. The patient must continue to ingest folic acid and are placed on a daily folic acid supplement .

A thin client is prescribed iron dextran intramuscularly. What is most important action taken by the nurse when administering this medication? Employs the Z-track technique Uses a 23-gauge needle Injects into the deltoid muscle Rubs the site vigorously

Employs the Z-track technique When iron medications are given intramuscularly, the nurse uses the Z-track technique to avoid local pain and staining of the skin. The gluteus maximus muscle is used. The nurse avoids rubbing the site vigorously and uses a 18- or 20-gauge needle.

A client with chronic kidney disease has chronic anemia. What pharmacologic alternative to blood transfusion may be used for this client? GM-CSF Erythropoietin Eltrombopag Thrombopoietin

Erythropoietin Erythropoietin (epoetin alfa [Epogen, Procrit]) is an effective alternative treatment for clients with chronic anemia secondary to diminished levels of erythropoietin, as in chronic renal disease. This medication stimulates erythropoiesis.

A patient with acute myeloid leukemia (AML) is having hematopoietic stem cell transplantation (HSCT) with radiation therapy. In which complication do the donor's lymphocytes recognize the patient's body as foreign and set up reactions to attack the foreign host? Acute respiratory distress syndrome Graft-versus-host disease Remission Bone marrow depression

Graft-versus-host disease Patients who undergo HSCT have a significant risk of infection, graft-versus host disease (in which the donor's lymphocytes [graft] recognize the patient's body as "foreign" and set up reactions to attack the foreign host), and other complications.

A nursing instructor is evaluating a student caring for a neutropenic client. The instructor concludes that the nursing student demonstrates accurate knowledge of neutropenia based on which intervention? Monitoring the client's temperature and reviewing the client's complete blood count (CBC) with differential Monitoring the client's breathing and reviewing the client's arterial blood gases Monitoring the client's heart rate and reviewing the client's hemoglobin Monitoring the client's blood pressure and reviewing the client's hematocrit

Monitoring the client's temperature and reviewing the client's complete blood count (CBC) with differential Clients with neutropenia often do not exhibit classic signs of infection. Fever is the most common indicator of infection, yet it is not always present. No definite symptoms of neutropenia appear until the client develops an infection. A routine CBC with differential can reveal neutropenia before the onset of infection.

Which cell of hematopoiesis is responsible for the production of red blood cells (RBCs) and platelets? Myeloid stem cell Lymphoid stem cell Monocyte Neutrophil

Myeloid stem cell The myeloid stem cell is responsible not only for all nonlymphoid white blood cells, but also for the production of red blood cells and platelets. Lymphoid cells produce either T or B lymphocytes. A monocyte is large WBC that becomes a macrophage when is leaves the circulation and moves into body tissues. A neutrophil is a fully mature WBC capable of phagocytosis.

A client with a diagnosis of pernicious anemia comes to the clinic reporting of numbness and tingling in his arms and legs. What do these symptoms indicate? Loss of vibratory and position senses Neurologic involvement Severity of the disease Insufficient intake of dietary nutrients

Neurologic involvement In clients with pernicious anemia, numbness and tingling in the arms and legs and ataxia are the most common signs of neurologic involvement. Some affected clients lose vibratory and position senses. Jaundice, irritability, confusion, and depression are present when the disease is severe. Insufficient intake of dietary nutrients is not indicated by these symptoms

A client with acute myeloid leukemia has a fever. What pathophysiological process does the nurse recognize is the cause of the client's fever? Pancytopenia Thrombocytopenia Anemia Neutropenia

Neutropenia Fever and infection result from a decrease in neutrophils (neutropenia). Decreased red blood cells (anemia) cause weakness, fatigue, dyspnea on exertion, and pallor in AML. Pancytopenia, an overall decrease in all blood components, is not cause of fever in clients with AML. Decreased platelet count (thrombocytopenia) causes petechiae and bruising in AML.

The nurse provides care for an older adult client, diagnosed with anemia, who has a hemoglobin of 9.6 g/dL and a hematocrit of 34%. To determine the cause of the client's blood loss, which is the priority nursing action? Observe the client's stools for blood. Evaluate the client's dietary intake. Monitor the client's body temperature. Monitor the client's blood pressure.

Observe the client's stools for blood. If an older adult is anemic, blood loss from the gastrointestinal (GI) or genitourinary (GU) tracts is suspected. Observing the stool for blood will determine if the source of the client's bleeding is in the GI tract. Iron-deficiency anemia is unusual in older adults because the body does not eliminate excessive iron, thus increasing total body iron stores and necessitating maintenance of hydration. If evaluation of the GI and GU tracts does not reveal a source of bleeding, evaluating the client's diet may be appropriate; however, this is not the priority nursing action. Monitoring the client's body temperature and BP will assist the nurse in determining the source of the client's blood loss, but these are not priority nursing actions.

The nurse is caring for a client with multiple myeloma. Why would it be important to assess this client for fractures? Osteopathic tumors destroy bone causing fractures. Osteoclasts break down bone cells so pathologic fractures occur. Osteolytic activating factor weakens bones producing fractures. Osteosarcomas form producing pathologic fractures.

Osteoclasts break down bone cells so pathologic fractures occur. The abnormal plasma cells proliferate in the bone marrow, where they release osteoclast-activating factor. This, in turn, causes osteoclasts to break down bone cells, resulting in increased blood calcium and pathologic fractures. The plasma cells also form single or multiple osteolytic (bone-destroying) tumors that produce a "punched-out" or "honeycombed" appearance in bones such as the spine, ribs, skull, pelvis, femurs, clavicles, and scapulae. Weakened vertebrae lead to compression of the spine accompanied by significant pain. The other options are distractors for this question.

While assessing a client, the nurse will recognize what as the most obvious sign of anemia? Pallor Tachycardia Flow murmurs Jaundice

Pallor On physical examination, pallor is the most common and obvious sign of anemia. Other findings may include tachycardia and flow murmurs. Patients with hemolytic anemia may exhibit jaundice and splenomegaly.

The nurse is screening donors for blood donation. Which client is an acceptable donor for blood? Has a history of viral hepatitis as a teenager 10 years ago Received a blood transfusion within 1 year Reports having a cold 1 month ago that resolved quickly Had a dental extraction 2 days ago for caries in a tooth

Reports having a cold 1 month ago that resolved quickly Donors must meet certain requirements to be able to donate blood. A client should be in good health, such as the client who had a cold more than 1 month ago that resolved quickly. Those excluded from donating blood have a history of viral hepatitis, report a blood transfusion within 12 months, and had a dental extraction within 72 hours. The reason for exclusion is that they are at increased risk of transmitting an infectious disease.

The nurse is assessing a client admitted with a deep vein thrombosis with an elevated red blood cell count. The admitting diagnosis is polycythemia vera. What is the hallmark clinical sign of PV? splenomegaly weight gain peripheral edema pale body color

Splenomegaly Splenomegaly is the hallmark of PV. Patients typically have a ruddy complexion and splenomegaly. Symptoms result from increased blood volume (headache, dizziness, tinnitus, fatigue, weight loss, paresthesias, and blurred vision). Edema, pale body color, and weight gain are not classic symptoms of PV.

A client is prescribed 325 mg/day of oral ferrous sulfate. What does the nurse include in client teaching? Take 1 hour before breakfast Take with dairy products Decrease intake of fruits and juices Decrease intake of dietary fiber

Take 1 hour before breakfast Instructions the nurse will provide for the client taking oral ferrous sulfate is to administer the medication on an empty stomach. Instructions also include that there is decreased absorption of iron with food, particularly dairy products. The client is to increase vitamin C intake (fruits, juices, tomatoes, broccoli), which will enhance iron absorption. The client is to also increase foods high in fiber to decrease risk of constipation.

Which nursing intervention should be incorporated into the plan of care to manage the delayed clotting process in a client with leukemia? Implement neutropenic precautions Eliminate direct contact with others who are infectious Apply prolonged pressure to needle sites or other sources of external bleeding Monitor temperature at least once per shift

Apply prolonged pressure to needle sites or other sources of external bleeding For a client with leukemia, the nurse should apply prolonged pressure to needle sites or other sources of external bleeding. Reduced platelet production results in a delayed clotting process and increases the potential for hemorrhage. Implementing neutropenic precautions and eliminating direct contact with others are interventions to address the risk for infection.

A nurse is caring for a client with multiple myeloma. Which laboratory value is the nurse most likely to see? Hypercalcemia Hyperkalemia Hypernatremia Hypermagnesemia

Hypercalcemia Calcium is released when bone is destroyed, causing hypercalcemia. Multiple myeloma doesn't affect potassium, sodium, or magnesium levels.

When assessing a female client with a disorder of the hematopoietic or the lymphatic system, which assessment is most essential? Health history, such as bleeding, fatigue, or fainting Menstrual history Age and gender Lifestyle assessments, such as exercise routines

Health history, such as bleeding, fatigue, or fainting When assessing a client with a disorder of the hematopoietic or the lymphatic system, it is essential to assess the client's health history. An assessment of drug history is essential because some antibiotics and cancer drugs contribute to hematopoietic dysfunction. Aspirin and anticoagulants may contribute to bleeding and interfere with clot formation. Because industrial materials, environmental toxins, and household products may affect blood-forming organs, the nurse needs to explore exposure to these agents. Age, gender, menstrual history, or lifestyle assessments, such as exercise routines and habits, do not directly affect the hematopoietic or lymphatic system.

The nurse is instructing the client with polycythemia vera how to perform isometric exercises such as contracting and relaxing the quadriceps and gluteal muscle during periods of inactivity. What does the nurse understand is the rationale for this type of exercise? Isometric exercise programs are inclusive of all muscle groups and have an aerobic effect to increase the heart rate. Isometric exercise decreases the workload of the heart and restores oxygenated blood flow. This type of exercise increases arterial circulation as it returns to the heart. Contraction of skeletal muscle compresses the walls of veins and increases the circulation of venous blood as it returns to the heart.

Contraction of skeletal muscle compresses the walls of veins and increases the circulation of venous blood as it returns to the heart. Isometric exercise induce contraction of skeletal muscle so that it compresses the walls of veins and increases the circulation of venous blood as it returns to the heart. Isometric exercises do not have an aerobic effect and should not increase the heart rate; although, it may increase blood pressure. Isometric exercise does not decrease the workload of the heart. Arterial flow moves blood flow away from the heart after being oxygenated.

The nurse is preparing information to help a client with neutropenia and limited mobility reduce the risk of infection. Which information will the nurse include in this teaching? Select all that apply. Avoid working in the garden. Increase the intake of fluids to 3 L per day. Use the incentive spirometer every 4 hours. Report a new onset of fever to the health care provider. Encourage socialization with others.

Avoid working in the garden. Increase the intake of fluids to 3 L per day. Use the incentive spirometer every 4 hours. Report a new onset of fever to the health care provider. Neutropenia is the result of decreased production of neutrophils or increased destruction of cells. Neutrophils are essential in preventing and limiting bacterial infection. A client with neutropenia is at increased risk for infection from both exogenous and endogenous sources. Actions to reduce the risk of an infection include avoiding working in the garden because of microorganisms in the soil. Fluid intake should be increased to 3 L per day. An incentive spirometer may be used every 4 hours while awake for clients with neutropenia who have limited mobility. Any indications of an infection such as a fever should be reported to the health care provider. The client would be advised to avoid people with infections and avoid crowds and not increase the amount of time out of doors with other people.

A client is receiving platelets. In order to decrease the risk of circulatory overload in this client, what action should the nurse take? Administer each unit slowly over 3-4 hours. Infuse each unit over 30-60 minutes per client tolerance. Monitor vital signs closely before transfusion and once per shift. Flush the intravenous line with a liter of saline between units.

Infuse each unit over 30-60 minutes per client tolerance. Infuse each unit of FFP over 30-60 minutes per client tolerance. Platelet clumping will occur if administered too slowly. Vital signs should be monitored before and throughout the transfusion, not just once per shift. A liter of saline is too large an amount to flush the intravenous line and would contribute to fluid overload.