Adult Nurse I Exam 1
A trauma nurse cares for several patients with fractures. Which patient would the nurse identify as at highest risk for developing deep vein thrombosis?
A 74-year-old man who smokes and has a fractured pelvis
An intensive care nurse is aware of the need to identify clients who may be at risk of developing disseminated intravascular coagulation (DIC). Which of the following ICU clients most likely faces the highest risk of DIC?
A client who is being treated for septic shock
A client with kidney injury has decreased erythropoietin production. Upon analysis of the client's complete blood count, the nurse will expect which of the following results?
A decreased hemoglobin and hematocrit
The nurse is preparing to administer a unit of platelets to an adult client. When administering this blood product, which of the following actions should the nurse perform?
Administer the platelets as rapidly as the client can tolerate
A client's low hemoglobin level has necessitated transfusion of PRBCs. Prior to administration, what action should the nurse perform?
Assess the client's vital signs to establish baselines
When teaching a client with sickle cell disease about strategies to prevent crises, what measures should the nurse recommend?
Avoiding cold temperatures and ensuring sufficient hydration
A woman who is in her third trimester of pregnancy has been experiencing an exacerbation of iron deficiency anemia in recent weeks. When providing the client with nutritional guidelines and meal suggestions, what foods would be most likely to increase the woman's iron stores?
Beef liver accompanied by orange juice
A client is being treated for DIC and the nurse has prioritized the nursing diagnosis of Risk for Deficient Fluid Volume Related to Bleeding. How can the nurse best determine if goals of care relating to this diagnosis are being met?
Closely monitor intake and output
A client newly diagnosed with thrombocytopenia is admitted to the medical unit. After the admission assessment, the client asks the nurse to explain the disease. What potential etiology should the nurse explain to this client?
Decreased production of platelets
A client on the medical unit is receiving a unit of PRBCs. Difficult IV access has necessitated a slow infusion rate and the nurse notes that the infusion began 4 hours ago. What is the nurse's most appropriate action?
Discontinue the remainder of the PRBC transfusion and inform the health care provider
A client with poorly controlled diabetes has developed end-stage kidney injury and consequent anemia. When reviewing this client's treatment plan, the nurse should anticipate the use of what drug?
Epoetin alfa
An adult client has been diagnosed with iron deficiency anemia. What nursing diagnosis is most likely to apply to this client's health status?
Fatigue related to decreased oxygen-carrying capacity
A client comes to the clinic reporting fatigue and the health interview is suggestive of pica. Laboratory findings reveal a low serum iron level and a low ferritin level. With what would the nurse suspect that the client will be diagnosed?
Iron deficiency anemia
A nurse is providing education to a client with iron deficiency anemia who has been prescribed iron supplements. What should the nurse include in health education?
Iron will cause the stools to darken in color
A client's blood work reveals a platelet level of 17,000/mm3. When inspecting the client's integumentary system, what finding would be most consistent with this platelet level?
Petechiae
A client's diagnosis of atrial fibrillation has prompted the primary provider to prescribe warfarin. When assessing the therapeutic response to this medication, what is the nurse's most appropriate action?
Review the client's international normalized ratio (INR)
A client suffers a leg wound which causes minor blood loss. As a result of bleeding, the process of primary hemostasis is activated. What will occur during this process?
Severed blood vessels constrict
The nurse caring for a client receiving a transfusion notes that 15 minutes after the infusion of packed red blood cells (PRBCs) has begun, the client is having difficulty breathing and complains of severe chest tightness. What is the most appropriate initial action for the nurse to take?
Stop the transfusion immediately
A client is being treated for the effects of a longstanding vitamin B12 deficiency. What aspect of the client's health history would most likely predispose her to this deficiency?
The client is a vegan.
A client is being treated in the ICU after a medical error resulted in an acute hemolytic transfusion reaction. What was the etiology of this client's adverse reaction?
The donor blood was incompatible with that of the client.
A client is admitted to the hospital with pernicious anemia. The nurse should prepare to administer which of the following medications?
Vitamin B12