EX2

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 11.0g/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.

A client with a history of congestive heart failure has an order to receive 1 unit of packed red blood cells (RBCs). If the nurse hangs the blood at 12:00 pm, by what time must the infusion be completed? 2:00 pm 3:00 pm 4:00 pm 6:00 pm

4pm When packed red blood cells (PRBCs) or whole blood is transfused, the blood should be administered within a 4-hour period because warm room temperatures promote bacterial growth

Which of the following is the most common hematologic condition affecting elderly patients? Anemia Thrombocytopenia Leukopenia Bandemia

ANEMIA

A complete blood count is commonly performed before a client goes into surgery. What does this test seek to identify? A. Potential hepatic dysfunction indicated by decreased blood urea nitrogen (BUN) and creatinine levels B. Low levels of urine constituents normally excreted in the urine C. Abnormally low hematocrit (HCT) and hemoglobin (Hb) levels D. Electrolyte imbalance that could affect the blood's ability to coagulate properly

Abnormally low hematocrit (HCT) and hemoglobin (Hb) levels Low preoperative HCT and Hb levels indicate the client may require a blood transfusion before surgery. If the HCT and Hb levels decrease during surgery because of blood loss, the potential need for a transfusion increases. Possible renal failure is indicated by elevated BUN or creatinine levels. Urine constituents aren't found in the blood. Coagulation is determined by the presence of appropriate clotting factors, not electrolytes.

A client is hospitalized 3 days prior to a total hip arthroplasty and reports a high level of pain with ambulation. The client has been taking warfarin at home, which is now discontinued. To prevent the formation of blood clots, which action should the nurse take? A. Administer the prescribed enoxaparin (Lovenox). B. Encourage a diet high in vitamin K. C. Have the client limit physical activity. D. Monitor partial thromboplastin (PTT) time.

Administer the prescribed enoxaparin (Lovenox). Clients who are prescribed warfarin at home and need to have a major invasive procedure stop taking warfarin prior to the procedure. Low molecular weight heparin, such as enoxaparin, may be used until the procedure is performed. The client will continue with a diet that has a daily consistent amount of vitamin K. The client needs to ambulate frequently throughout the day. Prothrombin (PT) time is monitored, not PTT, when warfarin had been administered.

The physician performs a bone marrow biopsy from the posterior iliac crest on a client with pancytopenia. What intervention should the nurse perform after the procedure? Pack the wound with half-inch sterile gauze Administer a topical analgesic to control pain at the site Apply pressure over the site for 5-7 minutes Elevate the head of the bed to 45 degrees

Apply pressure over the site for 5-7 minutes

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? A. Ask if taking a blood pressure has ever produced bleeding under the skin or in the arm joints. B. Ask if taking a blood pressure has ever produced pain in the upper arm. C. Ask if taking a blood pressure has ever caused bruising in the hand and wrist. D. 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.

The client has been diagnosed with myelodysplastic syndrome with an absolute neutrophil count less than 1000/mm³ and is being admitted to the hospital. The nurse A. Assigns the client to a private room B. Allows unlicensed assistive personnel who reports having a sore throat to provide care C. Places the client in isolation and allows no visitors D. Changes the water in the humidifier for oxygen therapy every 48 hours

Assigns the client to a private room The client with an absolute neutrophil count less than 1000/mm³ is to be placed in a private room. Staff with a sore throat or cold should not be assigned to provide care for this client. The client does not need to be placed in isolation, but other neutropenic precautions need to be followed, such as allowing no visitors with infection. Water in oxygen humidifiers should be changed every 24 hours.

The nurse is planning care for a client with severe fatigue secondary to anemia. What concept will the nurse use as the basis for planning interventions? A. Assisting in prioritizing activities. B. Determining what days to be active. C. Keeping long activity periods to build client stamina. D. Encouraging early and frequent activities.

Assisting in prioritizing activities. When planning care for a client with severe fatigue secondary to anemia, the nurse should act collaboratively with the client and assist in prioritizing activities. The client ultimately determines the balance between rest and activity, not the nurse. The nurse will balance activities and group nursing interventions in order to prevent client fatigue.

Which type of leukocyte contains histamine and is an important part of hypersensitivity reactions? Basophils B lymphocyte Plasma cell Neutrophil

Basophils Basophils contain histamine and are an integral part of hypersensitivity reactions. B lymphocytes are responsible for humoral immunity. A plasma cell secretes immunoglobulins. The neutrophil functions in preventing or limiting bacterial infection via phagocytosis.

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.

A client reports feeling tired, cold, and short of breath at times. Assessment reveals tachycardia and reduced energy. What would the nurse expect the physician to order? CBC antibiotic chest radiograph ECG

CBC Most clients with iron-deficiency anemia have reduced energy, feel cold all the time, and experience fatigue and dyspnea with minor physical exertion. The heart rate usually is rapid even at rest. The CBC and hemoglobin, hematocrit, and serum iron levels are decreased. A CBC would be ordered.

A male client has been receiving a continuous infusion of weight-based heparin for more than 4 days. The client's PTT is at a level that requires an increase of heparin by 100 units per hour. The client has the laboratory findings shown above. What is the most important action for the nurse to take? A. Continue with the present infusion rate of heparin. B. Consult with the physician about discontinuing heparin. C. Begin treatment with the prescribed warfarin (Coumadin). D. Increase the heparin infusion by 100 units per hour.

Consult with the physician about discontinuing heparin. Platelet counts may decrease with heparin therapy, and this client's platelet count has decreased. The client may have heparin-induced thrombocytopenia (HIT). Treatment of HIT includes discontinuing the heparin. The question asks about the most important action of the nurse and that is to consult with the physician about discontinuing heparin therapy. The nurse may continue with the current rate and should not increase the heparin dose until consulting with the physician. Warfarin is not administered until the platelet count has returned to normal levels.

A patient with chronic renal failure is examined by the health care provider for anemia. Which laboratory results will the nurse monitor? A. Decreased level of erythropoietin B. Decreased total iron-binding capacity C. Increased mean corpuscular volume D. Increased reticulocyte count

Decreased level of erythropoietin As renal function decreases, erythropoietin, which is produced by the kidney, also decreases. Because erythropoietin is produced outside the kidney, some erythropoiesis continues, even in patients whose kidneys have been removed. However, the number of red blood cells produced is small and the degree of erythropoiesis is inadequate.

When conducting a health assessment on a client suspected for having a hematological disorder, the nurse should collect which data? Select all that apply. Dietary intake Medication use Ethnicity Herbal supplements Hair color

Dietary intake Medication use Herbal supplement

A client receiving a unit of packed red blood cells (PRBCs) has been prescribed morphine 1 mg intravenously now for pain. What is the best method for the nurse to administer the morphine? Add the morphine to the blood to be slowly administered. Inject the morphine into a distal port on the blood tubing. Administer the morphine into the closest tubing port to the client for fast delivery. Disconnect the blood tubing, flush with normal saline, and administer morphine.

Disconnect the blood tubing, flush with normal saline, and administer morphine.

The charge nurse should intervene when observing a new nurse perform which action after a client has suffered a possible hemolytic blood transfusion reaction? Notifying the blood bank of the reaction. Disposing of the blood container and tubing in biohazard waste. Informing the client to leave a urine sample after the client's next void. Documenting the reaction in the client's medical record.

Disposing of the blood container and tubing in biohazard waste. The blood container and tubing should be returned to the blood bank for repeat typing and culture, and the blood bank should be notified of the reaction. A urine sample is collected as soon as possible to detect hemoglobin in the urine. Documenting the client's reaction in the medical record is an appropriate action.

The nurse is educating a patient with iron deficiency anemia about food sources high in iron and how to enhance the absorption of iron when eating these foods. What can the nurse inform the client would enhance the absorption? A. Eating calf's liver with a glass of orange juice B. Eating leafy green vegetables with a glass of water C. Eating apple slices with carrots D. Eating a steak with mushrooms

Eating calf's liver with a glass of orange juice Food sources high in iron include organ meats (e.g., beef or calf's liver, chicken liver), other meats, beans (e.g., black, pinto, and garbanzo), leafy green vegetables, raisins, and molasses. Taking iron-rich foods with a source of vitamin C (e.g., orange juice) enhances the absorption of iron.

A nurse in an oncology clinic is assessing a client who has early stage Hodgkin's lymphoma. Which of the following findings should the nurse expect? A. Bone and joint pain B. Enlarged lymph nodes C. Intermittent hematuria D. Productive cough

Enlarged lymph nodes Hodgkins lymphoma is a malignancy of lymphoid tissue found in the lymph nodes, spleen, liver, and bone marrow. The first manifestations of this cancer is often an enlarged painless lymph node (or nodes) that appears without a known cause. Other early manifestations include night sweats, unexplained weight loss fevers, and pruritus. The disease can spread to adjacent lymph nodes and later might spread outside the lymph nodes to the lungs, liver, bones or bone marrow. The spready of Hodgkins lymphoma usually occurs in an ordered pattern.

A patient is undergoing platelet pheresis at the outpatient clinic. What does the nurse know is the most likely clinical disorder the patient is being treated for? Essential thrombocythemia Extreme leukocytosis Sickle cell anemia Renal transplantation

Essential thrombocythemia Platelet pheresis is used to remove platelets from the blood in patients with extreme thrombocytosis or essential thrombocythemia (temporary measure)or in a single-donor platelet transfusion.

A nurse is teaching a client who is preoperative for a cystoscopy. Which of the following statements should the nurse make? A. you will need to keep the sutures clean after this procedure B. You will be placed on your left side for this procedure C. Expect to be on bed rest for 24 hr after this procedure D. Expect to have pink-tinged urine after this procedure

Expect to have pink-tinged urine after this procedure A cystoscopy is a procedure in which a scope is inserted into the urethra to diagnose or treat bladder problems. following the procedure pink tinged urine is expected

Which term describes the percentage of blood volume that consists of erythrocytes? Hematocrit Differentiation Erythrocyte sedimentation rate (ESR) Hemoglobin

Hematocrit Hematocrit is the percentage of blood volume consisting of erythrocytes. Differentiation is the development of functions and characteristics that differ from those of the parent stem cell. ESR is a laboratory test that measures the rate of settling of red blood cells (RBCs); an elevated rate is indicative of inflammation. Hemoglobin is the iron-containing protein of RBCs.

A nurse is performing an initial assessment and notes the client's skin is a gray-tan color, especially on the scars of the client's arms. Which hematological condition does the nurse suspect? Polycythemia Vitamin B12 deficiency Thrombocytopenia Hemochromatosis

Hemochromatosis Hemochromatosis is an autosomal recessive disease of excessive iron absorption. This results in bronze or gray-tan skin, especially over scars. The other answer choices are hematological conditions; however, these do not cause the skin to turn a gray-tan color.

A client is scheduled for surgery to remove an abdominal mass. The nurse knows that which reason hemodilution would be contraindicated as a method to provide blood to the client during the surgery? History of renal disease Previous thyroidectomy Treatment for osteoarthritis Takes medications for seasonal allergies

History of renal disease

A hospice nurse is providing education about palliative care to the partner of a client who has end-stage liver cancer. Which of the following statements by the partner indicates and understanding of teaching? A. I will do my best to try to get him to eat something B. I will lay him flat if his breathing becomes shallow C. I will use an electric blanket to keep him warm D. I will continue to talk to him even when he's sleeping

I will continue to talk to him even when he's sleeping The nurse should reinforce to the partner that the clients hearing is thought to be the last sense to leave during the dying process. Therefore continue to communicate softly with the client.

A nurse provides nutritional information for a patient diagnosed with an iron-deficiency anemia. What education should the nurse provide? A. Decrease the intake of citrus fruits because they interfere with iron absorption. B. Take an iron supplement with meals to reduce gastric irritation. C. Increase the intake of green, leafy vegetables. D. Decrease the intake of high-fat red meats, especially organ meats.

Increase the intake of green, leafy vegetables. Leafy greens, such as spinach, kale, swiss chard, collard and beet greens contain between 2.5-6.4 mg of iron per cooked cup. Clients should be encouraged to consume more green, leafy vegetables. Red meats, especially organ meats, are iron-rich foods and the client should not be discouraged from eating them. Vitamin C sources (citrus fruit and juices) enhance the absorption of iron, which should be taken 1 hour before or 2 hours after a meal.

A nurse is preparing an in-service about the stages of acute kidney injury (AKI). Which of the following pieces of information should the nurse include about prerenal azotemia? A. Prerenal azotemia begins prior to the onset of symptoms B. Interference with renal perfusion causes prerenal azotemia C. Prerenal azotemia is irreversible, even in the early stages D. Infections and tumors cause prerenal azotemia

Interference with renal perfusion causes prerenal azotemia Prerenal azotemia results from interference with renal perfusion such as from heart failure or hypovolemic shock. In early stages reversal of prerenal azotemia is possible with correction of hypovolemia and improvement in blood pressure and cardiac output

A patient who has long-term packed RBC (PRBC) transfusions has developed symptoms of iron toxicity that affect liver function. What immediate treatment should the nurse anticipate preparing the patient for that can help prevent organ damage? Iron chelation therapy Oxygen therapy Therapeutic phlebotomy Anticoagulation therapy

Iron chelation therapy

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? A. It is part of the required assessment information. B. It is important for the nurse to determine what type of foods the patient will eat. C. It may indicate deficiencies in essential nutrients. D. 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 reports feeling faint after donating blood. What is the nurse's best action? Assist the client into high-Fowler's position. Keep client in recumbent position to rest. Ambulate client with assistance. Place the client in Trendelenburg position.

Keep client in recumbent position to rest After blood donation, the donor should remain recumbent until he or she feels able to sit up. Donors who experience weakness or faintness should rest for a longer period. High-Fowler's position would not promote blood flow to the brain, and could cause the client to feel light-headed or faint. Ambulating a client who feels faint is not safe due to the high risk of falling. Trendelenburg position is not recommended after blood donation.

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 Various blood cell types have unique, major functions. Leukocytes fight infection, T lymphocytes are integral in cell-mediated immunity, plasma cells secrete immunoglobulin, and B lymphocytes are integral in humoral immunity.

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

Liver

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? A. Monitoring the client's temperature and reviewing the client's complete blood count (CBC) with differential B. Monitoring the client's breathing and reviewing the client's arterial blood gases C. Monitoring the client's heart rate and reviewing the client's hemoglobin D. 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

A client with a diagnosis of pernicious anemia comes to the clinic and reports numbness and tingling in the arms and legs. What do these symptoms indicate? A. Loss of vibratory and position senses B. Neurologic involvement C. Severity of the disease D. 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.

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).

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.

A nurse is caring for a client admitted with pernicious anemia. Which set of findings should the nurse expect when assessing the client? A. Pallor, bradycardia, and reduced pulse pressure B. Pallor, tachycardia, and a sore tongue C. Sore tongue, dyspnea, and weight gain D. Angina pectoris, double vision, and anorexia

Pallor, tachycardia, and a sore tongue

A nurse is caring for a client who is receiving chemotherapy to treat cancer. Which of the following adverse effects should the nurse anticipate from chemotherapy? A. Gingival hyperplasia B. Hirsutism C. Pancytopenia D. Weight gain

Pancytopenia ( a deficiency of white blood cells, red blood cells and platelet count) is an expected adverse effect of chemotherapy

A nurse is caring for a client with severe anemia. The client is tachycardic and reports dizziness and exertional dyspnea. What signs and symptoms might develop if this client goes into heart failure? A. Peripheral edema B. Nausea and vomiting C. Migraine D. Fever

Peripheral edema Cardiac status should be carefully assessed in clients with anemia. When the hemoglobin level is low, the heart attempts to compensate by pumping faster and harder in an effort to deliver more blood to hypoxic tissue. This increased cardiac workload can result in such symptoms such as tachycardia, palpitations, dyspnea, dizziness, orthopnea, and exertional dyspnea. Heart failure may eventually develop, as evidenced by an enlarged heart (cardiomegaly) and liver (hepatomegaly), and by peripheral edema. Nausea, migraine, and fever are not associated with heart failure.

A client awaiting a bone marrow aspiration asks the nurse to explain where on the body the procedure will take place. What body part does the nurse identify for the client? Posterior iliac crest Sternum Femur Ankle

Posterior iliac crest

The nurse obtains a unit of blood for the client, Donald D. Smith. The name on the label on the unit of blood reads Donald A. Smith. All the other identifiers are correct. What action should the nurse take? A. Administer the unit of blood B. Check with the blood bank first and then administer the blood with their permission C. Refuse to administer the blood D. Ask the client if he was ever known as Donald A. Smith

Refuse to administer the blood To ensure a safe transfusion, all components of the identification must be correct. The nurse should refuse to administer the blood and notify the blood bank about the discrepancy. The blood bank should then take the necessary steps to correct the name on the label on the unit of blood.

The nurse is working at a blood donation clinic. What teaching should the nurse provide to the donor immediately after blood donation? Hold the involved arm below the heart. Remove the band-aid after 5 minutes. Sit up promptly after the needle is removed. Remain for observation after eating and drinking.

Remain for observation after eating and drinking.

A nurse is assessing a client who has an abdominal aortic aneurysm (AAA). Which of the following findings indicates that the AAA is expanding? A. increased BP and decreased pulse rate B. Jugular vein distention and peripheral edema C. Report of sudden severe back pain D. Report of retrosternal chest pain radiating to the left arm

Report of sudden severe back pain An aortic aneurysm is a weak spot in the wall of the aorta (the primary artery that carries blood from the heart to the head and extremities) that allows the aorta to expand and increase in diameter. Sudden and increasing lower abdominal and back pain indicates that the aneurysm is extending downward and pressing on the lumbar sacral nerve roots

Place the following steps in order when determining the type and severity of a transfusion reaction. Use all options. Stop the transfusion. Assess the client. Notify the health care provider. Send the tubing and container to the blood bank. Notify the blood bank.

Stop the transfusion. Assess the client. Notify the health care provider. Notify the blood bank. Send the tubing and container to the blood bank.

The health care provider believes that the client has a deficiency in the leukocyte responsible for cell-mediated immunity. What should the nurse check the WBC count for? Basophils Monocytes Plasma cells T lymphocytes

T lymphocytes

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.

The nurse is caring for a client with hypoxia. What does the nurse understand is true regarding the client's oxygen level and the production of red blood cells? The kidneys sense low oxygen levels in the blood and produce erythropoietin, stimulating the bone marrow to produce more red blood cells. The bone marrow is stimulated by low oxygen levels in the blood to produce erythropoietin, maturing the red blood cells. The brain senses low oxygen levels in the blood and produces hemoglobin, which binds to more red blood cells. The kidneys sense low oxygen levels in the blood and produce hemoglobin, stimulating the marrow to produce more red blood cells.

The kidneys sense low oxygen levels in the blood and produce erythropoietin, stimulating the bone marrow to produce more red blood cells.

Place the order of the steps of primary hemostasis in correct order. The severed blood vessel constricts. Circulating inactive clotting factors convert to active forms. An unstable hemostatic plug is formed. The circulating platelets aggregate at the site and adhere to the vessel.

The severed blood vessel constricts. The circulating platelets aggregate at the site and adhere to the vessel. An unstable hemostatic plug is formed. Circulating inactive clotting factors convert to active forms.

After receiving chemotherapy for lung cancer, a client's platelet count falls to 98,000/mm3. What term should the nurse use to describe this low platelet count? Anemia Leukopenia Thrombocytopenia Neutropenia

Thrombocytopenia

x A nurse on a hematology/oncology floor is caring for a client with aplastic anemia. Which would not be included in the client's discharge instructions? A. Use a disposable razor when shaving. B. Avoid contact with family/friends who are sick. C. Encourage frequent handwashing. D. Plan for frequent periods of rest.

Use a disposable razor when shaving.

While caring for a client, the nurse notes petechiae on the client's trunk and lower extremities. What precaution will the nurse take when caring for this client? Use an electric razor when assisting client with shaving. Elevate the client's head of the bed. Where a mask when entering the client's room. Apply supplemental oxygen to maintain the client's oxygenation.

Use an electric razor when assisting client with shaving.

A nurse is caring for a client with thrombocytopenia. What is the best way to protect this client? A. Limit visits by family members. B. Encourage the client to use a wheelchair. C. Use the smallest needle possible for injections. D. Maintain accurate fluid intake and output records.

Use the smallest needle possible for injections. Because thrombocytopenia alters coagulation, it poses a high risk of bleeding. To help prevent capillary bleeding, the nurse should use the smallest needle possible when administering injections. The nurse doesn't need to limit visits by family members because they don't pose any danger to the client. The nurse should provide comfort measures and maintain the client on bed rest; activities such as using a wheelchair can cause bleeding. The nurse records fluid intake and output to monitor hydration; however, this action doesn't protect the client from a complication of thrombocytopenia.

a nurse is monitoring client for reperfusion following thrombolytic therapy to treat acute myocardial infarction (MI). Which of the following should the nurse identify to confirm reperfusion? A. Ventricular dysrhythmias B. Appearance of Q waves C. Elevated ST segments D. Recurrence of chest pain

Ventricular dysrhythmias The appearance of ventricular dysrhythmias following thrombolytic therapy is a sign of reperfusion of the coronary artery.

The client is to receive a unit of packed red blood cells. What is the nurse's first action? Check the label on the unit of blood with another registered nurse. Ensure that the intravenous site has a 20-gauge or larger needle. Observe for gas bubbles in the unit of packed red blood cells. Verify that the client has signed a written consent form.

Verify that the client has signed a written consent form.

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? A. Women lose iron through menstrual cycles B. Women rarely manifest the gene expression C. Women have lower hemoglobin levels D. Women require grater folic acid supplementation

Women lose iron through menstrual cycles

A nurse is providing teaching to a client who is preoperative for a renal biopsy. Which of the following statements should the nurse make? A. You will be NPO for 8 hr following the procedure B. An allergy to shellfish is a contraindication to this procedure C. You will need to be on bed rest following the procedure D. A creatinine clearance is needed prior to the procedure

You will need to be on bed rest following the procedure A renal biopsy involves a tissue biosy through needle insertion into the lower lobe of the kidney. The client should maintain bed rest in a supine position with a back roll for support for 2 to 24 hours following the procedure to reduce the risk of bleeding. the nurse can elevate the head of the bed.

The nurse is obtaining the health history of a client suspected of having a hematological condition. The nurse notes the client has a history of alcohol abuse. Which clinical presentation is related to alcohol consumption? Myelodysplastic syndrome Neutropenia Anemia Thrombocytopenia

anemia

The nurse should be alert to which adverse assessment finding when transfusing a unit of packed red blood cells (PRBCs) too rapidly? Crackles auscultated bilaterally Respiratory rate of 10 breaths/minute Oral temperature of 97°F Pain and tenderness in calf area

crackles auscultated bilaterally Increasing the flow rate of a blood transfusion too rapidly can result in circulatory overload. Fluid overload can be manifested by crackles in the lungs. A decreased respiratory rate and decreased temperature are not manifestations of fluid overload. Pain and tenderness in the calf area may indicate a thrombosis which is not as common a manifestation as fluid overload.

A nurse is teaching a client who has pernicious anemia. The nurse should encourage the client to increase consumption of which of the following foods? A. Eggs B. Squash C. Kale D. Tofu

eggs The nurse should encourage the client to increase consumption of foods rich in vitamin b12, such as dairy products, animal protein, poultry, shellfish, and eggs

A nurse is caring for a client who has severely elevated blood pressure. Which of the following findings should the nurse identify as a manifestation of hypertension? A. Vertigo B. Epistaxis C. Exophthalmos D. spondylolisthesis

epistaxis a nosebleed is a manifestation of elevated blood pressure. hypertension is often asymptomatic, but when it is severely elevated, it can also cause headaches dizziness facial flushing and fainting

A nurse is caring for a client whose surgeon informed him postoperatively that he has a metastasizing malignant neoplasm in the colon. Which of the following statements by the client should the nurse identify as an indication that the client understands this information? A. i have cancer of the colon that has begun to spread B. I have growths in my bowel that the doctor can treat easily C. As long as my tumor doesn't get any bigger ill be ok D. There is not much point in having more treatments

i have cancer of the colon that has begun to spread

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

petechiae

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." Despite advances in donor screening and blood testing, certain diseases can still be transmitted by transfusion of blood components (Chart 32-4).

A home care nurse visits a client diagnosed with atrial fibrillation who is ordered warfarin. The nurse teaches the client about warfarin therapy. Which statement by the client indicates the need for further teaching? A. "I'll watch my gums for bleeding when I brush my teeth." B. "I'll use an electric razor to shave." C. "I'll eat four servings of fresh, dark green vegetables every day." D. "I'll report unexplained or severe bruising to my doctor right away."

"I'll eat four servings of fresh, dark green vegetables every day." The client requires additional teaching if he states that he'll eat four servings of dark green vegetables every day. Dark, green vegetables contain vitamin K, which reverses the effects of warfarin. The client should limit his intake to one to two servings per day. The client should report bleeding gums and severe or unexplained bruising, which may indicate an excessive dose of warfarin. The client should use an electric razor to prevent cutting himself while shaving.

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.

Parents arrive to the clinic with their young child and inform the nurse the child has just been diagnosed with sickle cell disease. The parents ask the nurse how this could have happened and which one of them is the carrier. What is the best response by the nurse? A. "Most likely, the father is the carrier of the gene." B. "The trait is passed down through the mother." C. "The child must inherit two defective genes, one from each parent." D. "It is an acquired, not a hereditary disorder."

"The child must inherit two defective genes, one from each parent." Sickle cell disease is a hereditary disorder. To manifest this disorder, a person must inherit two defective genes, one from each parent, in which case all the hemoglobin is inherently abnormal. If the person inherits only one gene, the person carries the sickle cell trait. The hemoglobin of those who have sickle cell trait is about 40% affected. The other distractors are incorrect due to these factors.

A patient with sickle cell anemia is to begin treatment for the disease with hydroxyurea. What does the nurse inform the patient will be the benefits of treatment with this medication? Select all that apply. A. Fewer painful episodes of sickle cell crisis B. Lower incidence of acute chest syndrome C. Decreased need for blood transfusions D. Decreased need for other analgesic medications E. Ability to reverse the damage done from sickling of cells

-Fewer painful episodes of sickle cell crisis -Lower incidence of acute chest syndrome -Decreased need for blood transfusions Hydroxyurea is a chemotherapy agent that is effective in increasing fetal hemoglobin (i.e., hemoglobin F) levels in patients with sickle cell anemia, thereby decreasing the formation of sickled cells. Patients who receive hydroxyurea appear to have fewer painful episodes of sickle cell crisis, a lower incidence of acute chest syndrome, and less need for transfusions. However, whether hydroxyurea can prevent or reverse actual organ damage remains unknown.

A nurse is reviewing a client's most recent platelet count and identifies the need to institute bleeding precautions. Which result would the nurse most likely have noted to warrant these precautions? 200,000 /mm3 110,000/mm3 90,000/mm3 45,000/mm3

45000

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. A hemolytic reaction to mismatched blood b. A hemolytic reaction to Rh-incompatible blood c. A hemolytic allergic reaction caused by an antigen reaction d. 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 nurse is providing teaching to a client who has gout and urolithiasis. The client asks how to prevent future uric acid stones. Which of the following suggestions should the nurse provide? A. take allopurinol as prescribed B. exercise several times a week C. Limit intake of foods high in purine D. Decrease daily fluid intake E. Avoid citrus juices

A. take allopurinol as prescribed B. exercise several times a week C. Limit intake of foods high in purine

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? A. Isometric exercise programs are inclusive of all muscle groups and have an aerobic effect to increase the heart rate. B. Isometric exercise decreases the workload of the heart and restores oxygenated blood flow. C. This type of exercise increases arterial circulation as it returns to the heart. D. 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.

Post transfusion, the donor stands up immediately after the needle is withdrawn. The nurse should be alert for which vital sign change? Decreased blood pressure. Decreased pulse. Decreased respiratory rate. Elevated temperature.

Decreased pulse.

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.

A client wants to donate blood before his or her abdominal surgery next week. What should be the nurse's first action? A. Provide the client with a list of the nearest donation centers. B. Explain the time frame needed for autologous donation. C. Remind the client to take supplemental iron before donation. D. Tell the client that 2 units of blood will be needed.

Explain the time frame needed for autologous donation. Preoperative autologous donations are ideally collected 4 to 6 weeks before surgery. The nurse should first explain that time frame to this client. Surgery is scheduled in one week which means that autologous blood donation may not be an option for this client. A list of donation centers can be provided to the client; and even though iron is recommended and 2 units of blood may be suggested, the first action is to tell the client about the needed time frame for donation.

The nurse is preparing a patient for a bone marrow aspiration and biopsy from the site of the posterior superior iliac crest. What position will the nurse place the patient in? Lateral position with one leg flexed Lithotomy position Supine with head of the bed elevated 30 degrees Jackknife position

Lateral position with one leg flexed

A client with weakness, fatigue, and general malaise is being tested for iron deficiency anemia. Which laboratory values will the nurse expect to confirm this diagnosis? Select all that apply. Mean corpuscle volume of 70 Hematocrit of 56% Hemoglobin of 11.0 Ferritin level of 20 Total iron-binding capacity of 450 mcg/dL

Mean corpuscle volume of 70 Hemoglobin of 11.0 Ferritin level of 20 Total iron-binding capacity of 450 mcg/dL

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? A. Observe the client's stools for blood. B. Evaluate the client's dietary intake. C. Monitor the client's body temperature. D. 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.

A pregnant woman is hospitalized as the result of sickle-cell crisis. Which finding indicates the outcome has been achieved for this client? A. Reports joint pain less than 3 on a scale of 0 to 10 B. Takes hydroxyurea during her pregnancy C. Exhibits a temperature more than 100.3°F D. Describes the importance of staying cool

Reports joint pain less than 3 on a scale of 0 to 10 An expected outcome for a client experiencing a sickle-cell crisis is control and reduction of pain. Hydroxyurea is contraindicated in pregnancy because of the risk it poses for congenital abnormalities. An indication that the client is free from infection is exhibiting a normal temperature; 100.3°F is an elevated temperature. To minimize crises, the client needs to stay warm not cool.

A nurse is caring for a client with a diagnosis of lymphocytopenia. Which assessment finding will the nurse consider most concerning when caring for this client? Prothrombin time 12 seconds INR 0.9 Temperature of 37.7 degrees Celsius Blood pressure 132/92

Temperature of 37.7 degrees Celsius Lymphocytopenia is a decrease in the number of lymphocytes. Lymphocytes help to fight foreign invaders, such as infectious organisms. A temperature of 37.7 degree Celsius is a Fahrenheit temperature of 99.9. A low-grade fewer may be indicative of an infection. The other answer choices do not suggest infection and are not the priority concern.

A client with Hodgkin disease had a bone marrow biopsy yesterday and reports aching at the biopsy site, rated a 5 (on a 1-10 scale). After assessing the biopsy site, which nursing intervention is most appropriate? Notify the physician Administer aspirin (ASA) 325 mg po, as ordered Administer acetaminophen 500 mg po, as ordered Reposition the client to a high Fowler position and continue to monitor the pain

administer acetaminophen After a 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 biopsy, but the site of a biopsy may ache for 1 or 2 days. Warm tub baths and a mild analgesic agent (e.g., acetaminophen) may be useful. Aspirin-containing analgesic agents should be avoided it the immediate post-procedure period because they can aggravate or potentiate bleeding.

A nurse is completing a history and physical assessment for a client who has chronic pancreatitis. Which of the following findings should the nurse identify as a likely cause of the client's condition? A. High-calorie diet B. prior gastrointestinal illnesses C. Tobacco use D. Alcohol use

alcohol use Alcohol consumption is a major cause of chronic pancreatitis in the US long term alchold use disorder produces hypersecretion of protein in pancreatic secretions which results in protein plugs and calculi within the pancreatic ducts. Alcohol also has a direct toxic effect on the cells of the pancreas. Damage to these cells is more likely to occur and to be more severe in clients whose diets are poor in protein content and either very high or very low in fat

A nurse is caring for a client who has lung cancer that has metastasized. Which of the following findings indicates the client is developing superior vena cava syndrome? A. irregular cardiac rhythm B. numbness in the hands C. muscle cramps D. facial edema

facial edema Superior vena cava syndrome is a medical emergency resulting from a partial occlusion of the superior vena cava, leading to a decreased blood flow through the vein. Most cases of superior vena cave syndrome are associated with cancers involving the clients upper chest (advanced lung and breast cancers and lymphoma) the earliest manifestations of superior vena cava are facial and upper extremity edema. Death can result if the compression is not corrected

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 factor studies are used to identify diseases where these factors are absent or insufficient; hemophilia is among the most common of these diseases and is associated with Factor VII. Factor VII is not related to leukemia, lymphoma, or anemia.

A nurse is caring for a patient who has had a bone marrow aspiration with biopsy. What complication should the nurse be aware of and monitor the patient for? A. Hemorrhage B. Blood transfusion reaction C. Shock D. Splintering of bone fragments

hemorrhage Hazards of either bone marrow aspiration or biopsy include bleeding and infection. The risk of bleeding is somewhat increased if the patient's platelet count is low or if the patient has been taking a medication (e.g., aspirin) that alters platelet function.

A nurse is providing teaching to a client who has cervical cancer and is schedule to receive brachytherapy in an ambulatory care clinic. Which of the following statements by the client indicates and understanding of the teaching? A. i need to lie still in bed during my brachytherapy treatment B. I will have an implant placed once a month during my brachytherapy treatment C. I must stay at least 3 feet away from otheres between brachytherapy treatments D. I should expect some blood in my urine after each brachytherapy

i need to lie still in bed during my brachytherapy treatment

The nurse is caring for a client who has a unit of whole blood removed every 6 weeks as treatment for polycythemia vera. Which laboratory test will the nurse monitor to determine if the procedure is adversely affecting the client? Iron Calcium Potassium White blood cell count

iron Therapeutic phlebotomy is the removal of a certain amount of blood under controlled conditions. A client with an elevated hematocrit from polycythemia vera can usually be managed by periodically removing 1 unit (about 500 mL) of whole blood. Over time, this process can produce iron deficiency, Therapeutic phlebotomy does not affect the calcium or potassium levels or the white blood cell count.

A community health nurse is teaching a group of clients about melanoma. Which of the following characteristics of lesions associated with melanoma should the nurse include in the teaching? A. One solid color B. Symmetrical shape C. <6 mm in diameter D. Irregular border

irregular border the nurse should identify that skin cancer lesions, including melanoma are expected to exhibit border irregularity. The nurse should instruct clients on the use of the ABCDE when monitoring skin lesions: asymmetry of shape, border irregularity, color variation within one lesion, diameter of >6 mm, and evolution of any feature

A nurse is caring for a client who is receiving brachytherapy. which of the following measures should the nurse include in the clients plan of care? A. plan to spend extra time with the client to provide emotional support B. ensure that chemotherapy medications do not extravasate into the clients tissue C. Keep the door to the clients room closed D. Encourage family members and friend to visit for at least 1 hr per day

keep the door to the clients room closed brachytherapy is a type of radiation therapy during which the radiation source is in direct contact with the clients tumor. During the therapy the client emits radiation and is potentially hazardous to others. the client should be in a private room with a private bathroom and the nurse should keep the door to the clients room closed

a nurse is teaching a client who has chronic kidney disease. Which of the following instructions should the nurse include? A. limit fluid intake B. Limit caloric intake C. Eat a diet high in phosphorus D. Eat a diet high in protein

limit fluid intake should limit fluid intake to prevent hypervolemia.

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

lymphocyte

A nurse is reviewing a client's morning laboratory results and notes a left shift in the band cells. Based on this result, the nurse can interpret that the client may be developing an infection. may be developing anemia. has leukopenia. has thrombocytopenia.

may be developing an infection Less mature granulocytes have a single-lobed, elongated nucleus and are called band cells. Ordinarily, band cells account for only a small percentage of circulating granulocytes, although their percentage can increase greatly under conditions in which neutrophil production increases, such as infection. An increased number of band cells is sometimes called a left shift or shift to the left. Anemia refers to decreased red cell mass. Leukopenia refers to a less-than-normal amount of white blood cells in circulation. Thrombocytopenia refers to a lower-than-normal platelet count.

The nurse is completing a pretransfusion assessment to determine a female client's history of previous transfusions as well as previous reactions to transfusions. Which is the most important information to obtain from this client before the transfusion? Diagnosis Age Number of pregnancies Family history of transfusion reactions

number of pregnancies The history should include the type of reaction, its manifestations, the interventions required, and whether any preventive interventions were used in subsequent transfusions. The nurse assesses the number of pregnancies a woman has had because a high number can increase her risk of reaction due to antibodies developed from exposure to fetal circulation. Other concurrent health problems should be noted, with careful attention paid to cardiac, pulmonary, and vascular diseases.

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: A. to the bathroom. B. to the bedside commode. C. onto the bedpan. D. 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.

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 nurse is transfusing whole blood to a client with impaired renal function. During the transfusion, the client tells the nurse, "I feel very short of breath all of a sudden." What is the nurse's primary action? A. Assess the client's vital signs. B. Stop the infusion. C. Call the health care provider. D. Slow the infusion.

stop the infusion A client with impaired renal function is at increased risk for transfusion-associated circulatory overload (TACO). Signs of circulatory overload include dyspnea, orthopnea, tachycardia, an increase in blood pressure, and sudden anxiety. If the symptoms are mild, the nurse may be able to slow the infusion and administer diuretics; however, sudden shortness of breath should clue the nurse to immediately stop the infusion and sit the client upright with feet dangling. Next, the nurse will notify the health care provider after normal saline is infused into the site. Only after stopping the infusion will the nurse obtain the client's vital signs.

A nurse cares for a client with megaloblastic anemia who had a total gastrectomy three years ago. What statement will the nurse include in the client's teaching regarding the condition? A. "The condition is likely caused by a folate deficiency." B. "The condition causes abnormally small red blood cells." C. "The condition is likely caused by a vitamin B12 deficiency." D. "The condition causes abnormally rigid red blood cells."

the condition is likely caused by a vitamin b 12 deficiency Vitamin B12 combines with intrinsic factor produced in the stomach. The vitamin B12 -intrinsic factor complex is absorbed in the distal ileum. Clients who have had a partial or total gastrectomy may have limited amounts of intrinsic factor, and the absorption of vitamin B12 may be diminished. Megaloblastic anemia may be caused by a folate deficiency; however, the client's history of gastrectomy indicates the likely cause is a vitamin B12 deficiency. Megaloblastic anemia causes large erythrocytes (RBCs), not small or rigid.