last exam

Which risk factor does the nurse assess for to determine a client's cause of anemia?

Chronic alcoholism

The nurse observes yellowtinged sclera in a client with dark skin. Based on this assessment finding, what does the nurse do next?

Inspect the client's hard palate.

The nurse is caring for a client during a sickle cell crisis. Which intervention does the nurse implement for the client?

Keep the room temperature at 80° F.

When obtaining the client's health history, which priority question does the nurse ask this client?

"Do you notice any changes in your memory?"

The nurse is assessing a client with numerous areas of bruising. Which question does the nurse ask to determine the cause of this finding?

"Do you take aspirin?"

The nurse is planning discharge teaching for a client who has a splenectomy. Which statement does the nurse include in this client's teaching plan?

"Avoid crowds and people who are sick."

A client is newly diagnosed with sickle cell anemia. Which information does the nurse include in the client's discharge instructions?

"Be aware of the early symptoms of crisis."

The nurse is completing the preoperative checklist on a client. The client states, "I take an aspirin every day for my heart." How does the nurse respond?

"I need to call the surgeon and reschedule your surgery."

The nurse is teaching a client who has undergone a bone marrow biopsy. Which instruction does the nurse give the client?

"Monitor the biopsy site for bruising."

The nurse is assessing the following laboratory results of a client before discharge. Which instruction does the nurse include in this client's discharge teaching plan?

"Perform good hand hygiene."

The nurse is caring for four clients with hematologictype problems. Which client does the nurse prioritize to see first?

60yearold female with decreased erythropoietin

The nurse is caring for a client who had a bone marrow aspiration. The client begins to bleed from the aspiration site. Which action does the nurse perform?

Apply external pressure to the site.

The nurse is assessing a client with liver failure. Which assessment is the highest priority for this client?

Assessing for signs of bleeding

A client who has sickle cell anemia is admitted to the hospital. The client reports severe pain. Which action does the nurse take first?

Begin intravenous fluids at 250 mL/hr.

The nurse is administering a prescribed fibrinolytic to a client who is having a myocardial infarction (MI). Which adverse effect does the nurse monitor for?

Bleeding

The nurse prepares to administer a blood transfusion to a client. Which means of identification does the nurse use to ensure that the blood is administered to the correct client?

Compare the name and ID number on the blood product tag with the name and ID number on the client's ID band.

The nurse is assessing a client whose warfarin (Coumadin) therapy was discontinued 3 weeks ago. Which laboratory test result indicates that the client's warfarin therapy is no longer therapeutic?

International normalized ratio (INR), 0.9

The nurse is caring for a client who is receiving chemotherapy for cancer. Which intervention does the nurse implement for this client?

Maintain strict Standard Precautions.

The nurse is caring for a client who is receiving heparin therapy. How does the nurse evaluate the therapeutic effect of the therapy?

Monitor the partial thromboplastin time (PTT).

The nurse is transfusing red blood cells to a client who has sickle cell disease. Which laboratory result indicates that the nurse should discontinue the transfusion?

Serum iron level, 300 mcg/dL

The nurse is assessing a client with a history of heart failure who is receiving a unit of packed red blood cells. The client's respiratory rate is 33 breaths/min and blood pressure is 140/90 mm Hg. Which action does the nurse take first?

Slow the infusion rate of the transfusion.

The nurse is teaching a client who has iron deficiency anemia. Which food choice indicates that the client correctly understands the teaching?

Steak

A client who is receiving a unit of red blood cells begins to report chest and lower back pain. Which action does the nurse take first?

Stop the transfusion.

The nurse is caring for a client who has autoimmune thrombocytopenic purpura. Which intervention does the nurse implement for this client?

Avoid intramuscular injections.

The nurse is preparing a client for a bone biopsy and aspiration. The client asks,"Will this be painful?" How does the nurse respond?

"There is a chance that you may have pain."

The nurse is planning care for a client who has a platelet count of 30,000/mm3 Which intervention does the nurse include in this client's plan of care?

Bleeding Precautions

The nurse is planning care for a client who has leukemia. Which intervention does the nurse include in the plan of care to prevent fatigue?

Plan care for times when the client has the most energy.

The nurse is preparing to transfuse a third unit of red blood cells to a client.Which laboratory result is the nurse most concerned about?

Potassium level of 5.5 mg/dL

The nurse assesses that a client has a smooth, beefy red tongue. Which intervention does the nurse implement for this client?

Provide a diet high in green leafy vegetables.

The nurse is teaching a client who is being discharged after stem cell transplantation. Which instruction does the nurse include in this client's discharge teaching?

Wash your hands frequently.

The nurse is assessing a client's susceptibility to rejecting a transplanted kidney. Which result does the nurse recognize as increasing the client's chances of rejection?

Increased cytotoxiccytolytic T cell

The nurse is teaching a client who is being discharged to home after bone marrow transplantation. The client asks, "Why is it so important to protect myself from injury?" How does the nurse respond?

"Platelet recovery is slow, which makes you at risk for bleeding."

The nurse is teaching a client who has sickle cell disease and was admitted for splenomegaly and abdominal pain. Which instruction does the nurse include in the client's discharge teaching?

"Receive a yearly influenza vaccination."

The nurse is teaching a client who is scheduled to undergo allogeneic bone marrow transplantation. Which statements indicate that the client correctly understands the teaching? (Select all that apply.)

"The transplant does not start working immediately." "I will need chemotherapy before my transplant."

The nurse is teaching a client who has myelodysplastic syndrome. Which instruction does the nurse include in this client's teaching?

"Use a softbristled toothbrush."

The nurse is teaching a client who was recently diagnosed with thrombocytopenia. Which instruction does the nurse include in this client's discharge teaching?

"Use a softbristled toothbrush."

The nurse is preparing a client for surgery. The client states, "I am concerned I might be given blood products during surgery and this would be against my religious beliefs." How does the nurse respond?

"We can use other means to replace blood loss besides blood products."

The nurse is preparing a client for surgery. The client states, "I am concerned I might be given blood products during surgery and this would be against my religious beliefs." How does the nurse respond?

"We can use other means to replace blood loss besides blood products."

The nurse is caring for a 20 yearold man who has Hodgkin's lymphoma in the abdominal and pelvic regions. The client is scheduled for radiation therapy and states, "I want to have children someday, and this procedure will destroy my chances." How does the nurse respond?

"You have the option to store sperm in a sperm bank."

The nurse is preparing a client with leukemia for a peripheral stem cell transfusion. Which information does the nurse provide the client?

"Your urine may be red for a short time."

The nurse observes that a client, whose blood type is AB negative, is receiving a transfusion with type Onegative packed red blood cells. Which action does the nurse take first?

Assess and record the client's vital signs.

The nurse is planning discharge teaching for a client who has acute myelogenous leukemia (AML). Which instruction does the nurse include in this client's discharge plan?

Avoid contact sports.

The nurse is preparing to administer transfusion therapy to a client. Which interventions does the nurse implement before starting the infusion? (Select all that apply.)

Check the client's ABO and Rh types with the blood tag. Place a 20gauge needle or larger in the client's forearm. Assess the client's temperature.

The nurse is caring for a client who has a decreased serum iron level. Which intervention does the nurse prioritize for this client?

Dietary consult

The nurse is assessing a client with anemia. Which clinical manifestation does the nurse expect to see in this client?

Dyspnea with activity

The nurse is obtaining the health history of a client who has iron deficiency anemia. Which factor in this client's history does the nurse correlate with this diagnosis?

Eating a meatfree diet

The nurse is performing an admission assessment on a 46yearold client, who states, "I have been drinking a 12pack of beer every day for the past 20 years." Which laboratory abnormality does the nurse correlate with this history?

Elevated prothrombin time (PT)

The nurse is assessing a client who has a factor VIII deficiency. Which clinical manifestation does the nurse expect to assess in this client?

Excessive bleeding from a cut

The nurse is providing health promotion education to a client who has a family history of leukemia. Which factor does the nurse teach this client to avoid?

Exposure to ionizing radiation

The nurse is teaching a client who is receiving sodium warfarin (Coumadin). Which topics does the nurse include in the teaching plan? (Select all that apply.)

Foods high in vitamin K, Using acetaminophen (Tylenol) for minor pain, Use of a safety razor and soft toothbrush, Blood testing regimen

The nurse is teaching a client with vitamin B12 deficiency anemia to eat a diet high in this vitamin. Which meal selected by the client indicates that the client correctly understands the prescribed diet?

Fried liver and onions, orange juice, spinach salad

The nurse is monitoring a client with liver failure. Which assessments does the nurse perform when monitoring for bleeding in this client? (Select all that apply.)

Gums, Urine, Stool

The nurse helps to ambulate a client who has anemia. Which clinical manifestation indicates that the client is not tolerating the activity?

Heart rate of 110 beats/min

A female client is admitted with the medical diagnosis of anemia. The nurse assesses for which potential cause?

Heavy menses

The nurse is assessing a 75yearold male client. Which blood value indicates that the client is experiencing normal changes associated with aging?

Hemoglobin, 13.0 g/dL

The nurse is caring for a client who has an elevated white blood cell count. Which intervention does the nurse implement for this client?

Obtain the client's temperature.

The registered nurse is assigning a practical nurse to care for a client who has leukemia. Which instruction does the registered nurse provide to the practical nurse when delegating this client's care?

Perform effective hand hygiene frequently.