NUR1
A client in sickle cell crisis has been hospitalized during her pregnancy. After giving discharge instructions, the nurse determines the client needs further teaching when she makes which statement? a) "Signs of any type of infection must be reported immediately." b) "At the earliest signs of a crisis, I need to seek treatment." c) "I will need more frequent appointments during the remainder of the pregnancy." d) "I will need to take an iron supplement even if my laboratory values are normal."
"I will need to take an iron supplement even if my laboratory values are normal." Sickle cell disease is an autosomal recessive disorder requiring both parents to have a sickle cell trait to pass the disease to a child. Deoxygenated hemoglobin cells assume a sickle shape and obstruct tissues. Tissue obstruction causes hypoxia to the area (vaso-occlusion) and results in pain, called sickle cell crisis. This type of anemia is an inherited disorder; it is not caused by lack of iron in the diet. Iron supplementation is needed only if there is laboratory evidence of iron deficiency anemia. Self-monitoring for any type of infections or sickle cell crisis and increased frequency of antenatal care visits are part of the teaching plan of care.
Question: A client is to receive a blood transfusion of packed RBCs for severe anemia. Place the following steps in the order a nurse would follow to administer this product. All options must be used. 1. Record baseline vital signs. 2. Verify the blood bag identification, ABO group, and Rh compatibility against the client information. 3. Remain with the client and watch for signs of a transfusion reaction. 4. Put on gloves, a gown, and a face shield. 5. Check the packed cells for abnormal color, clumping, gas bubbles, and expiration date. 6. Flush the I.V.intravenous tubing and line with normal saline solution.
1,5,2,4,6,3 Record baseline vital signs. Check the packed cells for abnormal color, clumping, gas bubbles, and expiration date. Verify the blood bag identification, ABO group, and Rh compatibility against the client information. Put on gloves, a gown, and a face shield. Flush the I.V.intravenous tubing and line with normal saline solution. Remain with the client and watch for signs of a transfusion reaction. To administer a blood transfusion, the nurse would follow the steps as listed above. Begin with obtaining a baseline set of vital signs. Next, assess the blood product and verify for the client and blood accuracy. Begin the transfusion by using protective equipment, flush tubing's, and administer blood products. Two client identifiers must be checked before the transfusion Careful assessment is needed in watching for a transfusion reaction. Note that the transfusion may be withheld if the client's temperature is 100°F (37.8°C) or greater.
A nurse is taking care of two clients who have a prescription to receive a blood transfusion of packed red blood cells at the same time. The first client's blood pressure dropped from the preoperative value of 120/80 mm Hg to a postoperative value of 100/50 mm Hg. The second client is hospitalized because he developed dehydration and anemia following pneumonia. After checking the patency of their IV lines and vital signs, what should the nurse do next? a) Ask another nurse to verify the compatibility of both units at the same time. b) Call for and hang the first client's blood transfusion. c) Call for both clients' blood transfusions at the same time. d) Ask another nurse to call for and hang the blood for the second client.
Call for and hang the first client's blood transfusion. When two clients are to receive blood at the same time, the nurse should call for and hang the clients' transfusions separately to avoid error. The nurse should call for and hang the first client's blood first because this client has experienced a change in blood pressure over a short period of time. The nurse should next call and hang the second client's blood transfusion as there is no indication that this client is unstable at this time. The nurse should not call for both units of transfusions at the same time due to the increased risk of misidentification. The nurse should not verify compatibility of both units at the same time due to the increased risk of misidentification. It is not necessary to involve two nurses because the second client can wait until the nurse has time to hang the blood
A mother asks the nurse if her child's iron-deficiency anemia is related to the child's frequent infections. The nurse responds based on the understanding of which of the following? a) Children with iron-deficiency anemia are less susceptible to infection than are other children. b) Little is known about iron-deficiency anemia and its relationship to infection in children. c) Children with iron-deficiency anemia are more susceptible to infection than are other children. d) Children with iron-deficiency anemia are equally as susceptible to infection as are other children.
Children with iron-deficiency anemia are more susceptible to infection than are other children. Children with iron-deficiency anemia are more susceptible to infection because of marked decreases in bone marrow functioning with microcytosis.
A client with iron deficiency anemia is taking iron supplements. The nurse emphasizes to the client that the drug will have increased absorption if taken with: a) milk. b) beta-carotene. c) food. d) orange juice.
orange juice Ascorbic acid (vitamin C) increases iron absorption. Taking iron with a food rich in ascorbic acid, such as orange juice, increases absorption. Milk delays iron absorption. It is best to give iron on an empty stomach to increase absorption. Beta-carotene does not affect iron absorption.
A client with iron-deficiency anemia is prescribed liquid iron supplements. The nurse evaluates the client's understanding of how to take this drug. Which statement indicates the client has adequate knowledge? a) "I will dilute the medication and drink it with a straw." b) "I will report any black stools to the health care provider." c) "I will check my gums for any bleeding." d) "I can use antidiarrheal drugs if I develop diarrhea."
"I will dilute the medication and drink it with a straw." Liquid iron supplements should be diluted and taken through a straw to help decrease the likelihood of staining the teeth. Iron causes constipation, not diarrhea. It is normal for the client's stools to become dark during iron therapy. Iron does not cause bleeding gums.
A nurse is preparing to administer a unit of blood to a client with anemia. After its removal from the refrigerator, the blood should be administered within: a) 6 hours. b) 2 hours. c) 1 hour. d) 4 hours.
4 hours. Refrigeration delays the growth of bacteria in the blood. After the blood is removed from the refrigerator, it must be administered within 4 hours. If the blood is administered too rapidly, within 1 or 2 hours, the client could experience fluid overload. Six hours is too long because the extended time out of refrigeration increases the risk of contamination and growth of bacteria.
A client with chronic hepatitis C is experiencing nausea, anorexia, and fatigue. During the health history the client states that he is homosexual, drinks one to two glasses of wine with dinner, is taking St. John's Wort for a "bit of depression," and takes acetaminophen for frequent headaches. What should the nurse do? Select all that apply. a) Encourage the client to obtain sufficient rest. b) Instruct the client that the wine with meals can be beneficial for cardiovascular health. c) Advise the client of the need for additional testing for HIV. d) Instruct the client to ask the health care provider (HCP) about taking any other medications as they may interact with medications the client is currently taking. e) Instruct the client to increase the protein in his diet and eat less frequently.
Encourage the client to obtain sufficient rest. • Advise the client of the need for additional testing for HIV. • Instruct the client to ask the health care provider (HCP) about taking any other medications as they may interact with medications the client is currently taking. Clients with chronic hepatitis C should abstain from alcohol as it can speed cirrhosis and end-stage liver disease. Clients should also check with their HCPs before taking any nonprescription or prescription medications, or herbal supplements. It is also important that clients who are infected with HCV be tested for HIV, as clients who have both HIV and HCV have a more rapid progression of liver disease than those who have HCV alone. Clients with HCV and nausea should be instructed to eat four to five times a day to help reduce anorexia and nausea. The client should obtain sufficient rest to manage the fatigue.
A client who follows a vegetarian diet was referred to a dietitian for nutritional counseling for anemia. Which client outcome indicates that the client does not understand nutritional counseling? The client: a) cooks tomato-based foods in iron pots. b) adds dried fruit to cereal and baked goods. c) adds vitamin C to all meals. d) drinks coffee or tea with meals.
drinks coffee or tea with meals. Coffee and tea increase gastrointestinal motility and inhibit the absorption of nonheme iron. Clients are instructed to add dried fruits to dishes at every meal because dried fruits are a nonheme or nonanimal iron source. Cooking in iron cookware, especially acid-based foods such as tomatoes, adds iron to the diet. Clients are instructed to add a rich supply of vitamin C to every meal because the absorption of iron is increased when food with vitamin C or ascorbic acid is consumed
Question: A client with a gastrointestinal bleed has vomited 600 mL of frank red blood and is now pale and diaphoretic. Vital signs are BP 88/50 mm Hg, HR 120 bpm, RR 24 breaths/min. What are the priority nursing interventions for this client? Place in order of priority. Use all options. 1. Initiate two large-bore intravenous lines. 2. Prepare the client for the operating room. 3. Position the client on the left side. 4. Reassess vital signs and oxygen saturation. 5. Notify the physician.
3,1,5,4,2, Position the client on the left side. Initiate two large-bore intravenous lines. Notify the physician. Reassess vital signs and oxygen saturation. Prepare the client for the operating room. Explanation: The client would immediately be placed on his/her side to avoid aspiration of bloody vomitus. Next, IVs would need to be inserted as the BP has decreased and the client is in danger of hypovolemic shock. The physician would be notified, followed by reassessment of vital signs and preparing the client for surgery.
The healthcare provider is assisting a patient with severe anemia with ambulation. The patient suddenly experiences dyspnea. What should the healthcare provider do first? Please choose from one of the following options. A)Administer oxygen to the patient. B)Ask a colleague to get a wheelchair for the patient. C)Quickly assist the patient back to their bed. D)Ease the patient to the floor to prevent injury.
B) Ask a colleague to get a wheelchair for the patient
A client must receive a blood transfusion of packed red blood cells (RBCs) for severe anemia. What I.V. fluid should the nurse use to prime the tubing before hanging this blood product? a) Dextrose 5% in water as this is considered an isotonic solution b) Current guidelines suggest that no priming is needed since blood products must be infused alone c) Lactated Ringer's solution as this is considered an isotonic solution d) Normal saline solution as this is considered an isotonic solution
Normal saline solution as this is considered an isotonic solution Normal saline solution is used for administering blood transfusions. Lactated Ringer's solution or dextrose solutions may cause blood clotting or RBC hemolysis. Current guidelines do not indicate a "no priming" method without NSS
A nurse notices that a client admitted for exacerbation of chronic obstructive pulmonary disease is short of breath. The client has signed an advance directive indicating that he doesn't want to be resuscitated. The nurse should: a) check the client's oxygen saturation. b) not provide any care. c) call the physician. d) get the crash cart.
check the client's oxygen saturation The nurse should check the client's oxygen saturation before she calls the physician. The fact that the client has signed an advance directive doesn't mean that the nurse shouldn't provide any care. There's no reason for the nurse to get the crash cart at this point.
When assessing a client's I.V. insertion site, a nurse notes normal color and temperature at the site and no swelling. However, the I.V. solutions haven't infused at the ordered rate; the flow rate is slow even with the roller clamp wide open. When the nurse lowers the I.V. fluid bag, no blood returns to the tubing. What should the nurse do first? a) Irrigate the I.V. tubing with 1 ml of normal saline solution. b) Check the tubing for kinks and reposition the client's wrist and elbow. c) Elevate the I.V. fluid bag. d) Discontinue the I.V. infusion at that site and restart it in the other arm.
Check the tubing for kinks and reposition the client's wrist and elbow. The nurse should check for common causes of a decreased I.V. flow rate, such as kinks in the tubing and poor positioning of the affected arm. The nurse should discontinue the I.V. infusion only if other measures fail to solve the problem. Irrigating I.V. tubing may dislodge any clots that are present. Elevating the I.V. fluid bag may help if the nurse finds no kinks and if repositioning doesn't resolve the problem.
A client with anemia has been admitted to the medical-surgical unit. Which assessment findings are characteristic of iron deficiency anemia? a) Dyspnea, tachycardia, and pallor b) Itching, rash, and jaundice c) Nights sweats, weight loss, and diarrhea d) Nausea, vomiting, and anorexia
Dyspnea, tachycardia, and pallor Signs of iron deficiency anemia include dyspnea, tachycardia, and pallor, as well as fatigue, listlessness, irritability, and headache. Night sweats, weight loss, and diarrhea may signal acquired immunodeficiency syndrome. Nausea, vomiting, and anorexia may be signs of hepatitis B. Itching, rash, and jaundice may result from an allergic or hemolytic reaction
Which of the following findings in a client diagnosed with heart failure would require a nurse to take immediate action? a) Pain in the right upper abdominal quadrant b) Slight bilateral ankle edema c) Weight gain of 2 pounds (1 kg) in 3 days d) An extra heart sound (S3) immediately following the second heart sound (S2)
Pain in the right upper abdominal quadrant Pain in the right upper quadrant may indicate increased venous insufficiency and the healthcare provider should be immediately notified. Common findings that are not unexpected in clients with heart failure include auscultation of S3, slight ankle edema, and weight gain of 2 pounds (1kg) in 3 days.
When developing the plan of care for a client with aplastic anemia, the nurse should include which goal? a) Perform activities of daily living without excessive fatigue or dyspnea. b) Describe self-care behaviors to prevent the transmission to family members. c) Correctly demonstrate how to take prescribed anticoagulant drug therapy. d) Learn how to administer weekly vitamin B12 injections.
Perform activities of daily living without excessive fatigue or dyspnea. With aplastic anemia, measures to conserve energy and reduce oxygen requirements are essential. Therefore, an appropriate goal would be to strive to perform activities of daily living without excessive fatigue or dyspnea. The client needs adequate vitamin B12 in the diet. However, vitamin B12 injections usually are not required. Anticoagulants are contraindicated in clients with low platelet counts, which often occur in aplastic anemia. Aplastic anemia is not contagious. Thus, measures to prevent transmission are inappropriate.
A client receiving a blood transfusion experiences an acute hemolytic reaction. Which nursing intervention is the most important? a) Stop the transfusion, notify the blood bank, and administer antihistamines. b) Assess the temperature, blood pressure, and check for blood in the urine. Then stop the transfusion. c) Slow the transfusion and monitor the client's vital signs. d) Stop the transfusion, infuse normal saline solution, and call the physician.
Stop the transfusion, infuse normal saline solution, and call the physician. When a transfusion reaction occurs, the transfusion should be immediately stopped, normal saline solution should be infused to maintain venous access, and the physician and blood bank should be notified immediately. Other nursing actions include saving the blood bag and tubing, rechecking the blood type and identification numbers on the blood tags, monitoring vital signs, obtaining necessary laboratory blood and urine samples, providing proper documentation, and monitoring and treating for shock. Because they can cause red blood cell hemolysis, dextrose solutions should not be infused with blood products. Antihistamines are administered for a mild allergic reaction, not a hemolytic reaction
Which of the following statements heard during shift report identifies an important priority for action? a) A client is reluctant to ambulate on the evening of surgery. b) A postoperative client's pulse has been increasing, and the blood pressure is decreasing. c) A postoperative client has not voided for 5 hours after surgery. d) A postoperative client is drowsy and slow to respond when the analgesic is at its maximal effect.
A postoperative client's pulse has been increasing, and the blood pressure is decreasing. This indicates that the status of the client is rapidly changing. When there is an increase in the pulse postoperatively, this could indicate hemorrhage with the body compensating. When the blood pressure is decreasing, this could indicate that the body is now decompensating. Each of the other postoperative situations would represent a normal finding.
A 12-year-old African-American boy has experienced significant blood loss and may require a blood transfusion. The boy's mother, father, and sisters are currently present at his bedside in the emergency department. How should the nurse direct questions and teaching about his condition and treatment? a) Address the mother, as African-American families are commonly matriarchal. b) Ask the boy's father what should be done, but make eye contact with everyone in the room. c) Assess who is the dominant member of the family and then address that person. d) Direct questions to the family collectively to avoid presuming who is dominant.
Assess who is the dominant member of the family and then address that person. While African-American families are often matriarchal, this fact does not mean that the nurse should not assess the structure and roles of the family on an individual basis. This assessment is preferable to acting on a generalization, even if it is a generalization that may be accurate for many families who are culturally similar.
A client has fatigue, temperature of 99.5° F (37.5° C), dark bronze skin, and dark urine. Hemoglobin level 9 g/dl (90 g/L); hematocrit is 49 (0.49), and red blood cells are 2.75 million/µl (2.75 X 1012/L). What should the nurse do first? a) Place the client on bed rest. b) Keep the client out of sunlight. c) Place the client on contact isolation. d) Initiate an intake and output record.
Initiate an intake and output record. The nurse should prepare to start an intake and output record because the client is exhibiting clinical manifestations of anemia with jaundice and is demonstrating a fluid imbalance. The client does not need to be on bed rest at this point. The client is not contagious and does not need to be placed in contact isolation. The changes in the color of the skin and urine are related to the jaundice and will not be affected by sunlight.
During an assessment of a patient experiencing acute hemorrhage and anemia, the healthcare provider would most likely expect to find: Please choose from one of the following options. Hypotension Jaundice Nausea Tachycardia
Tachycardia The acute blood loss will impair oxygen delivery to the tissues. The healthcare provider will expect to find signs of the body compensating for the acute blood loss. The heart rate will increase in an attempt to deliver more oxygen to the tissues. The body will also compensate by increasing the blood pressure, so hypotension will not be expected in the acute phase.
Which foods should the nurse encourage the mother to offer to her child with iron-deficiency anemia? a) potato, peas, and chicken b) macaroni, cheese, and ham c) pudding, green vegetables, and rice d) rice cereal, whole milk, and yellow vegetables
potato, peas, and chicken Potatoes, peas, chicken, green vegetables, and fortified cereal contain significant amounts of iron and therefore would be recommended. Milk and yellow vegetables are not good iron sources. Rice by itself also is not a good source of iron. Macaroni, cheese, and ham are not high in iron. While pudding (made with fortified milk) and green vegetables contain some iron, the better diet has protein and iron from the chicken and potato
When obtaining the diet history from a client with anemia, the nurse should include questions specifically about which vitamins or minerals that are most likely missing in this client's diet? Select all that apply. a) vitamin K b) vitamin B6 c) vitamin B12 d) vitamin C e) iron
• vitamin B6 • vitamin B12 • iron Vitamins B6, B12, and iron are important in the production of red blood cells. Therefore, the nurse should question the client specifically about food intake that contains these vitamins and minerals. Vitamin C helps iron absorption and plays a small role in red blood cell production. Vitamin K has little role in the production of red blood cells.
A 4-year-old child is having a sickle cell crisis. The initial nursing intervention should be to: a) administer antibiotics. b) provide oral and I.V. fluids. c) administer folic acid supplements. d) place ice packs on the client's painful joints.
provide oral and I.V. fluids. Initial nursing interventions for the child in a sickle cell crisis include providing hydration and oxygenation to prevent more sickling. Pain relief is also a concern. However, painful joints are treated with analgesics and warm packs because cold packs may increase sickling. Antibiotics will be given to treat a sickle cell crisis if it's thought to be bacterial but only after hydration and oxygenation have been addressed. Daily supplements of folic acid will help counteract anemia but they aren't a priority during sickle cell crisis.
A client has been admitted with a diagnosis of cerebrovascular accident (CVA) and right-sided hemiplegia. Which of the following neurologic deficits would the nurse assess for? Select all that apply. a) Inability to see to the left b) Poor judgment and impulsive behavior c) Loss of consciousness d) Expressive aphasia e) Weak hand grasp on the left side
• Expressive aphasia • Weak hand grasp on the left side Right-sided hemiplegia is caused by damage to the left hemisphere of the brain. Expressive and receptive dysphasias are associated with damage to the left hemisphere, where the dominant speech centers are located in most people. The client would also present with weakness on the left side due to the damage to the left side of the brain. Loss of consciousness would not be a correct response as it can be associated with many conditions. Poor judgment and impulsive behavior are associated with cerebral cortex damage.
Question: The nurse has received the first unit of blood for a client with a diagnosis of gastrointestinal (GI) hemorrhage. What are the nursing responsibilities prior to administering the blood to the client? Place in order of priority. Use all options. 1Review signs and symptoms of transfusion reaction with the client prior to administration of the blood product. 2 Change the IV solution to normal saline. 3 Check the medication orders for an antihistamine in the event of a transfusion reaction. 4 Ask the client about previous transfusion and if reactions have occurred. 5 Check the blood product against the client identification bracelet.
4,2,5,1,3 Ask the client about previous transfusion and if reactions have occurred. Change the IV solution to normal saline. Check the blood product against the client identification bracelet. Review signs and symptoms of transfusion reaction with the client prior to administration of the blood product. Check the medication orders for an antihistamine in the event of a transfusion reaction. Prior to initiating a blood transfusion, the client must be assessed for any previous reactions. Once that is ascertained, the IV can be changed to normal saline and the blood checked. The nurse can then review signs and symptoms of a possible reaction and check the medication orders.
A 14-year-old girl with sickle cell disease has her fourth hospitalization for sickle cell crisis. Her family is planning a ski vacation in the mountains. What should the nurse tell the parents? a) Explain that the high altitude may cause a crisis. b) Encourage them to go on the trip. c) Suggest the trip be postponed until next year. d) Go on the trip, but find a sitter for the 14-year-old.
Explain that the high altitude may cause a crisis. High altitude causes deoxygenation, which might precipitate a crisis. In clients with sickle cell anemia, cells sickle when the client experiences any situation where increased demand for oxygen is needed, such as in an infection or dehydration, or when low oxygen concentration is experienced, such as in high altitudes or deep sea diving. Crises can commonly be prevented by maintaining hydration. It would be unsafe to encourage the family, or to say nothing about taking the client to high altitude areas, but giving the parents adequate information will allow them to make an appropriate decision. Postponing the trip or leaving the child at home does not address the immediate concern for the child's health.
A school-age child is admitted to the hospital in vasoocclusive sickle cell crisis. Place the prescriptions in the order of priority (first to last) that the nurse should implement them. All options must be used. 1. Administer morphine for the pain. 2. Draw blood for electrolyte levels and pH balance. 3. Start an intravenous infusion. 4. Start oxygen via nasal cannula.
Start an intravenous infusion. Start oxygen via nasal cannula. Administer morphine for the pain. Draw blood for electrolyte levels and pH balance. The nurse should first start an intravenous infusion because dehydration increases sickling of cells; maintaining fluid balance is the top priority. The nurse should next start oxygen and then administer morphine for pain. Last, the nurse should obtain a blood sample for laboratory studies.
A client is admitted with heart failure and pulmonary edema. To help alleviate respiratory distress, the nurse should perform which of the following actions? Select all that apply.
• Elevate head of bed to 90 degrees. • Administer diuretics as ordered. Elevating the head of the bed allows maximum lung expansion because gravity reduces the pressure of the abdominal viscera on the diaphragm and lungs. Diuretics are administered to a client with heart failure and pulmonary edema to decrease the fluid buildup in the lungs and decrease the workload of the heart. Placing a pillow under the legs would not correct shortness of breath. The client could not tolerate a position for postural drainage based on the current respiratory status.
A home care nurse is making a visit with a client who has a colostomy. While the nurse is changing the client's appliance, the client's next-door neighbor wants to visit. Which intervention by the nurse is most appropriate? Select all that apply. a) Suggest that the neighbor come in and educate them as a caregiver. b) Have the neighbor wait in the next room until the appliance is changed. c) Cover the appliance and allow the neighbor to enter. d) Ask the neighbor to come back in 20 minutes. e) Tell the neighbor only family is allowed right now.
• Have the neighbor wait in the next room until the appliance is changed. • Ask the neighbor to come back in 20 minutes. The home care nurse should either ask the client to wait in the other room or come back in 20 minutes. Client privacy is a priority even in the home care setting. Allowing the neighbor to enter the room violates client privacy and confidentiality. Suggesting the neighbor come in and learn how to change the appliance is inappropriate because the client did not request help from the neighbor.
A client with iron deficiency anemia is refusing to take the prescribed oral iron medication because the medication is causing nausea; the client is also constipated. What actions should the nurse take? Select all that apply. a) Suggest that the client use ginger when taking the medication. b) Ask the client what is causing the nausea. c) Tell the client to use stool softeners to minimize constipation. d) Suggest that the client take the iron with orange juice. e) Offer to administer the medication by an intramuscular injection.
• Suggest that the client use ginger when taking the medication. • Ask the client what is causing the nausea. • Suggest that the client take the iron with orange juice. Nausea and vomiting are common adverse effects of oral iron preparations. The nurse should first ask the client why the client does not want to take the oral medication, and then suggest ways to decrease the nausea and vomiting. Ginger may help minimize the nausea, and the client can try this remedy and evaluate its effectiveness. Iron should be taken on an empty stomach but can be taken with orange juice. The client can evaluate if this helps the nausea. Stool softeners should not be used in clients with iron deficiency anemia. Instead, constipation can be prevented by following a high-fiber diet. Administering iron intramuscularly is done only if other approaches are not effective.
Which client is most appropriate for the registered nurse to assign to the licensed practical nurse (LPN)? a) Multiparous woman who just received ergonovine maleate (Methergine) b) Multiparous woman with polymicrobial necrotizing fasciitis. c) Multiparous woman with Klebsiella pneumoniae cystitis d) Multiparous woman with Enterobacter cystitis and sickle cell crisis
Multiparous woman with Klebsiella pneumoniae cystitis The klebsiella pneumoniae organism is a common cause of cystitis. The care of this client is appropriate for the registered nurse (RN) to delegate to the LPN. Ergonovine is ordered for postpartum hemorrhage. Because the client recently received the medication, she might be unstable, which would require the RN's assessment skills. Enterobacter commonly causes cystitis; however, the client's condition is complicated by sickle cell crisis, which requires the care of an RN. Necrotizing fasciitis is characterized by erythema, discharge, severe pain, severe tissue necrosis, and partial liquefaction of fascia; the severity of the disease requires that an RN administer care.
The couple with the lowest risk of having a child with sickle cell anemia disease is the one in which the: a) father is HbA and the mother is HbS. b) father is HbS and the mother is HbAS. c) father is HbS and the mother is HbS. d) father is HbAS and the mother is HbAS.
father is HbA and the mother is HbS. If the father has normal hemoglobin (HbA) and the mother has sickle cell anemia (HbS), the couple has a 0% chance of having a child with sickle cell anemia. If both parents have sickle cell anemia, the couple has a 100% chance of having a child with sickle cell anemia. If the father has sickle cell anemia and the mother has sickle cell trait (HbAS), the couple has a 50% chance of having a child with sickle cell anemia. If both parents have sickle cell trait, the couple has a 25% chance of having a child with sickle cell anemia.
The nurse determines that a client's abdominal wound has eviscerated. What should the nurse do first? a) Place the client in reverse Trendelenburg's position. b) Cover the wound with sterile saline-moistened dressings. c) Notify the health care provider. d) Reinsert the protruding viscera into the abdominal cavity.
Cover the wound with sterile saline-moistened dressings. In the event of wound evisceration, the first action would be to cover the wound with a sterile towel or dressing moistened with sterile normal saline solution to prevent possible infection and keep the protruding viscera moist. The nurse should notify the health care provider once the area is covered with sterile saline-moistened dressings. Reinserting any protruding viscera is never attempted because of the possible risks for infection and perforation. Typically, the client is placed supine with knees flexed to reduce tension on the protruding viscera.
A client with a history of cardiac disease has just returned to the cardiac unit post-cardiac catheterization at the femoral site. The nurse is aware that interventions for this client would include which of the following? Select all that apply. a) Maintain NPO for 2 to 4 hours. b) Ensure that the client is kept flat in bed for 4-6 hours after the procedure. c) Check the pulse distal to the catheter insertion site. d) Monitor heart rate and rhythm. e) Administer antiarrhythmic medications as ordered.
• Check the pulse distal to the catheter insertion site. • Monitor heart rate and rhythm The pulse should be assessed because a trauma at the insertion site may interfere with blood flow distal to the site. There is also danger of bleeding or occlusion. The heart rate and rhythm would also be monitored for any complications. The other answers are incorrect as there is no reason for NPO status. Post-procedure patients are flat for as long as 8 hours, administration is an action not an assessment, and there is no reason to anticipate antiarrhythmic drugs.
A client comes into the emergency department with extreme fatigue. He is malnourished and laboratory tests reveal severe anemia. Based on an understanding of how vitamin and mineral deficiencies are associated with anemia, the nurse should specifically ask the client about the intake of food high in which of the following nutrients? a) Vitamin K b) Thiamine, riboflavin, and niacin c) Vitamins A, E, and C d) Vitamins B6 and B12, folate, iron, and copper
Vitamins B6 and B12, folate, iron, and copper Many vitamin and mineral deficiencies can result in anemia. Intake of alll of these vitamins and minerals need to be assessed, preferably through a nutrition assessment. Deficiencies of vitamins A, B6, and C result in a small cell, microcytic anemia. Folate and vitamin B12 deficiencies result in a large cell, macrocytic anemia. Iron, copper, and vitamin E deficiencies can also result in anemia. Vitamin K alters clotting time, but is not associated with anemia
A client who is receiving a blood transfusion begins to have difficulty breathing. The nurse notes an elevated blood pressure and a cough. Based on these signs, the nurse should prepare to manage which complication? a) circulatory overload b) acute hemolytic reaction c) anaphylactic reaction d) sepsis
circulatory overload The symptoms of difficulty breathing, elevated blood pressure, and cough are indicative of circulatory overload. Circulatory overload occurs when blood is infused more rapidly than the circulatory system can accommodate. Anaphylactic reactions are manifested by urticaria, wheezing, and shock. Sepsis begins with a rapid onset of chills and fever. Acute hemolytic reaction is typically manifested by chills, fever, low back pain, and flushing.
A client with pernicious anemia asks why she must take vitamin B12 injections forever. Which is the nurse's best response? a) "The reason for your vitamin deficiency is an inability to absorb the vitamin because the stomach is not producing sufficient amounts of a factor that allows the vitamin to be absorbed." b) "The reason for your vitamin deficiency is an inability to absorb the vitamin because the stomach is not producing sufficient acid." c) "The reason for your vitamin deficiency is an increased requirement for the vitamin because of rapid red blood cell production." d) "The reason for your vitamin deficiency is an excessive excretion of the vitamin because of kidney dysfunction."
The reason for your vitamin deficiency is an inability to absorb the vitamin because the stomach is not producing sufficient amounts of a factor that allows the vitamin to be absorbed." Most clients with pernicious anemia have deficient production of intrinsic factor in the stomach. Intrinsic factor attaches to the vitamin in the stomach and forms a complex that allows the vitamin to be absorbed in the small intestine. The stomach is producing enough acid, there is not an excessive excretion of the vitamin, and there is not a rapid production of red blood cells in this condition.
A client is receiving a unit of packed red blood cells. Before the transfusion started, the client's blood pressure was 90/50 mm Hg, pulse rate 100 bpm, respirations 20 breaths/minute, and temperature 98° F (36.7° C). Fifteen minutes after the transfusion starts, the client's blood pressure is 92/54 mm Hg, pulse 100 bpm, respirations 18 breaths/minute, and temperature is 101.4° F (38.6° C). The nurse should first: a) obtain a prescription for antibiotics. b) stop the transfusion. c) raise the head of the bed. d) offer the client a cool washcloth.
stop the transfusion. The nurse's first action should be to clamp off the transfusion because the client is having a transfusion reaction. It is most important that the client not receive any more blood. Other measures may be appropriate after the blood has been stopped. The nurse should raise the head of the bed if the client becomes short of breath. There is no need for antibiotic therapy for a blood transfusion related to a temperature spike. The nurse can provide a cool washcloth for a headache or fever; however, this is not a priority.
The nurse receives report on the assigned clients at the beginning of the second shift. Which client should the nurse plan to assess first after receiving report? a) an elderly client with pneumonia who is exhibiting periods of confusion b) a client receiving total parenteral nutrition (TPN) via a central line with 400 mL remaining in the IV fluid bottle c) a young client with chest tubes placed for treatment of a pneumothorax who is resting comfortably d) a client who is scheduled for an abdominal perineal resection in the morning and is visiting with the family
an elderly client with pneumonia who is exhibiting periods of confusion Because of the elderly client's diagnosis of pneumonia and periods of confusion, there is the potential for client injury and decreased levels of oxygenation. The nurse should assess this client first. The client going to surgery does not require the nurse's attention right away. The TPN solution is infusing and will not require changing immediately. The client with chest tubes is not in imminent danger; the nurse can continue to assess this client but not as a priority.
What directives should the nurse provide to a young female adult with sickle cell anemia? Select all that apply. a) Avoid flying on commercial airlines. b) Know that pregnancy with sickle cell disease increases the risk of a crisis. c) Drink plenty of fluids when outside in hot weather. d) Be aware that since she is homozygous for HbS, she carries the sickle cell trait. e) Avoid being in high altitudes.
• Avoid being in high altitudes. • Drink plenty of fluids when outside in hot weather. • Know that pregnancy with sickle cell disease increases the risk of a crisis. The nurse should teach the client to drink plenty of fluids when outside in hot weather to avoid becoming dehydrated. The client should avoid being in high altitudes, such as mountains above 5,000 feet (1,524 m), where the lower availability of oxygen could precipitate a sickle cell crisis. The nurse should alert young women with sickle cell anemia that pregnancy increases the risk of a crisis. People who are homozygous for HbS have sickle cell anemia; the heterozygous form is the sickle cell carrier trait. A client with sickle cell anemia may fly on commercial airlines; the airplane is pressurized and has an adequate oxygen level.
Which safety measures would be most important to implement when caring for a client who is receiving 2 units of packed red blood cells (PRBCs)? Select all that apply. a) Stop the transfusion if a reaction occurs, but keep the line open. b) Use a 22-gauge catheter for optimal flow of a blood transfusion. c) Inspect the blood bag for leaks, abnormal color, and clots. d) Take vital signs every 15 minutes while the unit is transfusing. e) Infuse a unit of PRBCs in less than 4 hours. f) Verify that the ABO and Rh of the 2 units are the same.
• Infuse a unit of PRBCs in less than 4 hours. • Stop the transfusion if a reaction occurs, but keep the line open. • Inspect the blood bag for leaks, abnormal color, and clots. The American Association of Blood Banks and Canadian Blood Services recommend that two qualified people, such as two registered nurses, compare the name and number on the identification bracelet with the tag on the blood bag. Verifying that the two units are the same is not a recommendation. Rather, the verification is always with the client, not with bags of blood. A unit of blood should infuse in 4 hours or less to avoid the risk of septicemia since no preservatives are used. When a blood transfusion reaction occurs, the blood transfusion should be stopped immediately, but the IV line should be kept open so that emergency medications and fluids can be administered. The unit of PRBCs should be inspected for contamination by looking for leaks, abnormal color, clots, and excessive air bubbles. When a unit of PRBCs is being transfused, vital signs are assessed before the transfusion begins, after the first 15 minutes, and then every hour until 1 hour after the transfusion has been completed. When PRBCs are being administered, a 20-gauge or larger needle is needed to avoid destroying the red blood cells (RBCs) passing through the lumen and to allow for maximal flow rate.
