Unit 6- Ch 33 with rationales
A client with pernicious anemia is receiving parenteral vitamin B12 therapy. Which client statement indicates effective teaching about this therapy? "I will receive parenteral vitamin B12 therapy until my signs and symptoms disappear." "I will receive parenteral vitamin B12 therapy until my vitamin B12 level returns to normal." "I will receive parenteral vitamin B12 therapy monthly for 6 months to a year." "I will receive parenteral vitamin B12 therapy for the rest of my life."
"I will receive parenteral vitamin B12 therapy for the rest of my life." Explanation: Because a client with pernicious anemia lacks intrinsic factor, oral vitamin B12 can't be absorbed. Therefore, parenteral vitamin B12 therapy is recommended and required for life.
A nurse caring for a client who has hemophilia is getting ready to take the client's vital signs. What should the nurse do before taking a blood pressure? Ask if taking a blood pressure has ever produced bleeding under the skin or in the arm joints. Ask if taking a blood pressure has ever produced pain in the upper arm. Ask if taking a blood pressure has ever caused bruising in the hand and wrist. Ask if taking a blood pressure has ever produced the need for medication.
Ask if taking a blood pressure has ever produced bleeding under the skin or in the arm joints. Explanation: 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.
Which of the following are assessment findings associated with thrombocytopenia? Select all that apply. Bleeding gums Epistaxis Hematemesis Bradypnea Hypertension
Bleeding gums Epistaxis Hematemesis Pertinent findings of thrombocytopenia include: bleeding gums, epistaxis, hematemesis, hypotension, and tachypnea.
You are caring for a 13-year-old diagnosed with sickle cell anemia. The client asks you what they can do to help prevent sickle cell crisis. What would be an appropriate answer to this client? Avoid any sports that tire you out. Drink at least 8 glasses of water every day. Avoid any activity that makes you short of breath. Stay on oxygen therapy 24/7.
Drink at least 8 glasses of water every day. Explanation: During the physical examination, observe the client's appearance, looking for evidence of dehydration, which may have triggered a sickle cell crisis. Clients are taught moderation, not avoidance of activities. Most clients with sickle cell disease are not on oxygen therapy 24/7.
A thin client is prescribed iron dextran intramuscularly. What is most important action taken by the nurse when administering this medication? Employs the Z-track technique Uses a 23-gauge needle Injects into the deltoid muscle Rubs the site vigorously
Employs the Z-track technique Explanation: When iron medications are given intramuscularly, the nurse uses the Z-track technique to avoid local pain and staining of the skin. The gluteus maximus muscle is used. The nurse avoids rubbing the site vigorously and uses a 18- or 20-gauge needle.
A patient with End Stage Kidney Disease is taking recombinant erythropoietin for the treatment of anemia. What laboratory study does the nurse understand will have to be assessed at least monthly related to this medication? Potassium level Creatinine level Hemoglobin level Folate levels
Hemoglobin level Explanation: When using recombinant erythropoietin, the hemoglobin must be checked at least monthly (more frequently until a maintenance dose is established) and the dose titrated to ensure the hemoglobin level does not exceed 12 g/dL.
Which of the following describes a red blood cell (RBC) that has pale or lighter cellular contents? Hypochromic Normocytic Microcytic Hyperchromic
Hypochromic Explanation: An RBC that has pale or lighter cellular contents is hypochromic. A normocytic RBC is normal or average in size. A microcytic RBC is smaller than normal. Hyperchromic is used to describe an RBC that has darker cellular contents.
A client is receiving chemotherapy for cancer. The nurse reviews the client's laboratory report and notes that he has thrombocytopenia. To which nursing diagnosis should the nurse give the highest priority? Activity intolerance Impaired tissue integrity Impaired oral mucous membranes Ineffective tissue perfusion: Cerebral, cardiopulmonary, GI
Ineffective tissue perfusion: Cerebral, cardiopulmonary, GI Explanation: These are all appropriate nursing diagnoses for the client with thrombocytopenia. However, the risk of cerebral and GI hemorrhage and hypotension pose the greatest risk to the physiological integrity of the client.
A client with a diagnosis of pernicious anemia comes to the clinic reporting of numbness and tingling in his arms and legs. What do these symptoms indicate? Loss of vibratory and position senses Neurologic involvement Severity of the disease Insufficient intake of dietary nutrients
Neurologic involvement Explanation: 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 nurse, caring for a client in the emergency room with a severe nosebleed, becomes concerned when the client asks for a bedpan. The nurse documents the stool as loose, tarry, and black looking. The nurse suspects the client may have thrombocytopenia. What should be the nurse's priority action? Stop the nosebleed Put in an IV line Ask someone to clean the bedpan Notify the physician
Notify the physician Explanation: Thrombocytopenia is evidenced by purpura, small hemorrhages in the skin, mucous membranes, or subcutaneous tissues. Bleeding from other parts of the body, such as the nose, oral mucous membrane, and the gastrointestinal tract, also occurs. Internal hemorrhage, which can be severe and even fatal, is possible. This nurse should notify the physician of the suspected disorder.
A client diagnosed with systemic lupus erythematosus comes to the emergency department with severe back pain. The client is taking prednisone daily and reported feeling pain after manually opening the garage door. What adverse effect of long-term corticosteroid therapy is most likely responsible for the pain? Hypertension Osteoporosis Muscle wasting Truncal obesity
Osteoporosis Explanation: Hypertension, osteoporosis, muscle wasting, and truncal obesity are all adverse effects of long-term corticosteroid therapy; however, osteoporosis commonly causes compression fractures of the spine. Hypertension, muscle wasting, and truncal obesity aren't likely to cause severe back pain.
A nurse is caring for a client admitted with pernicious anemia. Which set of findings should the nurse expect when assessing the client? Pallor, bradycardia, and reduced pulse pressure Pallor, tachycardia, and a sore tongue Sore tongue, dyspnea, and weight gain Angina pectoris, double vision, and anorexia
Pallor, tachycardia, and a sore tongue Explanation: Pallor, tachycardia, and a sore tongue are all characteristic findings in pernicious anemia. Other clinical manifestations include anorexia; weight loss; a smooth, beefy red tongue; a wide pulse pressure; palpitations; angina pectoris; weakness; fatigue; and paresthesia of the hands and feet. Bradycardia, reduced pulse pressure, weight gain, and double vision aren't characteristic findings in pernicious anemia.
A nurse should expect to administer which vaccine to the client after a splenectomy? Recombivax HB Attenuvax Pneumovax 23 Tetanus toxoid
Pneumovax 23 Explanation: Pneumovax 23, a polyvalent pneumococcal vaccine, is administered prophylactically to prevent the pneumococcal sepsis that sometimes occurs after splenectomy. Recombivax HB is a vaccine for hepatitis B. Attenuvax is a live, attenuated virus vaccine for immunization against measles (rubeola). Tetanus toxoid is administered to prevent tetanus resulting from impaired skin integrity caused by traumatic injury.
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 Explanation: In adults, bone marrow is usually aspirated from the posterior iliac crest and rarely from the sternum. Bone marrow is not aspirated from the femur or ankle.
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? Administer the unit of blood Check with the blood bank first and then administer the blood with their permission Refuse to administer the blood Ask the client if he was ever known as Donald A. Smith
Refuse to administer the blood Explanation: 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.
A client at the clinic has just been diagnosed with iron deficiency anemia. What would you recommend the client consume to promote the absorption of iron? Vitamin E Meat, egg yolks, oysters, and shellfish Rich sources of vitamin C Sources of vitamin B12
Rich sources of vitamin C Explanation: Sources of vitamin C such as citrus fruits and juices, strawberries, green peppers, and tomatoes enhance the absorption of nonheme iron. To maximize nonheme iron absorption, the client should consume a rich source of vitamin C at every meal. Meat, egg yolks, oysters, and shellfish are the sources of heme iron whose absorption is influenced by body need. Vitamin E and sources of vitamin B12 do not promote the absorption of iron.
The nurse is preparing the patient for a test to determine the cause of vitamin B12 deficiency. The patient will receive a small oral dose of radioactive vitamin B12 followed by a large parenteral dose of nonradioactive vitamin B12. What test is the patient being prepared for? Bone marrow aspiration Schilling test Bone marrow biopsy Magnetic resonance imaging (MRI) study
Schilling test Explanation: The classic method of determining the cause of vitamin B12 deficiency is the Schilling test, in which the patient receives a small oral dose of radioactive vitamin B12, followed in a few hours by a large, nonradioactive parenteral dose of vitamin B12 (this aids in renal excretion of the radioactive dose).
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 Explanation: 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.
A client has a history of sickle cell anemia with several sickle cell crises over the past 10 years. What blood component results in sickle cell anemia? hemoglobin S hemoglobin F hemoglobin A hemoglobin M
hemoglobin S Explanation: Hemoglobin A (HbA) normally replaces fetal hemoglobin (HbF) about 6 months after birth. In people with sickle cell anemia, however, an abnormal form of hemoglobin, hemoglobin S (HbS), replaces HbF. HbS causes RBCs to assume a sickled shape under hypoxic conditions.
An client has pernicious anemia and has been receiving treatment for several years. What is the client lacking that results in pernicious anemia? intrinsic factor vitamin B extrinsic factor hemoglobin
intrinsic factor Explanation: Pernicious anemia develops when a client lacks intrinsic factor, which normally is present in stomach secretions. Intrinsic factor is necessary for absorption of vitamin B12. Vitamin B12, the extrinsic factor in blood, is required for the maturation of erythrocytes.
Which of the following is the most common hematologic condition affecting elderly patients Anemia Thrombocytopenia Leukopenia Bandemia
Anemia Explanation: Anemia is the most common hematologic condition affecting elderly patients: with each successive decade of life, the incidence of anemia increases. Thrombocytopenia is a low platelet count. Leukopenia is a low leukocyte count. Bandemia is an increased number of band cells.
A nurse cares for a client suspected of having iron deficient anemia. Which diagnostic test will the nurse expect the health care provider to order in order to definitively diagnose the condition? Blood smear Bone marrow aspiration Serum ferritin Complete blood count
Bone marrow aspiration Explanation: The definitive method of diagnosis for iron deficiency anemia is bone marrow aspiration. The other answer choices may also be used to help with the diagnosis of the condition; however, these are not definitive diagnostic tests.
Which is a symptom of hemochromatosis? Bronzing of the skin Inflammation of the mouth Inflammation of the tongue Weight gain
Bronzing of the skin Explanation: 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 who is diagnosed multiple myeloma experiences decreased production of red blood cells (RBCs). Which prescribed medication should the nurse prepare to administer to increase the production of erythrocytes? Filgrastim Pegfilgrastim Erythropoietin Dexamethasone
Erythropoietin Explanation: The medication erythropoietin can be used to stimulate the production of red blood cells; therefore, this is the prescribed medication that the nurse prepares to administer to the client. Filgrastim and pegfilgrastim promote proliferation of neutrophils, not erythrocytes. Dexamethasone is a corticosteroid that is prescribed for clients who are diagnosed with multiple myeloma to inhibit the inflammatory immune response.
A patient with chronic renal failure is examined by the health care provider for anemia. Which laboratory results will the nurse monitor? Decreased level of erythropoietin Decreased total iron-binding capacity Increased mean corpuscular volume Increased reticulocyte count
Decreased level of erythropoietin Explanation: 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.
The nurse is caring for a client with external bleeding. What is the nurse's priority intervention? Elevation of the extremity Pressure point control Direct pressure Application of a tourniquet
Direct pressure Explanation: Applying direct pressure to an injury is the initial step in controlling bleeding. Elevation reduces the force of flow, but direct pressure is the first step. The nurse may use pressure point control for severe or arterial bleeding. Pressure points (those areas where large blood vessels can be compressed against bone) include femoral, brachial, facial, carotid, and temporal artery sites. The nurse should avoid applying a tourniquet unless all other measures have failed, because it may further damage the injured extremity.
During the review of morning laboratory values for a client reporting severe fatigue and a red, swollen tongue, the nurse suspects chronic, severe iron deficiency anemia based on which finding? Elevated hematocrit concentration Enlarged mean corpuscular volume (MCV) Low ferritin level concentration Elevated red blood cell (RBC) count
Low ferritin level concentration Explanation: The most consistent indicator of iron deficiency anemia is a low ferritin level, which reflects low iron stores. As the anemia progresses, the MCV, which measures the size of the erythrocytes, also decreases. Hematocrit and RBC levels are also low in relation to the hemoglobin concentration.
A nurse is doing a physical examination of a child with sickle cell anemia. When the child asks why the nurse auscultates the lungs and heart, what would be best the response by the nurse? To detect the abnormal sounds suggestive of acute chest syndrome and heart failure To detect the evidence of infection such as fever and tachycardia To detect the evidence of dehydration that might have triggered a sickle cell crisis To detect the motor strength and stroke-related signs and symptoms
To detect the abnormal sounds suggestive of acute chest syndrome and heart failure Explanation: The nurse auscultates the lungs and heart to detect abnormal sounds that indicate pneumonia, acute chest syndrome, and heart failure. The nurse assesses vital signs to detect evidence of infection, such as fever and tachycardia. During the physical examination, the nurse observes the client's appearance, looking for evidence of dehydration, which may have triggered a sickle cell crisis. The nurse assesses mental status, verbal ability, and motor strength to detect stroke-related signs and symptoms.
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? "Most likely, the father is the carrier of the gene." "The trait is passed down through the mother." "The child must inherit two defective genes, one from each parent." "It is an acquired, not a hereditary disorder."
"The child must inherit two defective genes, one from each parent." Explanation: 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.
The nurse and the client are discussing some strategies for ingesting iron to combat the client's iron-deficiency anemia. Which is among the nurse's strategies? Drink liquid iron preparations with a straw. Take iron with an antacid to avoid stomach upset. Avoid vitamin C as it prevents absorption. Taking iron pills with milk aids in absorption.
Drink liquid iron preparations with a straw. Explanation: Dilute liquid preparations of iron with another liquid such as juice and drink with a straw to avoid staining the teeth. Avoid taking iron simultaneously with an antacid, which interferes with iron absorption. Drink orange juice or take other forms of vitamin C with iron to promote its absorption.
The nurse observes the laboratory studies for a client in the hospital with fatigue, feeling cold all of the time, and hemoglobin of 8.6 g/dL and a hematocrit of 28%. What finding would be an indicator of iron-deficiency anemia? Erythrocytes that are microcytic and hypochromic Erythrocytes that are macrocytic and hyperchromic Clustering of platelets with sickled red blood cells An increased number of erythrocytes
Erythrocytes that are microcytic and hypochromic Explanation: A blood smear reveals erythrocytes that are microcytic (smaller than normal) and hypochromic (lighter in color than normal). It does not reveal macrocytic (larger than normal) or hyperchromic erythrocytes. Clustering of platelets with sickled red blood cells would indicate sickle cell anemia. An increase in the number of erythrocytes would indicate polycythemia vera.
The nurse is performing an assessment for a client with anemia admitted to the hospital to have blood transfusions administered. Why would the nurse need to include a nutritional assessment for this patient? It is part of the required assessment information. It is important for the nurse to determine what type of foods the patient will eat. It may indicate deficiencies in essential nutrients. It will determine what type of anemia the patient has.
It may indicate deficiencies in essential nutrients. Explanation: A nutritional assessment is important, because it may indicate deficiencies in essential nutrients such as iron, vitamin B12, and folate.
The most common cause of iron-deficiency anemia in premenopausal women includes which of the following? Menorrhagia Inadequate iron supplementation Iron malabsorption Lack of vitamin B12
Menorrhagia Explanation: The most common cause of iron deficiency anemia in premenopausal women is menorrhagia. In pregnancy, it may be caused by inadequate intake of iron. Iron malabsorption may occur following a gastrectomy or with celiac disease. Lack of vitamin B12 is also a potential cause of anemia.
The nurse is screening donors for blood donation. Which client is an acceptable donor for blood? Has a history of viral hepatitis as a teenager 10 years ago Received a blood transfusion within 1 year Reports having a cold 1 month ago that resolved quickly Had a dental extraction 2 days ago for caries in a tooth
Reports having a cold 1 month ago that resolved quickly Explanation: Donors must meet certain requirements to be able to donate blood. A client should be in good health, such as the client who had a cold more than 1 month ago that resolved quickly. Those excluded from donating blood have a : - history of viral hepatitis, - report a blood transfusion within 12 months, - and had a dental extraction within 72 hours. The reason for exclusion is that they are at increased risk of transmitting an infectious disease.
An older adult client who is a vegetarian has a hemoglobin of 10.2 gm/dL, vitamin B12 of 68 pg/mL (normal: 200-900 pg/mL), and MCV of 110 cubic micrometers. After interpreting the data, what instruction should the nurse give to the client? Ingest a diet higher in vitamin B12 sources. Supplement the diet with vitamin B12. Continue with the diet but include more sources of iron. Change the vegetarian diet and begin to eat red meat.
Supplement the diet with vitamin B12. Explanation: Data support that the client is experiencing megaloblastic anemia. Findings include the laboratory test results, the client's older age, and the client's status as a vegetarian. Many vegetarians need to supplement their diet with vitamin B12. Eating more foods with vitamin B12 will not provide enough of this vitamin for the client's body. Increasing iron sources will not resolve the client's anemia. Telling the client to discontinue the vegetarian practice and eat red meat is nontherapeutic.
A client admitted to the hospital in preparation for a splenectomy to treat autoimmune hemolytic anemia asks the nurse about the benefits of splenectomy. Which statement best explains the expected effect of splenectomy? It will remove the major site of red blood cell (RBC) destruction. It will reduce the destruction of platelets by macrophages. It will increase production of platelets by the bone marrow. It will increase red blood cell (RBC) production to compensate for blood loss.
It will remove the major site of red blood cell (RBC) destruction. Explanation: For clients with autoimmune hemolytic anemia, if corticosteroids do not produce remission, a splenectomy (i.e., removal of the spleen) may be performed because it removes the major site of RBC destruction.
Which term refers to an abnormal decrease in white blood cells, red blood cells, and platelets? Pancytopenia Anemia Leukopenia Thrombocytopenia
Pancytopenia Explanation: Pancytopenia is defined as an abnormal decrease in WBCs, RBCs, and platelets. The condition may be congenital (present from birth) or acquired. Anemia refers to decreased red cell mass. Leukopenia refers to a less-than-normal amount of WBCs in circulation. Thrombocytopenia refers to a lower-than-normal platelet count.
A female patient has a hemoglobin of 6.4 g/dL and is preparing to have a blood transfusion. Why would it be important for the nurse to obtain information about the patient's history of pregnancy prior to the transfusion? A high number of pregnancies can increase the risk of reaction. If the patient has never been pregnant, it increases the risk of reaction. Obtaining information about gravidity and parity is routine information for all female patients. If the patient has been pregnant, she may have developed allergies.
A high number of pregnancies can increase the risk of reaction. Explanation: The patient history is an important component of the pretransfusion assessment to determine the history of previous transfusions as well as previous reactions to transfusion. 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.
A nurse cares for clients with hematological disorders and notes that women are diagnosed with hemochromatosis at a much lower rate than men. What is the primary reason for this? Women lose iron through menstrual cycles Women rarely manifest the gene expression Women have lower hemoglobin levels Women require grater folic acid supplementation
Women lose iron through menstrual cycles Explanation: Hemochromatosis is a genetic condition where excess iron is absorbed in the GI tract and deposited in various organs, making them dysfunctional. Women are often less affected than men because women lose excess iron through their menstrual cycles. The other answer choices are not correct reasons why women are impacted less than men with hemochromatosis.
A patient is taking prednisone 60 mg per day for the treatment of an acute exacerbation of Crohn's disease. The patient has developed lymphopenia with a lymphocyte count of less than 1,500 mm3. What should the nurse monitor the client for? The onset of a bacterial infection Bleeding Abdominal pain Diarrhea
The onset of a bacterial infection Explanation: Lymphopenia (a lymphocyte count less than 1,500/mm3) can result from ionizing radiation, long-term use of corticosteroids, uremia, infections (particularly viral infections), some neoplasms (e.g., breast and lung cancers, advanced Hodgkin disease), and some protein-losing enteropathies (in which the lymphocytes within the intestines are lost) (Kipps, 2010). When lymphopenia is mild, it is often without sequelae; when severe, it can result in bacterial infections (due to low B lymphocytes) or in opportunistic infections (due to low T lymphocytes).
The nurse is caring for an older adult client who has been admitted to the unit with anemia. What would the nurse expect the client to possibly exhibit? Excessive consumption of coffee or tea Elimination of iron by the body Decrease in the total body iron stores with age Blood loss from the gastrointestinal or genitourinary tract
Blood loss from the gastrointestinal or genitourinary tract Explanation: If an older adult is anemic, blood loss from the gastrointestinal or genitourinary tract is suspected. This is because iron-deficiency anemia is unusual in older adults as the body does not eliminate excessive iron, causing total body iron stores to increase with age. Excessive consumption of coffee or tea is not a causative factor for anemia in older adults.
A client with severe anemia reports symptoms of tachycardia, palpitations, exertional dyspnea, cool extremities, and dizziness with ambulation. Laboratory test results reveal low hemoglobin and hematocrit levels. Based on the assessment data, which nursing diagnoses is most appropriate for this client? Ineffective tissue perfusion related to inadequate hemoglobin and hematocrit Imbalanced nutrition, less than body requirements, related to inadequate intake of essential nutrients Risk for falls related to complaints of dizziness Fatigue related to decreased hemoglobin and hematocrit
Ineffective tissue perfusion related to inadequate hemoglobin and hematocrit Explanation: The symptoms indicate impaired tissue perfusion due to a decrease in the oxygen-carrying capacity of the blood. Cardiac status should be carefully assessed. 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 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.
A client with idiopathic thrombocytopenic purpura (ITP) is admitted to an acute care facility. The nurse monitors the client's platelet count and observes closely for signs and symptoms of bleeding. The client is at greatest risk for cerebral hemorrhage when the platelet count falls below what number? 10,000/?l. 20,000/?l. 75,000/?l. 135,000/?l.
10,000/?l. Explanation: The client with ITP is at greatest risk for cerebral hemorrhage when the platelet count falls below 10,000/?l. Although platelet counts of 20,000/?l and 75,000/?l are below normal and increase the client's risk for bleeding, they don't increase the risk as much as a platelet count below 10,000/?l. A platelet count of 135,000/?l is normal and wouldn't occur in a client with ITP. Idiopathic: arises spontaneously or for which the cause is unknown.
A patient with end-stage kidney disease (ESKD) has developed anemia. What laboratory finding does the nurse understand to be significant in this stage of anemia? Potassium level of 5.2 mEq/L Magnesium level of 2.5 mg/dL Calcium level of 9.4 mg/dL Creatinine level of 6 mg/100 mL
Creatinine level of 6 mg/100 mL Explanation: The degree of anemia in patients with end-stage renal disease varies greatly; however, in general, patients do not become significantly anemic until the serum creatinine level exceeds 3 mg/100 mL.
A client with anemia is prescribed an oral iron supplement. Which statement indicates that teaching about this supplement has been effective? "I will stop taking it if my stool turns black." "I will take it in the morning with orange juice." "I will be sure to take this medication with food." "I will limit my intake of raw fruit and vegetables."
"I will take it in the morning with orange juice." Explanation: The client should be instructed to take the iron supplements on an empty stomach with a source of vitamin C such as orange juice. Iron supplements will turn the stool dark or black; this does not indicate that the supplement should be stopped. The supplement should be taken 1 hour before meals or 2 hours after a meal and not with a meal. The client should be instructed to increase the intake of high-fiber foods to reduce the risk of constipation.
A clinical nurse specialist (CNS) is orienting a new graduate registered nurse to an oncology unit where blood product transfusions are frequently administered. In discussing ABO compatibility, the CNS presents several hypothetical scenarios. The new graduate knows that the greatest likelihood of an acute hemolytic reaction would occur when giving: A-positive blood to an A-negative client. O-negative blood to an O-positive client. O-positive blood to an A-positive client. B-positive blood to an AB-positive client.
A-positive + blood to an A-negative client. Explanation: An acute hemolytic reaction occurs when there is an ABO or Rh incompatibility. For example, giving A blood to a -> B client would cause a hemolytic reaction. Likewise, giving Rh- +positive blood to an -> Rh-negative client would cause a hemolytic reaction. It's safe to give Rh-negative blood to an --> Rh-positive client if there is a blood type compatibility. O-negative blood is the universal donor and can be given to all other blood types. AB clients can receive either A or B blood as long as there isn't an Rh incompatibility. from google for option C= O positive red blood cells are not universally compatible to all types, but they are compatible to any red blood cells that are positive (A+, B+, O+, AB+).
A patient with sickle cell disease is brought to the emergency department by a parent. The patient has a fever of 101.6°F, heart rate of 116, and a respiratory rate of 32. The nurse auscultates bilateral wheezes in both lung fields. What does the nurse suspect this patient is experiencing? Pneumocystis pneumonia Acute chest syndrome An exacerbation of asthma Pulmonary edema
Acute chest syndrome Explanation: Acute chest syndrome is manifested by fever, respiratory distress (tachypnea, cough, wheezing), and new infiltrates seen on the chest x-ray. These signs often mimic infection, which is often the cause. However, the infectious etiology appears to be atypical bacteria such as Chlamydia pneumoniae and Mycoplasma pneumoniae as well as viruses such as respiratory syncytial virus and parvovirus. Other causes include pulmonary fat embolism, pulmonary infarction, and pulmonary thromboembolism. Seventy-five percent of patients who develop acute chest syndrome had a painful vaso-occlusive crisis, usually lasting an average of 2.5 days prior to developing symptoms of acute chest syndrome (Laurie, 2010).
A client comes to the walk-in clinic complaining of weakness and fatigue. While assessing this client, the nurse finds evidence of petechiae and ecchymoses. The nurse notes that the spleen appears enlarged. What would the nurse suspect is wrong with this client? Aplastic anemia Pernicious anemia Iron-deficiency anemia Agranulocytosis
Aplastic anemia Explanation: Clients with aplastic anemia experience all the typical characteristics of anemia (weakness and fatigue). In addition, they have frequent opportunistic infections plus coagulation abnormalities that are manifested by unusual bleeding, small skin hemorrhages called petechiae, and ecchymoses (bruises). The spleen becomes enlarged with an accumulation of the client's blood cells destroyed by lymphocytes that failed to recognize them as normal cells, or with an accumulation of dead transfused blood cells. The blood cell count shows insufficient numbers of blood cells. A bone marrow aspiration confirms that the production of stem cells is suppressed. This scenario does not describe a client with pernicious anemia, iron-deficiency anemia, or agranulocytosis.
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 Few clients with suspected iron deficiency anemia undergo bone marrow aspiration. In many clients, the diagnosis can be established with other tests. The first test is a decrease in ferritin level. The diminished iron stores cause small erythrocytes to be produced by the marrow. Therefore, as the anemia progresses, the MCV, which measures the size of the erythrocytes, also decreases. Clients with iron deficiency anemia have a low serum iron level and an elevated total iron-binding capacity, which measures the transport protein supplying the marrow with iron as needed. The hematocrit level will decrease and not increase in iron deficiency anemia.
The nurse provides care for an older adult client, diagnosed with anemia, who has a hemoglobin of 9.6 g/dL and a hematocrit of 34%. To determine the cause of the client's blood loss, which is the priority nursing action? Observe the client's stools for blood. Evaluate the client's dietary intake. Monitor the client's body temperature. Monitor the client's blood pressure.
Observe the client's stools for blood. Explanation: 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.
