A&C Exam 2 questions
A client sustains a crushing injury to the lower left leg, and a below-the-knee amputation is performed. For which common clinical manifestation of a pulmonary embolus would the nurse asses for in this client? Select all that apply Sharp chest pain acute onset of dyspnea pain in the residual limb absence of the popliteal pulse blanching of the affected extremity
Sharp chest pain & acute onset of dyspnea Emboli can occur with crushing injuries of the extremities. Lodging of a thrombus in the pulmonary system results in a lack of oxygen to pulmonary tissues, causing localized sharp chest pain. Lodging of a thrombus in the pulmonary system will result in decreased breath sounds and dyspnea.
Which diagnosis increases the risk for development of a pulmonary embolism? Atrial fibrillation Forearm laceration Migraine headache Respiratory infection
A Fib Inadequate atrial contraction that occurs during fibrillation leads to pooling of blood in both atria that may result in thrombus formation. Dislodgement of thrombus in the right atria will lead to pulmonary embolism, whereas dislodgement of thrombus in the left atria may lead to embolic stroke.
When a client with a suspected pulmonary embolism is scheduled for a spiral computes tomography (CT) scan, which action would the nurse take before the procedure? Check the client's blood glucose levels Obtain informed consent from the client Assess if the client is allergic to shellfish Instruct the client to remove his or her dentures
Assess if the client is allergic to shellfish before preparing the client for the test, the nurse would assess if the client is allergic to shellfish because the contrast used in the test is iodine based
Which nursing action would be included in the plan of care when a client is admitted with thrombocytopenia? Select all that apply Avoid intramuscular injections institute neutropenic precautions monitor the WBC count administer prescribe anticoagulants examine the skin for ecchymotic areas
Avoid intramuscular injections & examine the skin for ecchymotic areas Intramuscular injections should be avoided because of the increased risk of bleeding and possible hematomia formation. Decreased platelets increase the risk of bleeding, which leads to ecchymoses.
Which teaching would the nurse provide to a client with newly diagnosed pancytopenia cause by chemotherapy? A. Begin a program of meticulous mouth care B. Avoid traumatic injury and exposure to infection C. Increase oral fluid intake to at least 3 L/day D. Report unusual muscle cramps or tingling sensations in the extremities
Avoid traumatic injury and exposure to infection Reduced platelets increase the likelihood of uncontrolled bleeding; reduced lymphocytes increase the susceptibility to infection
Which statement indicates that the client has a correct understanding of the condition after the nurse has finished teaching a client about sickle cell anemia? A. "I have abnormal platelets." B. "I have abnormal hemoglobin." C. "I have abnormal hematocrit." D. "I have abnormal white blood cells."
B. I have abnormal hemoglobin The patient with sickle cell anemia has abnormal hemoglobin, hemoglobin S, causing the red blood cells to stiffen and elongate into a sickle
Which client statement demonstrates an understanding of cyanocobalamin (vitamin B12) prescribed for pernicious anemia? A. B12 injections every month B. vitamin B12 supplements every morning with breakfast C. eat a diet high in green vegetables D. increase intake of processed foods
B12 injections every month Vitamin B12 is administered via injection on a weekly or monthly basis
When caring for a client with a possible pulmonary embolism, the nurse will anticipate preparing the client for which test? a. chest x-ray b. thoracic ultrasound c. CT d. MRI
CT Helical CT is the most commonly used test to detect pulmonary embolism. Chest x-ray may be normal with pulmonary embolism and is not useful as a diagnostic tool.
Which action would the nurse take first when caring for a client with a possible pulmonary embolus? auscultate the chest obtain vital signs elevate the head of the bed notify the rapid response team
Elevate the head of the bed Elevating promotes better gas exchange by reducing the pressure of the abdominal organs on the diaphragm and increasing thoracic excursion
Which clotting factor would a nurse explain is deficient to the parents of a child newly diagnosed with hemophilia A? Factor II Factor XII Factor IX Factor VIII
Factor VIII Hemophilia type A is from deficiency of Factor VIII
Which laboratory test result would the nurse expect to be decreased in a client with iron-deficiency anemia? A. ferritin level B. platelet count C. white blood cell count D. total iron-binding capacity
Ferritin level Ferritin, a form of stored iron, is reduced with iron-deficiency anemia. Total iron-binding capacity will be increased.
Which cause would a nurse suspect is responsible for warmth, redness, and tenderness identified at a client's intravenous (IV) site? rapid fluid delivery phlebitis allergic response infiltration
Phlebitis Phlebitis is an inflammation that can occur from prolonged IV infusion at a site, undiluted irritating medications and other causes. It manifests as increased warmth, redness, and tenderness.
After reviewing a client's complete blood cell count, which finding would be the most important for the nurse to communicate to the health care provider? Hematocrit 41% Hemoglobin 12 g/dL (120 g/L) Platelet count 75,000 mm^3 (75x10^9/L) White blood cell count 5100 mm^3 (5.1x10^9/L)
Platelet count 75,000 mm^3 (75x10^9/L) Normal platelet count is 150,000 to 400,000 mm^3. This clients low platelet count increases risk for bleeding and requires further diagnostic testing and treatment
Which dietary choices by a client with iron deficiency anemia indicate that the nurse's dietary teaching has been effective? Select all that apply A. scrambled eggs B. steamed carrots C. spinach salad D. dried apricots E. Baked potato F. sliced oranges
Scrambled eggs, Baked potato, Spinach salad, Dried apricots Eggs, potatoes, dark green vegetables, and dried apricots are high in iron
When performing a focused assessment on a client with a possible diagnosis of iron deficiency anemia, which location would the nurse examine? Select all that apply. Sclera Nail beds Conjuctivae Palms of hands Bony prominences
Nail beds, conjunctivae, and palms of hands Nail beds lose their pink coloration bc of reduced hemoglobin. A reduced amount of hemoglobin deceases pink color of conjunctivae. Palms of hands will become pale bc of the decreased hemoglobin.
Which response will a nurse give to the parents of a child with sickle cell anemia who ask about their child taking iron supplements to help treat anemia? A. taking supplements will not help with this condition B. it is advised that iron be taken with orange juice to aid in absorption C. an over-the-counter multivitamin with iron should meet the needs of the child D. it is advised that liquid iron supplements be given through a straw to prevent staining the teeth
A Taking iron supplements will not help. Sickle cell anemia is not caused by too little iron in the blood; it's caused by not having enough red blood cells. Taking iron supplements could cause harm, because the extra iron builds up in the body and can damage organs. Although iron is better absorbed when taken with orange juice, in the case of sickle cell anemia supplements are not given.
Which laboratory finding would the nurse expect in a toddler with iron-deficiency anemia in addition to decreased hemoglobin and hematocrit levels? Select all that apply A. mycrocytic red blood cells B. hyperchromic red blood cells C. low total iron-binding capactiy D. slightly reduced reticulocyte count E. increased erythrocyte sedimentation rate (ESR)
A & D In iron-deficiency anemia, the red blood cells are microcytic with a decreased mean corpuscular volume. The reticulocyte count is within the expected range or slightly reduced.
Which mechanism would the nurse attempt to increase to prevent postoperative deep vein thrombosis? a.coagulability of the blood b. velocity of the venous return c. effectiveness of internal respiration d. oxygen-carrying capacity of the blood
B because venous stasis is the major predisposing factor of pulmonary emboli, the venous flow velocity should be increased through activity
The nurse caring for a child with a low platelet count would monitor the child's urine for the presence of which component? Protein glucose erythrocytes lymphocytes
Erythrocytes A low platelet count predisposes the child to bleeding, which may be evident in the urine. RBC are seen microscopically in the sediment
A 60 year old client with gastric cancer has a shiny tongue, paresthesias of the limbs, and ataxia. The laboratory results show cobalamin levels of 125 pg/mL. Which medication would the nurse expect to be prescribed for the client? A. Oral hydroxyurea B. Vitamin B12 injections C. Oral Iron supplements D. Erythropoietin injections
Vitamin B12 injections A shiny tongue, paresthesias of the limbs, ataxia, and cobalamin of 125 pg/mL (normal: 200- 835 pg/mL) are the manifestations of pernicious anemia. The client has pernicious anemia due to a vitamin B12 deficiency and should be given vitamin B12 injections.
A pregnant client with iron-deficiency anemia is prescribed iron supplements daily. To help the client increase iron absorption, the nurse should suggest that the client eat foods high in which substance? A. vitamin C B. fat content C. water content D. vitamin B complex
Vitamin C Vitamin C aids the absorption of iron
Information about which vitamin would be included when teaching a client with atrial fibrillation about a new prescription for warfarin? A. vitamin K B. Vitamin D C. Vitamin B 1 D. Vitamin B 12
Vitamin K Warfarin causes inhibition of vitamin K-dependent clotting factors, and the use of vitamin K would affect the therapeutic effect of warfarin
Which action will the nurse take for a client with a suspected pulmonary embolus? Select all that apply administer oxygen at high flow rates notify the rapid response team lower the head of the client's bed place the client on a cardiac monitor anticipate rapid administration of warfarin
administer oxygen notify rapid response place the client on a cardiac monitor
Which prescribed treatment would the nurse question when a client who has sickle cell anemia has been admitted with acute chest syndrome? A. oxygen administration B. daily folic acid tablet C. daily iron supplement D. morphine sulfate prn
Daily iron supplement The nurse would question the use of iron supplements in sickle cell anemia because sickle cells disease is not caused by iron deficiency
Which manifestation would the nurse include when the parents of a child who has just been diagnosed with hemophilia A ask what symptoms of bleeding should they look for in the future? Select all that apply Nosebleeds (epistaxis) blood in the urine (hematuria) painful and swollen joints (hemarthrosis) easy bruising frequent fevers fast clotting of injuries dark-colored tarry stools
Nosebleeds, blood in the urine, painful and swollen joints, easy bruising and dark-colored tarry stools