Blood

A client asks the nurse how long the client will need vitamin B12 injections. Which response by the nurse is best?

"For the rest of your life."

The school nurse teaches a wellness class to a group of high school students. The nurse should intervene if a student makes which of the following statements?

"I'm not going to use public toilets ever again."

The community health nurse teaches a class on disease prevention at a community health fair. One of the participants states, "I have heard the term 'incubation period' but I do not know what it means. What is it exactly?" Which of the following is the best response by the nurse?

"Incubation period is the time between when a person gets infected and when actual symptoms appear."

The nurse plans discharge for an elderly client diagnosed with anemia. The nurse learns the client lives in a two-story house and all the bedrooms are on the second floor. It is most important for the nurse to ask which question?

"Where do you plan to sleep?"

The spouse of a client diagnosed with pernicious anemia asks why vitamin B12 can't be given in pill form. Which response by the nurse is correct?

"Your spouse's stomach doesn't secrete the necessary substance for B12 to be absorbed orally."

The nurse cares for a client diagnosed with AIDS reporting diarrhea. It is most important for the nurse to include which implementation in the client's plan of care?

Decrease roughage in the diet.

The nurse performs a home care visit to an elderly client diagnosed with iron deficiency anemia. The client states that even though she is taking her "iron pill" daily, the client is feeling more and more fatigued. Which of the following actions should the nurse take first?

Obtain a stool specimen to test for occult blood.

The nurse understands that hematocrit measures which of the following?

Ratio of red blood cells to fluid volume.

The nurse counsels a client diagnosed with iron deficiency anemia. The nurse determines teaching is effective if the client selects which menu?

Flank steak, green leafy vegetables, and prunes.

If a client has an anaphylactic reaction to an antibiotic, it is most important for the nurse to take which action after notifying the health care provider?

Give epinephrine subcutaneously.

The nurse cares for a client diagnosed with sickle cell crisis. The client's child comes to visit the parent, and the nurse observes the child has an upper respiratory infection. It is most important for the nurse to take which action?

Give the child a mask to wear when visiting the client.

The nurse cares for a client diagnosed with confusion due to AIDS dementia complex. It is most important for the nurse to take which action?

Give the client simple directions.

The nurse understands which best describes what clients diagnosed with disseminated intravascular coagulation (DIC) experience?

Hemorrhage and clotting.

The nurse prepares a client for a Schilling test. Which information is most important for the client to know before starting the test?

How to collect a 24 hour urine.

The nurse counsels a client reporting fatigue and shortness of breath due to AIDS. Which action by the nurse is most important?

Instruct the client to sit while preparing meals.

The nurse understands which is the most common type of anemia?

Iron-deficiency anemia

The nurse performs diet teaching for a client with iron deficiency anemia. The nurse determines teaching is successful if the client selects which item from the menu?

Liver and onions, spinach, and rice pudding with raisins.

The nurse reviews the health care provider's orders for a client diagnosed with hemophilia. It is most important for the nurse to question which order?

Meperidine 75mg IM q 4 hours pro for severe pain.

The nurse identifies which client is most likely to have latex hypersensitivity?

A client diagnosed with spina bifida. **serious health hazard for children with spina bifida due to repeated exposure; also at risk are health care workers and people who routinely use latex condoms; reaction can range from contact dermatitis to anaphylaxis

A young adult diagnosed with hemophilia bumps his knee and develops painful swelling of the knee. In caring for the client, which action is most appropriate for the nurse to take initially?

Apply ice to the knee and elevate the leg.

The nurse cares for a client diagnosed with polycythemia vera. The nurse expects to make which observation?

Dark, flushed face. **blood in tissues in incompletely oxygenated; intense itching due to vasodilation occurs; blood moves slowly due to increased viscosity.

The nurse cares of a client diagnosed with autoimmune thrombocytopenia purport. Which nursing diagnosis is a priority when caring for this patient?

Risk for injury **protect client from situations that can cause bleeding; monitor closely; avoid IM injections, apply firm pressure after needlestick; ice areas of trauma; test urine and stool for occult blood, use electric razor and avoid mouth trauma

The home care nurse visits a client diagnosed with AIDS. The nurse should intervene if which of the following is observed?

Soiled linens are placed in a laundry hamper. **keep soiled laundry in a plastic bag.

The nurse in the hematology clinic prepares a class series on immunologic diseases for new clients. Which organs should the nurse describe as being considered part of the immune system of the body?

Spleen and thymus

The parents of a newly circumcised infant are informed that their child has hemophilia A. One parent is crying and expresses concern that the child will bleed to death. The other parent says, "Just give me the fact. We will deal with it." It is most important for the nurse to give what information initially?

The availability of replacement therapy of clotting factors.

The nurse cares for clients on the med/surg unit. The nurse identifies which client has a disease that is considered autoimmune?

The client diagnosed with multiple sclerosis.

Several days following bone marrow aspiration, the nurse notes the client has a temperature of 103 degrees F, and there is yellow drainage from the aspiration site. Which interpretation by the nurse is most accurate?

The client has developed osteomyelitis

Which of the following symptoms indicates to the home health nurse that a client has an infection?

The client has lymphadenopathy.

The nurse obtains a history from a client admitted with a diagnosis of sickle cell crisis. The nurse identifies which factor contributed to the sickle cell crisis?

The client recently had an upper respiratory infection.

The nurse cares of a client with a sickle cell crisis. The nurse determines care is appropriate if which observation is made?

The client's intake is 1600 mL for 8 hours. **dehydration precipitates sickle cell crisis; client should take in at lease 2000 mL per hour by oral and parenteral route; do not offer caffeinated beverages.