CH 33 Prep U
A client's family member asks the nurse why disseminated intravascular coagulation (DIC) occurs. Which statement by the nurse correctly explains the cause of DIC? "DIC occurs when the immune system attacks platelets and causes massive bleeding." "DIC is caused when hemolytic processes destroy erythrocytes." "DIC is a complication of an autoimmune disease that attacks the body's own cells." "DIC is caused by abnormal activation of the clotting pathway, causing excessive amounts of tiny clots to form inside organs."
"DIC is caused by abnormal activation of the clotting pathway, causing excessive amounts of tiny clots to form inside organs." Explanation: The inflammatory response initiates the process of inflammation and coagulation. The natural anticoagulant pathways within the body are simultaneously impaired, and the fibrinolytic system is suppressed, allowing a massive amount of tiny clots forms in the microcirculation. As the platelets and clotting factors form microthrombi, coagulation fails. Thus, the paradoxical result of excessive clotting is bleeding. Decline in organ function is usually a result of excessive clot formation (with resultant ischemia to all or part of the organ).
A client with megaloblastic anemia reports mouth and tongue soreness. What instruction will the nurse give the client regarding eating while managing the client's symptoms? "Eat cold, bland foods with a large amount of water." "Eat low-fiber blended foods only." "Eat small amounts of bland, soft foods frequently." "Eat larger amounts of bland, soft foods less frequently."
"Eat small amounts of bland, soft foods frequently." Explanation: Because the client with megaloblastic anemia often reports mouth and tongue soreness, the nurse should instruct the client to eat small amounts of bland, soft foods frequently. The other answer choices do not factor in the client's mouth soreness or need for nutrition.
Which nursing instructions help parents of a child with hemophilia provide a safe home environment for their child? "Be a role model to your child by wearing a helmet when riding a bike so your child will, too." "Talk with your child about home safety and have him problem-solve hypothetical situations about his health." "Establish a written emergency plan including what to do in specific situations and the names and phone numbers of emergency contacts." "Pad the corners of coffee tables when your child is a toddler and provide kneepads for sports when the child is older."
"Establish a written emergency plan including what to do in specific situations and the names and phone numbers of emergency contacts." Explanation: Establishing a written emergency plan that includes what to do in specific situations helps the family provide safety measures for their child with hemophilia. Padding corners of furniture and using kneepads don't help provide a safe home environment for children of all ages. Telling the parents to be a role model by wearing a bike helmet is only applicable to children who are old enough to emulate their parent's behaviors. Having the child problem-solve hypothetical health situations doesn't help provide a safe environment; it addresses problem solving.
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 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 until my signs and symptoms disappear."
"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 client with anemia is prescribed an oral iron supplement. Which statement indicates that teaching about this supplement has been effective? "I will take it in the morning with orange juice." "I will limit my intake of raw fruit and vegetables." "I will be sure to take this medication with food." "I will stop taking it if my stool turns black."
"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 home care nurse visits a client diagnosed with atrial fibrillation who is ordered warfarin. The nurse teaches the client about warfarin therapy. Which statement by the client indicates the need for further teaching? "I'll report unexplained or severe bruising to my doctor right away." "I'll use an electric razor to shave." "I'll eat four servings of fresh, dark green vegetables every day." "I'll watch my gums for bleeding when I brush my teeth."
"I'll eat four servings of fresh, dark green vegetables every day." Explanation: The client requires additional teaching if he states that he'll eat four servings of dark green vegetables every day. Dark, green vegetables contain vitamin K, which reverses the effects of warfarin. The client should limit his intake to one to two servings per day. The client should report bleeding gums and severe or unexplained bruising, which may indicate an excessive dose of warfarin. The client should use an electric razor to prevent cutting himself while shaving.
A female client with the beta-thalassemia trait plans to marry a man of Italian ancestry who also has the trait. Which client statement indicates that she understands the teaching provided by the nurse? "If my fiancé was of Middle Eastern descent, I wouldn't be worried about having children." "I need to learn how to give myself vitamin B12 injections." "I'll see a genetic counselor before starting a family." "Thalassemia is treated with iron supplements."
"I'll see a genetic counselor before starting a family." Explanation: Two people with the beta-thalassemia trait have a 25% chance of having a child with thalassemia major, a potentially life-threatening disease. Iron supplements aren't used to treat thalassemia; in fact, they could contribute to iron overload. Vitamin B<!sub>12!sub> injections are used to treat pernicious anemia, not thalassemia. Thalassemia occurs primarily in people of Italian, Greek, African, Asian, Middle Eastern, East Indian, and Caribbean descent.
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 child must inherit two defective genes, one from each parent." "It is an acquired, not a hereditary disorder." "The trait is passed down through the mother."
"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 monitors the laboratory data for several clients who are diagnosed with hypoproliferative anemias. For each laboratory data, click to specify if the finding indicates microcytic anemia or megaloblastic anemia: 1. increased total iron-binding capacity (TIBC) 2. decreased folate 3. increased mean corpuscular volume (MCV) 4. decreased mean corpuscular volume (MCV) 5. decreased reticulocytes 6. decreased vitamin B12
1. Microcytic Anemia 2. Megaloblastic Anemia 3. Megaloblastic Anemia 4. Microcytic Anemia 5. Microcytic Anemia 6. Megaloblastic Anemia
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. 135,000/?l. 75,000/?l. 20,000/?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.
A health care provider prescribes one tablet of ferrous sulfate daily for a 15-year-old girl who experiences heavy blood flow during her menstrual cycle. The nurse advises the patient and her parent that this over-the-counter preparation must be taken for how many months before stored iron replenishment can occur? 1 to 2 months Longer than 12 months 3 to 5 months 6 to 12 months
6 to 12 months Explanation: Ferrous sulfate can increase hemoglobin levels in a few weeks, and anemia may be corrected in a few months. However, it takes 6 to 12 months for stored iron replenishment to occur.
The nurse is caring for four clients on the medical-surgical unit of the hospital. What client is most likely to be receiving treatment for sickle cell crisis? A 29-year-old European American male A 36-year-old Eastern European female A 24-year-old Native American/First Nations female A 19-year-old male of African-American descent
A 19-year-old male of African-American descent Explanation: Sickle cell disease is a common genetic disorder found primarily in clients of African descent but also in people from Mediterranean and Middle Eastern countries. It is unlikely that a Caucasian male, Native American/First Nations female, or Eastern European female will be affected by this disease.
A few minutes after beginning a blood transfusion, a nurse notes that a client has chills, dyspnea, and urticaria. The nurse reports this to the health care provider immediately because the client probably is experiencing which problem? A hemolytic reaction to mismatched blood A hemolytic reaction caused by bacterial contamination of donor blood A hemolytic reaction to Rh-incompatible blood A hemolytic allergic reaction caused by an antigen reaction
A hemolytic allergic reaction caused by an antigen reaction Explanation: Hemolytic allergic reactions are fairly common and may cause chills, fever, urticaria, tachycardia, dyspnea, chest pain, hypotension, and other signs of anaphylaxis a few minutes after blood transfusion begins. Although rare, a hemolytic reaction to mismatched blood can occur, triggering a more severe reaction and, possibly, leading to disseminated intravascular coagulation. A hemolytic reaction to Rh-incompatible blood is less severe and occurs several days to 2 weeks after the transfusion. Bacterial contamination of donor blood causes a high fever, nausea, vomiting, diarrhea, abdominal cramps and, possibly, shock.
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: O-negative blood to an O-positive client. A-positive blood to an A-negative 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.
The nurse is caring for a client with an exacerbation of sickle cell disease (SCD). Which finding indicates to the nurse that the client is experiencing a liver complication from this condition? Abdominal pain Weakness Glucose intolerance Fatigue
Abdominal pain Explanation: Sickle cell disease (SCD) is an autosomal recessive disorder caused by inheritance of the sickle hemoglobin (HbS) gene. It is associated with severe hemolytic anemia. The HbS gene results in production of a defective hemoglobin molecule that causes the erythrocyte to change shape when exposed to low oxygen tension. The erythrocyte usually has a round, biconcave, pliable shape which in SCD becomes rigid and sickle shaped. Complications of SCD can affect all body systems. Evidence that the client is experiencing a complication in the liver would be the development of abdominal pain. Fatigue and weakness indicate complications involving the central nervous system and heart. Glucose intolerance is not identified as a complication of SCD.
A complete blood count is commonly performed before a client goes into surgery. What does this test seek to identify? Abnormally low hematocrit (HCT) and hemoglobin (Hb) levels Potential hepatic dysfunction indicated by decreased blood urea nitrogen (BUN) and creatinine levels Low levels of urine constituents normally excreted in the urine Electrolyte imbalance that could affect the blood's ability to coagulate properly
Abnormally low hematocrit (HCT) and hemoglobin (Hb) levels Explanation: Low preoperative HCT and Hb levels indicate the client may require a blood transfusion before surgery. If the HCT and Hb levels decrease during surgery because of blood loss, the potential need for a transfusion increases. Possible renal failure is indicated by elevated BUN or creatinine levels. Urine constituents aren't found in the blood. Coagulation is determined by the presence of appropriate clotting factors, not electrolytes.
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? An exacerbation of asthma Pneumocystis pneumonia Acute chest syndrome 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).
The nurse is talking with the parents of a toddler who was diagnosed with hemophilia A. What instruction should the nurse give to the parents? Encourage the toddler to participate in playground activities with other toddlers Administer factor VIII intravenously at the first sign of bleeding Administer over-the-counter preparations for a cold Use nasal packing for any nose bleeds
Administer factor VIII intravenously at the first sign of bleeding Explanation: Clients and families are taught to administer factor VIII intravenously. This helps to prevent bleeding episodes. Activities that minimize trauma are allowed for the toddler, however, playground activities may place the toddler at risk for increased bleeding. Over-the-counter cold preparations are to be avoided because they will interfere with platelet aggregation. Nasal packing is avoided because when the nasal packing is removed, bleeding may occur.
A client with sickle cell crisis is admitted to the hospital in severe pain. While caring for the client during the crisis, which is the priority nursing intervention? Limiting the client's intake of oral and IV fluids Encouraging the client to ambulate immediately Administering and evaluating the effectiveness of opioid analgesics Limit foods that contain folic acid
Administering and evaluating the effectiveness of opioid analgesics Explanation: The priority nursing intervention is to manage the acute pain. Client-controlled analgesia is frequently used in the acute care setting. A patient with sickle cell crisis experiences severe extreme pain, the use of IV fluids and oral intake is need to hydrate the patient, the patient is initially placed on bed rest during the crisis due to extreme fatigue. The patient must continue to ingest folic acid and are placed on a daily folic acid supplement .
For a client diagnosed with idiopathic thrombocytopenia purpura (ITP), which nursing intervention is appropriate? Administering stool softeners, as ordered, to prevent straining during defecation Administering platelets, as ordered, to maintain an adequate platelet count Giving aspirin, as ordered, to control body temperature Teaching coughing and deep-breathing techniques to help prevent infection
Administering stool softeners, as ordered, to prevent straining during defecation Explanation: The nurse should take measures to prevent bleeding because the client with ITP is at increased risk for bleeding. Straining at stool causes the Valsalva maneuver, which may raise intracranial pressure (ICP), thus increasing the risk for intracerebral bleeding. Therefore, the nurse should give stool softeners to prevent straining, which may result from constipation. Teaching coughing techniques would be inappropriate because coughing raises ICP. Platelets rarely are transfused prophylactically in clients with ITP because the cells are destroyed, providing little therapeutic benefit. Aspirin interferes with platelet function and is contraindicated in clients with ITP.
A young female client has pale nailbeds. Her hemoglobin count is 10.2 gm/dL and her hematocrit count is 30%. She reports fatigue and states, "I'm tired all the time." The client also reports excessive menstrual flow. The nurse assesses further and determines the client's diet is balanced and provides adequate calories. The client is prescribed supplemental iron therapy. The highest nursing diagnosis is: Altered tissue perfusion related to diminished oxygen-carrying capacity of the blood Deficient knowledge related to new information with no previous experience Altered nutrition: less than body requirements, related to inadequate intake of nutrients Fatigue related to diminished oxygen-carrying capacity of the blood
Altered tissue perfusion related to diminished oxygen-carrying capacity of the blood Explanation: All the nursing diagnoses are appropriate for this client who is experiencing anemia. Physiological needs take priority per Maslow's hierarchy of needs. Under physiological needs, airway, breathing, and then circulation take priority. Altered tissue perfusion would be classified under circulation, thus making it the priority over the other diagnoses listed.
Which of the following is the most common hematologic condition affecting elderly patients? Thrombocytopenia Leukopenia Anemia 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 client is brought to the ED reporting fatigue, large amounts of bruising on the extremities, and abdominal pain localized in the left upper quadrant. A health history reveals the client has been treated for a sore throat three times in the past 2 months. Laboratory tests indicate severe anemia, significant neutropenia, and thrombocytopenia. Based on the symptoms, what could be the client's diagnosis? Hemolytic anemia Sickle cell anemia Iron deficiency anemia Aplastic anemia
Aplastic anemia Explanation: Aplastic anemia can be congenital or acquired, but most cases are idiopathic. It can be triggered by infection. The manifestations of aplastic anemia are symptoms of anemia, purpura (bruising), retinal hemorrhages, significant neutropenia, and thrombocytopenia. Other lymphadenopathies and splenomegaly sometimes occur.
A client comes to the walk-in clinic reporting weakness and fatigue. While assessing this client, the nurse finds evidence of petechiae and ecchymoses and notes that the spleen appears enlarged. What would the nurse suspect is wrong with this client? Iron deficiency anemia Pernicious anemia Aplastic 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 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.
A client in end-stage renal disease is prescribed epoetin alfa and oral iron supplements. Before administering the next dose of epoetin alfa and oral iron supplement, what is the priority action taken by the nurse? Holds the epoetin alfa if the BUN is elevated Ensures the client has completed dialysis treatment Questions the administration of both medications Assesses the hemoglobin level
Assesses the hemoglobin level Explanation: Erythropoietin (epoetin alfa [Epogen]) with oral iron supplements can raise hematocrit levels in the client with end-stage renal disease. The nurse should check the hemoglobin prior to administration of erythropoietin, because too high a hemoglobin level can put the client at risk for heart failure, myocardial infarction, and cerebrovascular accident. Erythropoietin may be administered during dialysis treatments. The BUN will be elevated in the client with end-stage renal disease.
A nurse cares for a client with anemia requiring nutritional supplementation. Which nursing intervention best promotes client adherence with the prescribed therapy? Assist the client to use a medication reminder system for the therapeutic regimen. Develop a therapeutic regimen recommendation for the client. Assist the client to incorporate the therapeutic regimen into daily activities. Develop a therapeutic regimen based on the client's understanding of the medication.
Assist the client to incorporate the therapeutic regimen into daily activities. Explanation: The best way for the nurse to promote adherence to the therapeutic regimen is to assist the client to incorporate the therapeutic regimen into daily activities. This action is the only answer choice that is a collaborative effort with the client and is the reason it is correct.
The nurse is planning care for a client with severe fatigue secondary to anemia. What concept will the nurse use as the basis for planning interventions? Encouraging early and frequent activities. Determining what days to be active. Keeping long activity periods to build client stamina. Assisting in prioritizing activities.
Assisting in prioritizing activities. Explanation: When planning care for a client with severe fatigue secondary to anemia, the nurse should act collaboratively with the client and assist in prioritizing activities. The client ultimately determines the balance between rest and activity, not the nurse. The nurse will balance activities and group nursing interventions in order to prevent client fatigue.
A patient describes numbness in the arms and hands with a tingling sensation. The patient also frequently stumbles when walking. What vitamin deficiency does the nurse determine may cause some of these symptoms? B12 Iron Thiamine Folate
B12 Explanation: The hematologic effects of vitamin B12 deficiency are accompanied by effects on other organ systems, particularly the gastrointestinal tract and nervous system. Patients with pernicious anemia may become confused; more often, they have paresthesias in the extremities (particularly numbness and tingling in the feet and lower legs). They may have difficulty maintaining their balance because of damage to the spinal cord, and they also lose position sense (proprioception).
When teaching a client with iron deficiency anemia about appropriate food choices, the nurse encourages the client to increase the dietary intake of which foods? Fruits high in vitamin C, such as oranges and grapefruits Dairy products Berries and orange vegetables Beans, dried fruits, and leafy, green vegetables
Beans, dried fruits, and leafy, green vegetables Explanation: Food sources high in iron include organ meats (e.g., beef or calf liver, chicken liver), other meats, beans (e.g., black, pinto, and garbanzo), leafy and green vegetables, raisins, and molasses. Taking iron-rich foods with a source of vitamin C (e.g., orange juice) enhances the absorption of iron.
Which of the following are assessment findings associated with thrombocytopenia? Select all that apply. Hematemesis Bradypnea Hypertension Bleeding gums Epistaxis
Bleeding gums Epistaxis Hematemesis Explanation: Pertinent findings of thrombocytopenia include: bleeding gums, epistaxis, hematemesis, hypotension, and tachypnea.
A nurse is caring for an older client who has been admitted to the unit with iron-deficiency anemia. What would the nurse suspect? Decrease in the total body iron stores with age Blood loss from the gastrointestinal or genitourinary tract Excessive consumption of coffee or tea Elimination of iron by the body
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.
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? Blood loss from the gastrointestinal or genitourinary tract Decrease in the total body iron stores with age Elimination of iron by the body Excessive consumption of coffee or tea
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.
Which is a symptom of Cooley anemia? Inflammation of the mouth Bronzing of the skin Inflammation of the tongue Dyspnea
Bronzing of the skin Explanation: Clients with Cooley anemia exhibit symptoms of severe anemia and a bronzing of the skin, which is caused by hemolysis of erythrocytes. Dyspnea, stomatitis (inflammation of the mouth), and glossitis (inflammation of the tongue) are symptoms of pernicious anemia.
Which is a symptom of hemochromatosis? Inflammation of the tongue Inflammation of the mouth Bronzing of the skin 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 nurse working with clients diagnosed with sickle cell disease notices that sickle cell crisis cases increase in the winter months. What is the primary pathophysiological reason for this? Colder temperatures increases vessel pressures. Colder temperatures slows the blood flow. Colder temperatures worsens sickling. Colder temperatures impairs oxygen uptake.
Colder temperatures slows the blood flow. Explanation: Colder temperatures lead to vasoconstriction, which slows the blood flow. Colder temperatures do not worsen sickling or impair oxygen uptake. Vasoconstriction does increase vessel pressures but the vessel pressures are not the reason that sickle cell crisis increases with colder temperatures.
A young client is diagnosed with glucose-6-phosphate dehydrogenase deficiency (G-6-PD). After reviewing the client's recent activities, what instruction should the nurse recommend to the client? Stop drinking excessive caffeinated beverages in less than 24 hours. Consult a health care provider about ingesting trimethoprim/sulfamethoxazole for a urinary tract infection. Discontinue exposure on a sun tanning bed. Quit cigarette smoking.
Consult a health care provider about ingesting trimethoprim/sulfamethoxazole for a urinary tract infection. Explanation: Certain drugs can cause hemolysis associated with G-6-PD, such as trimethoprim/sulfamethoxazole. The other options do not cause the hemolysis.
A male client has been receiving a continuous infusion of weight-based heparin for more than 4 days. The client's PTT is at a level that requires an increase of heparin by 100 units per hour. The client has the laboratory findings shown above. What is the most important action for the nurse to take? Begin treatment with the prescribed warfarin (Coumadin). Consult with the physician about discontinuing heparin. Increase the heparin infusion by 100 units per hour. Continue with the present infusion rate of heparin.
Consult with the physician about discontinuing heparin. Explanation: Platelet counts may decrease with heparin therapy, and this client's platelet count has decreased. The client may have heparin-induced thrombocytopenia (HIT). Treatment of HIT includes discontinuing the heparin. The question asks about the most important action of the nurse and that is to consult with the physician about discontinuing heparin therapy. The nurse may continue with the current rate and should not increase the heparin dose until consulting with the physician. Warfarin is not administered until the platelet count has returned to normal levels.
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 Creatinine level of 6 mg/100 mL Magnesium level of 2.5 mg/dL Calcium level of 9.4 mg/dL
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 patient with chronic renal failure is examined by the health care provider for anemia. Which laboratory results will the nurse monitor? Decreased total iron-binding capacity Decreased level of erythropoietin Increased reticulocyte count Increased mean corpuscular volume
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.
A nurse cares for a client with a hematological disorder and malnutrition. What is the nurse's best understanding of how the client's nutritional status may worsen the client's hematological condition? Decreased fat stores lead to decreased ability for red blood cells Decreased carbohydrates lead to decreased oxygen affinity of the hemoglobin Decreased calories lead to decreased immune response Decreased protein stores lead to decreased immune response
Decreased protein stores lead to decreased immune response Explanation: Decreased protein stores lead to a decreased immune response and worsening of the client's hematological condition. Decreased intake of carbohydrates, calories, or fat stores are not the primary sources for worsening of the client's condition.
A nurse cares for several clients with anemia and notes that all the clients have different types of anemia. What is the nurse's best understanding of how anemias are classified, based on the deficiency of erythrocytes? Select all that apply. Quantity of erythrocytes Destruction of erythrocytes Defective production of erythrocytes Loss of erythrocytes Shape of erythrocytes
Defective production of erythrocytes Destruction of erythrocytes Loss of erythrocytes Explanation: A physiologic approach classifies anemia according to whether the deficiency in erythrocytes is caused by a defect in their production (i.e., hypoproliferative anemia), by their destruction (i.e., hemolytic anemia), or by their loss (i.e., bleeding). Shape and quantity of erythrocytes are not categories of classifications of anemia.
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.
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? Taking iron pills with milk aids in absorption. Avoid vitamin C as it prevents absorption. Drink liquid iron preparations with a straw. Take iron with an antacid to avoid stomach upset.
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.
A client with anemia has been admitted to the medical-surgical unit. Which assessment findings are characteristic of iron deficiency anemia? Nausea, vomiting, and anorexia Dyspnea, tachycardia, and pallor Nights sweats, weight loss, and diarrhea Itching, rash, and jaundice
Dyspnea, tachycardia, and pallor Explanation: 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.
The nurse is educating a patient with iron deficiency anemia about food sources high in iron and how to enhance the absorption of iron when eating these foods. What can the nurse inform the client would enhance the absorption? Eating a steak with mushrooms Eating leafy green vegetables with a glass of water Eating calf's liver with a glass of orange juice Eating apple slices with carrots
Eating calf's liver with a glass of orange juice Explanation: Food sources high in iron include organ meats (e.g., beef or calf's liver, chicken liver), other meats, beans (e.g., black, pinto, and garbanzo), leafy green vegetables, raisins, and molasses. Taking iron-rich foods with a source of vitamin C (e.g., orange juice) enhances the absorption of iron.
A thin client is prescribed iron dextran intramuscularly. What is most important action taken by the nurse when administering this medication? Rubs the site vigorously Uses a 23-gauge needle Injects into the deltoid muscle Employs the Z-track technique
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.
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? An increased number of erythrocytes Erythrocytes that are macrocytic and hyperchromic Clustering of platelets with sickled red blood cells Erythrocytes that are microcytic and hypochromic
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.
A patient has been diagnosed with thrombocytopenia. What are the primary nursing interventions while instituting corticosteroid therapy in this patient? Eliminate aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs). Examine the extremities for redness. Gradually taper the dose and frequency of medication. Palpate the lymph nodes and tonsils every shift.
Gradually taper the dose and frequency of medication. Explanation: For a patient with thrombocytopenia, he or she gradually tapers the dose and frequency of steroid medication before discontinuing it to avoid adrenal insufficiency or crisis. Eliminating aspirin and NSAIDS will help manage bleeding tendencies. Assessment of the extremities, tonsils, or the lymph nodes is part of a physical examination of a patient and not applicable to corticosteroid therapy.
When assessing a client with a disorder of the hematopoietic or the lymphatic system, which assessment is most essential? Health history, such as bleeding, fatigue, or fainting Menstrual history Lifestyle assessments, such as exercise routines Age and gender
Health history, such as bleeding, fatigue, or fainting Explanation: When assessing a client with a disorder of the hematopoietic or the lymphatic system, it is essential to assess the client's health history. An assessment of drug history is essential because some antibiotics and cancer drugs contribute to hematopoietic dysfunction. Aspirin and anticoagulants may contribute to bleeding and interfere with clot formation. Because industrial materials, environmental toxins, and household products may affect blood-forming organs, the nurse needs to explore exposure to these agents. Menstrual history, age, gender, and lifestyle assessments, such as exercise routines and habits, do not directly affect the hematopoietic or lymphatic system.
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? Folate levels Potassium level Creatinine level Hemoglobin level
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.
A nurse provides nutritional information for a patient diagnosed with an iron-deficiency anemia. What education should the nurse provide? Take an iron supplement with meals to reduce gastric irritation. Increase the intake of green, leafy vegetables. Decrease the intake of high-fat red meats, especially organ meats. Decrease the intake of citrus fruits because they interfere with iron absorption.
Increase the intake of green, leafy vegetables. Explanation: Leafy greens, such as spinach, kale, swiss chard, collard and beet greens contain between 2.5-6.4 mg of iron per cooked cup. Clients should be encouraged to consume more green, leafy vegetables. Red meats, especially organ meats, are iron-rich foods and the client should not be discouraged from eating them. Vitamin C sources (citrus fruit and juices) enhance the absorption of iron, which should be taken 1 hour before or 2 hours after a meal.
While assessing a client, the nurse discovers the client has a history of restless leg syndrome. Which hematological condition does the nurse associate with this condition? Sickle cell disease Folate deficiency anemia Iron deficiency anemia Thalassemiaf
Iron deficiency anemia Explanation: Restless leg syndrome is common in as many as 24% of those with iron deficiency anemia.
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 may indicate deficiencies in essential nutrients. 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 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.
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 increase red blood cell (RBC) production to compensate for blood loss. It will remove the major site of red blood cell (RBC) destruction. It will increase production of platelets by the bone marrow. It will reduce the destruction of platelets by macrophages.
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.
A nurse assesses a client diagnosed with megaloblastic anemia. Which clinical findings will the nurse most likely find? Select all that apply. Ulcerated corners of the mouth Smooth, red tongue Jaundice Restless leg syndrome Concave nails
Jaundice Ulcerated corners of the mouth Concave nails Explanation: Megaloblastic anemia may cause angular cheilosis (ulcerated corners of the mouth), jaundice (a yellowing of the skin and sclera), and concave nails. A smooth, red tongue and restless leg syndrome are associated with iron deficiency anemia.
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? Low ferritin level concentration Elevated red blood cell (RBC) count Enlarged mean corpuscular volume (MCV) Elevated hematocrit concentration
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.
During a routine assessment of a patient diagnosed with anemia, the nurse observes the patient's beefy red tongue. The nurse is aware that this is a sign of what kind of anemia? Megaloblastic Autoimmune Iron deficiency Folate deficiency
Megaloblastic Explanation: A beefy, red, sore tongue is a characteristic indicator of megaloblastic anemia. The nurse should assess for other signs such as fatigue, hypotension, and tachycardia. Safety issues should also be assessed because balance, coordination, and gait are affected.
The most common cause of iron-deficiency anemia in premenopausal women includes which of the following? Lack of vitamin B12 Menorrhagia Inadequate iron supplementation Iron malabsorption
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.
For a client with Hodgkin disease who has developed neutropenia, what is an appropriate nursing intervention to include in the care plan? Omitting fresh fruits and vegetables from the diet Monitoring temperature every 4 hours Avoiding intramuscular (IM) injections Positioning the client to increase lung expansion
Monitoring temperature every 4 hours Explanation: For a client with neutropenia, monitoring temperature every 4 hours is essential. If the client develops a fever, the client is considered to have an infection and is usually admitted to the hospital. Cultures of blood, urine, and sputum, as well as a chest x-ray, are obtained.
A client with a diagnosis of pernicious anemia comes to the clinic and reports numbness and tingling in the arms and legs. What do these symptoms indicate? Loss of vibratory and position senses Neurologic involvement Insufficient intake of dietary nutrients Severity of the disease
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.
A nurse cares for a client with aplastic anemia. Which laboratory results will the nurse expect to find with this client? Select all that apply. White blood cell count 10,000/microliter Platelets 35,000 microliters Neutrophil count 1200/microliter Hemoglobin 7 g/dL Neutrophil count 17,000/microliter
Neutrophil count 1200/microliter Hemoglobin 7 g/dL Platelets 35,000 microliters Explanation: Aplastic anemia causes pancytopenia, or overall decrease to all myeloid stem cell-derived cells. Pancytopenia manifests as neutrophil count less than 1500/microliter, hemoglobin less than 10 g/dL, and platelets less than 50,000/microliter.
A nurse suspects that a patient may have aplastic anemia based on clinical manifestations and assessment. Which one of the following lab results would be consistent with this diagnosis? Hemoglobin level of 15 g/dL Neutrophil count of 50% Platelet level of 275,000/mm3 Erythrocyte count of 5.3 m/?L
Neutrophil count of 50% Explanation: Laboratory values consistent with a diagnosis of aplastic anemia would be a hemoglobin less than 9 g/dL, significant neutropenia and thrombocytopenia, and a reduced erythrocyte count.
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. Monitor the client's blood pressure. Monitor the client's body temperature. Evaluate the client's dietary intake.
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.
A client with multiple myeloma is complaining of severe pain when the nurse comes in to give a bath and change position. What is the priority intervention by the nurse? Inform the client that the bath and positioning is an important part of client care and will be done right after pain medication administration. Obtain the pain medication and delay the bath and position change until the medication reaches its peak. Inform the client that she will feel better after receiving a bath and clean sheets. Inform the client that the position must be changed, and then you will give her pain medication and omit the bath.
Obtain the pain medication and delay the bath and position change until the medication reaches its peak. Explanation: When pain is severe, the nurse delays position changes and bathing until an administered analgesic has reached its peak concentration level and the client is experiencing maximum pain relief. Pain medication should never be delayed to assist in the control of the level of pain. Pain will not be relieved by a bath and clean sheets, only analgesics at this point in the client's illness.
A nurse is caring for a client with iron deficiency anemia. Which food or beverage will the nurse suggest to the client to eat or drink when taking supplemental iron? Leafy green vegetables Milk Kidney beans Orange juice
Orange juice Explanation: Vitamin C found in orange juice improves the absorption of iron. The other answer choices are not the best for improving absorption of iron.
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? Truncal obesity Osteoporosis Hypertension Muscle wasting
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? Angina pectoris, double vision, and anorexia Pallor, tachycardia, and a sore tongue Sore tongue, dyspnea, and weight gain Pallor, bradycardia, and reduced pulse pressure
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.
Which term refers to an abnormal decrease in white blood cells, red blood cells, and platelets? Thrombocytopenia Pancytopenia Leukopenia Anemia
Pancytopenia Explanation: Pancytopenia is defined as an abnormal decrease in WBCs, RBCs, and platelets. The condition may be congenital 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.
The nurse's role in the management of polycythemia vera is primarily that of an educator. Choose the best health promotion advice that a nurse could give. Use compression stockings when walking to prevent deep vein thrombosis (DVT). Take aspirin daily to prevent clot formation. Take antiplatelets on a regular basis. Participate in regular phlebotomy procedures to decrease blood viscosity.
Participate in regular phlebotomy procedures to decrease blood viscosity. Explanation: Phlebotomy is a critical part of therapy and the only treatment that has demonstrated improved survival. Aspirin should be avoided, and antiplatelet therapy should be used with caution due to the risk of bleeding. Compression stockings are not necessary for walking but should be used for airplane travel.
A patient had gastric bypass surgery 3 years ago and now, experiencing fatigue, visits the clinic to determine the cause. The patient takes pantoprazole for the treatment of frequent heartburn. What type of anemia is this patient at risk for? Pernicious anemia Aplastic anemia Iron deficiency anemia Sickle cell anemia
Pernicious anemia Explanation: A deficiency of vitamin B 12 can occur in several ways. Inadequate dietary intake is rare but can develop in strict vegans (who consume no meat or dairy products). Faulty absorption from the GI tract is a more common cause. This occurs in conditions such as Crohn's disease, or after ileal resection or gastrectomy.
A nurse is developing a care plan for a client with disseminated intravascular coagulation (DIC). Which nursing intervention should the nurse include? Place a pressure-reducing mattress on the client's bed. Provide mouth care every 4 hours with lemon-glycerin swabs. Administer meperidine (Demerol) I.M. as needed for pain. Administer aspirin daily as ordered.
Place a pressure-reducing mattress on the client's bed. Explanation: A client with DIC is at risk for Impaired skin integrity secondary to bleeding or ischemia. The nurse should place the client on a pressure-reducing mattress and perform skin care every 2 hours. The nurse should avoid administering any medication that decreases platelet function, such as aspirin. The nurse should perform mouth care using sponge swabs and baking soda solution, not lemon-glycerin swabs, because lemon-glycerin swabs can dry the oral mucosa, which may lead to bleeding. I.M. injections should be avoided in clients with DIC because of the potential for bleeding.
While monitoring a client for the development of disseminated intravascular coagulation (DIC), the nurse should take note of which assessment parameters? Fibrinogen level, WBC, and platelet count Platelet count, prothrombin time, and partial thromboplastin time Thrombin time, calcium levels, and potassium levels Platelet count, blood glucose levels, and white blood cell (WBC) count
Platelet count, prothrombin time, and partial thromboplastin time Explanation: The diagnosis of DIC is based on the results of laboratory studies of prothrombin time, platelet count, thrombin time, partial thromboplastin time, and fibrinogen level as well as client history and other assessment factors. Blood glucose levels, WBC count, calcium levels, and potassium levels aren't used to confirm a diagnosis of DIC.
A nurse should expect to administer which vaccine to the client after a splenectomy? Tetanus toxoid Pneumovax 23 Recombivax HB Attenuvax
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? Femur Posterior iliac crest Sternum 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.
Which of the following is considered an antidote to heparin? Ipecac Protamine sulfate Vitamin K Narcan
Protamine sulfate Explanation: Protamine sulfate, in the appropriate dosage, acts quickly to reverse the effects of heparin. Vitamin K is the antidote to warfarin (Coumadin). Narcan is the drug used to reverse signs and symptoms of medication-induced narcosis. Ipecac is an emetic used to treat some poisonings.
A pregnant woman is hospitalized as the result of sickle-cell crisis. Which finding indicates the outcome has been achieved for this client? Reports joint pain less than 3 on a scale of 0 to 10 Exhibits a temperature more than 100.3°F Takes hydroxyurea during her pregnancy Describes the importance of staying cool
Reports joint pain less than 3 on a scale of 0 to 10 Explanation: An expected outcome for a client experiencing a sickle-cell crisis is control and reduction of pain. Hydroxyurea is contraindicated in pregnancy because of the risk it poses for congenital abnormalities. An indication that the client is free from infection is exhibiting a normal temperature; 100.3°F is an elevated temperature. To minimize crises, the client needs to stay warm not cool.
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? Meat, egg yolks, oysters, and shellfish Sources of vitamin B12 Vitamin E Rich sources of vitamin C
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.
A client with sickle cell disease is treated for a thrombotic event. Which organs or body systems does the nurse recognize as being at greatest risk for thrombosis in a client with sickle cell disease? Select all that apply. Liver Central nervous system Spleen Cardiac system Lungs
Spleen Lungs Central nervous system Explanation: Any organ can be the site of a thrombotic event in sickle cell disease; however, the lungs, central nervous system, and the spleen are at greatest risk due to these areas having slower circulation. The liver is often involved in sequestration in adults, and hemolysis may occur. Anemia affects the heart.
A patient with sickle cell disease comes to the emergency department and reports severe pain in the back, right hip, and right arm. What intervention is important for the nurse to provide? Administer aspirin Administer ibuprofen Begin oxygen at 2 L/M Start an intravenous line with dextrose 5% in 0.25 normal saline
Start an intravenous line with dextrose 5% in 0.25 normal saline Explanation: Adequate hydration is important during a painful sickling episode. Oral hydration is acceptable if the patient can maintain adequate fluid intake; IV hydration with dextrose 5% in water (D5W) or dextrose 5% in 0.25 normal saline solution (3 L/m2/24 h) may be required for a sickle crisis. Supplemental oxygen may also be needed.
A client with hemophilia was admitted after sustaining an injury while playing outdoors with friends. Initially, the client presented with severe bleeding but has since stabilized. Which interventions will the nurse include in the care plan for this client? Select all that apply. Encourage the client to use a soft toothbrush and rinse the mouth with warm water between and after meals. Eliminate aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs). Obtain an oral temperature to ensure accuracy. Support painful joints on pillows.
Support painful joints on pillows. Encourage the client to use a soft toothbrush and rinse the mouth with warm water between and after meals. Eliminate aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs). Explanation: Interventions are implemented to reduce pain and discomfort and to prevent further bleeding episodes. NSAIDs and aspirin are eliminated because these drugs can increase bleeding tendencies. The nurse takes the temperature over the temporal artery or tympanically to avoid oral or rectal injuries and checks the urine and stools for signs of bleeding.
A client is prescribed 325 mg/day of oral ferrous sulfate. What does the nurse include in client teaching? Take 1 hour before breakfast Decrease intake of fruits and juices Decrease intake of dietary fiber Take with dairy products
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 with chronic anemia has received multiple transfusions. Which client action would the nurse be concerned about relative to the client's condition? Takes over-the-counter iron supplements Takes a daily multiple vitamin pill Eliminates use of alcohol Takes 60 grams of protein each day
Takes over-the-counter iron supplements Explanation: When a client receives multiple transfusions and takes iron supplements, there may be a problem with iron overload. It is recommended that clients who are experiencing anemia either avoid or limit alcohol due to interference of alcohol with utilization of essential nutrients. The typical U.S. diet includes 60 grams of protein daily. Clients may be prescribed multivitamins.
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 Abdominal pain Diarrhea Bleeding
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).
A client is treated for anemia. What is the nurse's best understanding about the correlation between anemia and the client's iron stores? There is a strong correlation between iron stores and hemoglobin characteristics. There is a strong correlation between iron stores and hemoglobin levels. There is an inverse relationship between iron stores and hemoglobin levels. There is a weak correlation between iron stores and hemoglobin levels.
There is a strong correlation between iron stores and hemoglobin levels. Explanation: A strong correlation exists between laboratory values that measure iron stores and hemoglobin levels. After iron stores are depleted (as reflected by low serum ferritin levels), the hemoglobin level falls.
Which of the following is accurate regarding the use of corticosteroids for immune hemolytic anemia? Select all that apply. They decrease the macrophages ability to clear the antibody-coated RBCs. The treatment consists of low doses of corticosteroids. They produce lasting effects. Corticosteroids are not effective in the treatment of immune hemolytic anemia. If the hemoglobin returns to normal, the corticosteroid dose can be lowered.
They decrease the macrophages ability to clear the antibody-coated RBCs. If the hemoglobin returns to normal, the corticosteroid dose can be lowered. Explanation: The treatment consists of high doses of corticosteroids until hemolysis decreases. Corticosteroids decrease the macrophage's ability to clear the antibody-coated RBCs. If the hemoglobin level returns to normal, usually after several weeks, the corticosteroid dose can be lowered or, in some cases tapered and discontinued.
After receiving chemotherapy for lung cancer, a client's platelet count falls to 98,000/mm3. What term should the nurse use to describe this low platelet count? Thrombocytopenia Anemia Leukopenia Neutropenia
Thrombocytopenia Explanation: A normal platelet count is 140,000 to 400,000/mm3 in adults. Chemotherapeutic agents produce bone marrow depression, resulting in reduced red blood cell counts (anemia), reduced white blood cell counts (leukopenia), and reduced platelet counts (thrombocytopenia). Neutropenia is the presence of an abnormally reduced number of neutrophils in the blood and is caused by bone marrow depression induced by chemotherapeutic agents.
A nurse cares for a client with anemia after having a total gastrectomy a year ago. Which unique assessment findings will the nurse likely find when assessing this client that may not be present in another client with anemia? Select all that apply. Poor coordination Tingling in the fingers Shortness of breath Fatigue Weakness
Tingling in the fingers Poor coordination Explanation: The client likely has pernicious anemia, caused by a lack of intrinsic factor, found in the stomach. Paresthesias (tingling in the fingers) and poor coordination are unique to pernicious anemia. Shortness of breath, fatigue, and weakness are common to other anemias and not unique assessment findings.
A nurse is caring for a client with thalassemia who is being transfused. What is the nurse's role during a transfusion? To instruct the client to rest immediately if chest pain develops To assess for enlargement and tenderness over the liver and spleen To administer vitamin B12 injections To closely monitor the rate of administration
To closely monitor the rate of administration Explanation: In a client with thalassemia, when transfusions are necessary, the nurse closely monitors the rate of administration. Assessing for enlargement and tenderness over the liver and spleen, advising rest, or administering vitamin B12 injections are not indicated for thalassemia.
The nurse caring for an older adult with a diagnosis of leukemia would encourage the client to use an electric razor. What is the rationale for this statement by the nurse? Strong tissues and intact clotting mechanisms may prevent hemorrhage. The client is not at risk for infection from microorganisms. The client is at risk for spontaneous and uncontrolled bleeding. Trauma and microabrasions from a non-electric razor may contribute to anemia.
Trauma and microabrasions from a non-electric razor may contribute to anemia. Explanation: In a client with leukemia who is at risk for hemorrhage, the nurse handles the client gently when assisting and encourages the client to use electric razors. Trauma and microabrasions from razors may contribute to anemia from bleeding. Fragile tissues and altered clotting mechanisms may result in hemorrhage even after minor trauma. Therefore, the nurse inspects the skin for signs of bruising and petechiae and reports melena, hematuria, or epistaxis (nosebleeds). The risks for spontaneous and uncontrolled bleeding or infection from microorganisms are not addressed by the use of electric razors.
Folate deficiency occurs in people who rarely eat which of the following? Meat Fruit Bread Uncooked vegetables
Uncooked vegetables Explanation: Folate is found in green vegetables and liver. Folate deficiency occurs in people who rarely eat uncooked vegetables. Meat, fruit, and bread generally would not cause a folate deficiency.
A nurse on a hematology/oncology floor is caring for a client with aplastic anemia. Which would not be included in the client's discharge instructions? Encourage frequent handwashing. Avoid contact with family/friends who are sick. Plan for frequent periods of rest. Use a disposable razor when shaving.
Use a disposable razor when shaving. Explanation: People with aplastic anemia usually have insufficient erythrocytes, leukocytes, and platelets. Encourage behaviors that will lower the risk for bleeding. Avoiding contact with people who are sick reduces the risk of acquiring an infection. Handwashing reduces the risk of acquiring an infection. Anemia can cause fatigue and shortness of breath with even mild exertion.
During preparation for bowel surgery, a client receives an antibiotic to reduce intestinal bacteria. The nurse knows that hypoprothrombinemia may occur as a result of antibiotic therapy interfering with synthesis of which vitamin? Vitamin D Vitamin K Vitamin E Vitamin A
Vitamin K Explanation: Intestinal bacteria synthesize such nutritional substances as vitamin K, thiamine, riboflavin, vitamin B12, folic acid, biotin, and nicotinic acid. Antibiotic therapy may interfere with synthesis of these substances, including vitamin K. Intestinal bacteria don't synthesize vitamins A, D, or E.
Which medication is the antidote to warfarin? Aspirin Protamine sulfate Clopidogrel Vitamin K
Vitamin K Explanation: The antidote for warfarin is vitamin K. Protamine sulfate is the antidote for heparin. Aspirin and clopidogrel are both antiplatelet medications.
A young client is diagnosed with a mild form of hemophilia and is experiencing bleeding in the joints with pain. In preparing the client for discharge, what instructions should the nurse provide? Undergo genetic testing and counseling if the client is male. Take warm baths to lessen pain. Wear a medical identification bracelet. Take ibuprofen for joint pain.
Wear a medical identification bracelet. Explanation: Clients with hemophilia should wear a medical identification bracelet about having this disease. Ibuprofen interferes with platelet aggregation and may increase the client's bleeding. A warm bath may lessen pain but increase bleeding. Genetic testing and counseling are not necessary for male clients, because females are the carriers of the genetic material for hemophilia.
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 require grater folic acid supplementation Women rarely manifest the gene expression Women have lower hemoglobin levels Women lose iron through menstrual cycles
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.
Hemophilia A is the most common of the three types of hemophilia. What is diminished in the less serious form of hemophilia A, known as von Willebrand's disease? quality of factor XI quality of factor VIII amount and quality of factor VIII amount and quality of factor IX
amount and quality of factor VIII Explanation: In a less serious form of hemophilia A, von Willebrand's disease, the amount and quality of factor VIII is diminished.
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.
A client with sickle cell anemia has a: normal hematocrit. high hematocrit. normal blood smear. low hematocrit.
low hematocrit. Explanation: A client with sickle cell anemia has a low hematocrit and sickled cells on the smear. A client with sickle cell trait usually has a normal hemoglobin level, a normal hematocrit, and a normal blood smear.
A client admitted to the hospital with abdominal pain, anemia, and bloody stools reports feeling weak and dizzy. The client has rectal pressure and needs to urinate and move their bowels. The nurse should help them: to the bathroom. to a standing position so he can urinate. to the bedside commode. onto the bedpan.
onto the bedpan. Explanation: A client who's dizzy and anemic is at risk for injury because of his weakened state. Assisting him with the bedpan would best meet his needs at this time without risking his safety. The client may fall if walking to the bathroom, left alone to urinate, or trying to stand up.