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Anemia NCLEX Questions-New
Terms in this set (50)
mother asks the nurse if her child's iron deficiency anemia is related to the child's frequent infections. The nurse responds based on the understanding of which of the following?
Little is known about iron-deficiency anemia and its relationship to infection in children.
Children with iron deficiency anemia are more susceptible to infection than are other children.
Children with iron-deficiency anemia are less susceptible to infection than are other children.
Children with iron-deficient anemia are equally as susceptible to infection as are other children.
d. Children with iron-deficient anemia are equally as susceptible to infection as are other children
Rationale: Children with iron-deficiency anemia are more susceptible to infection because of marked decreases in bone marrow functioning with microcytosis
The clinic nurse instructs the mother of a child with sickle cell disease about the precipitating factors related to pain crisis. Which of the following, if identified by the mother as a precipitating factor, indicates the need for further instructions?
c. Fluid overload
Pain crisis may be precipitated by infection, dehydration, hypoxia, trauma, or physical or emotional stress.
The mother of a child with sickle cell disease should encourage fluid intake of 1 1/2 to 2 times the daily requirement to prevent dehydration
When a client is diagnosed with aplastic anemia, the nurse monitors for changes in which of the following physiological functions?
Intake and output
a. Bleeding tendencies
Aplastic anemia decreases the bone marrow production of RBCs, WBCs, and Platelets. The client is at risk for bruising and bleeding tendencies.
A client was admitted with iron deficiency anemia and blood-streaked emesis. Which question is most appropriate for the nurse to ask in determining the extent of the client's activity intolerance?
"What activities were you able to do 6 months ago compared with present?"
"How long have you had this problem?"
"Have you been able to keep up with all your usual activities?"
"Are you more tired now than you used to be?"
a. What activities were you able to do 6 months ago compared with present?
Rationale: It is difficult to determine activity intolerance without objectively comparing activities from one time frame to another. Because iron deficiency anemia can occur gradually and individual endurance varies, the nurse can best assess the clients activity tolerance by asking the client to compare activities 6 months ago and at the present
When discussing appropriate food choices with a patient who has iron-deficiency anemia and follows a low-cholesterol diet, the nurse will encourage the patient to increase the dietary intake of
eggs and muscle meats.
nuts and cornmeal.
milk and milk products.
legumes and dried fruits
d. legumes and dried fruits
Rationale: Legumes and dried fruits are high in iron and low in fat and cholesterol.
A client is beginning a regimen of ferrous sulfate or iron. As you prepare to administer the medication, it is important for you to advise the client that
Her urine will turn a dark orange
Her bowel movements will be dark and tarry
Her appetite will be diminished
Her vision will become slightly blurred
b. Her bowel movements will be dark and tarry
A patient who is having a sickle cell crisis asks the nurse why the sickling causes such pain. The nurse explains that the pain of sickling is caused by
Spasms of the blood cells as they change shape
Deposition of sickled red cells in the bone marrow
Tissue hypoxia caused by small blood vessel occlusion
Infectious processes in organs affected by the sickling
c. Tissue hypoxia caused by small blood vessel occlusion
The pain associated with sickle cell crisis is caused by ischemia as the sickled cells occlude small blood vessels and capillaries.
A child suspected of having sickle cell disease is seen in a clinic, and laboratory studies are performed. A nurse checks the lab results, knowing that which of the following would be increased in this disease?
c. Reticulocyte count
Rationale: A diagnosis is established based on a complete blood count, examination for sickled RBCs in the peripheral smear, and hemoglobin electrophoresis. Lab studies will show decreased HGB and HCT levels and a decreased platelet count, and increased reticulocyte count, and the presence of nucleated RBCS. Increased reticulocyte counts occur in children with sickle cell disease becuase the life span of their sickled RBCS is shortened
The nurse is preparing to teach a client with microcytic hypochromic anemia about the diet to follow after discharge. Which of the following foods should be included in the diet?
Eggs are high in Iron. Other foods high in iron are organ meats, muscle meats; shellfish, shrimp, and tuna; enriched, whole-grain, and fortified cereals and breads; legumes, nuts, dried fruits, and beans; oatmeal; and sweet potatoes.
Which of the following disorders results from a deficiency of factor VIII?
Sickle cell disease
c. Hemophilia A
Hemophilia A results from a deficiency of factor 8. Sickle cell disease is caused by a defective hemoglobin molecule. Christmas disease, AKA Hemophilia B, results in a factor 9 deficiecy
A client has been diagnosed with iron-deficiency anemia. The doctor has ordered an iron supplement but has also suggested a diet rich in iron. Which of the following foods should be included in the client's discharge iron-rich diet plan?
a. Egg yolks
The usual treatment for iron-deficiency anemia includes:
Vitamin B12 injection
Non-enteric-coated ferrous sulfate
Enteric-coated or sustained-release ferrous sulfate
Whole blood transfusion
b. Non-enteric-coated ferrous sulfate
The usual tx is 325 mg p.o. daily. enteric-coated and sustained rls formulas should be avoided, as they are poorly absorbed
A 52-year-old patient has a new diagnosis of pernicious anemia. After teaching the patient about pernicious anemia, the nurse determines that the patient understands the disorder when the patient states,
"I will need to have cobalamin (B12) injections regularly for the rest of my life."
"I will stop having a glass of wine with dinner."
"The numbness in my feet will go away once my hemoglobin level returns to normal."
"My diet should include more red meat or liver."
a. I will need to have cobalamin -B12 injections regularly for the rest of my life
A patient with sickle cell anemia is admitted to the hospital with a sickle cell crisis. While caring for the patient during the crisis, it is important for the nurse to
limit the patient's intake of oral and IV fluids.
evaluate the effectiveness of opioid analgesics.
encourage the patient to ambulate as much as tolerated.
teach the patient about high-protein, high-calorie foods.
b. evaluate the effectiveness of opioid analgesics
Pain is the most common clinical manifestation of a crisis and usually requires large doses of continuous opioids for control
Which of the following symptoms is expected with hemoglobin of 10 g/dl?
Shortness of breath
Mild anemia usually has no clinical signs.
Which of the following foods would the nurse encourage the mother to offer to her child with iron deficiency anemia?
Rice cereal, whole milk, and yellow vegetables
Potato, peas, and chicken
Macaroni, cheese, and ham
Pudding, green vegetables, and rice
b. Potato, peas, and chicken
Potato, peas, chicken, green vegetables, and rice cereal contain significant amounts of iron and therefore would be recommended. Milk and yellow vegetables are not good iron sources. Rice by itself also is not a good source of iron.
The nurse is caring for a child admitted with sickle-cell anemia sequestration crisis. The nurse plans care for a child with
Decreased red blood cell production
Petechia and bruising
Pooling of blood in the spleen
Swollen hands and feet
c. Pooling of blood in the spleen
The child with sickle-cell anemia who is in a sequestration crisis experiences pooling of blood in the spleen. Choice a is incorrect. Decreased red blood cell production occurs when the child with sickle-cell anemia is in an aplastic crisis. Choice b is incorrect. Petechia, tiny hemorrhagic spots on the skin and bruising occur with a decrease in white blood cells in diseases such as leukemia. Choice d is incorrect. Swollen hands and feet occur when the choice with sickle-cell anemia is in a vaso-occlusive crisis.
Because of the risks associated with administration of factor VIII concentrate, the nurse would teach the client's family to recognize and report which of the following?
Yellowing of the skin
Puffiness around the eyes
a. Yellowing of the skin
Because factor VIII concentrate is derived from large pools of human plasma, the risk of hepatitis is always present. Clinical manifestations of hepatitis include yellowing of the skin, mucous membranes, and sclera. Use of factor VIII concentrate is not associated with constipation, abdominal distention, or puffiness around the eyes.
A patient with a history of iron-deficiency anemia who has not taken iron supplements for several years is experiencing increased fatigue and occasional palpitations. The nurse would expect the patient's laboratory findings to include
hematocrit (Hct) 38%.
red blood cell count (RBC) 4,500,000/l.
hemoglobin (Hgb) 8.6 g/dl (86 g/L).
normal RBC indices.
c. hgb 8.6 g/dL
The patient's clinical manifestations indicate moderate anemia, which is consistent with a Hgb of 6 to 10 g/dl. The other values are all within the range of low-normal to normal.
When caring for a client with a coagulation disorder, your primary focus should be on:
Prevention of infection
Prevention of injury and hemorrhage
d. Prevention of injury and hemorrhage
During physical assessment of a patient, the nurse suspects a chronic, severe iron-deficiency anemia on finding
Gum bleeding and tenderness
Shiny, smooth tongue
Numbness of extremities
c. Shiny, smooth tongue
Loss of the papillae of the tongue occurs with chronic iron deficiency. Scleral jaundice is associated with hemolysis, gum bleeding and tenderness occur with thrombocytopenia or neutropenia, and extremity numbness is associated with vitamin B12 deficiency or pernicious anemia.
A patient has a folic acid deficiency related to chronic alcohol abuse. The nurse would expect a complete blood cell count (CBC) to reveal
macrocytic, normochromic red cells.
normocytic, normochromic red cells.
microcytic, hypochromic red cells.
microcytic, normochromic red cells.
a macrocytic, normochromic red cells
With folic acid deficiency, the cells are larger than normal, but the iron levels are normal or elevated, leading to findings of a macrocytic, normochromic anemia. Microcytic anemia, hypochromic anemia is more typical of iron deficiency. Normocytic, normochromic RBC indicate that the patient does not have anemia or may occur in patients with anemia-related chronic disease.
A client states that she is afraid of receiving vitamin B12 injections because of the potential toxic reactions. What is the nurse's best response to relieve these fears?
"Vitamin B12 will cause ringing in the eats before a toxic level is reached."
"Vitamin B12 may cause a very mild skin rash initially."
"Vitamin B12 may cause mild nausea but nothing toxic."
"Vitamin B12 is generally free of toxicity because it is water soluble."
d. Vitamin B12 is generally free of toxicity because it is water soluble
Vitamin B12 is a water-soluble vitamin. When water-soluble vitamins are taken in excess of the body's needs, they are filtered through the kidneys and excreted. Vitamin B12 is considered to be nontoxic. Adverse reactions that have occurred are believed to be related to impurities or to the preservative in B12 preparations. Ringing in the ears, skin rash, and nausea are not considered to be related to vitamin B12 administration.
The nurse understands that the client with pernicious anemia will have which distinguishing laboratory findings?
Schilling's test, elevated
Intrinsic factor, absent.
Sedimentation rate, 16 mm/hour
RBCs 5.0 million
b. intrinsic factor, absent
The defining characteristic of pernicious anemia, a megaloblastic anemia, is lack of the intrinsic factor, which results from atrophy of the stomach wall. Without the intrinsic factor, vitamin B12 cannot be absorbed in the small intestines, and folic acid needs vitamin B12 for DNA synthesis of RBCs. The gastric analysis was done to determine the primary cause of the anemia. An elevated excretion of the injected radioactive vitamin B12, which is protocol for the first and second stage of the Schilling test, indicates that the client has the intrinsic factor and can absorb vitamin B12 into the intestinal tract. A sedimentation rate of 16 mm/hour is normal for both men and women and is a nonspecific test to detect the presence of inflammation. It is not specific to anemias. An RBC value of 5.0 million is a normal value for both men and women and does not indicate anemia.
The nurse has provided nutritional teaching on foods high in folate to a client with folate deficiency related to malabsorption syndromes and poor nutrition. Which of the following foods, if chosen by the client, indicates that the client understands the teaching?
Liver, dark green leafy vegetables
Whole milk and eggs
Potatoes and carrots
Bread and fish
a. Liver, dark green leafy vegetables
Foods high in folate are liver, orange juice, cereals, whole grains, beans, nuts, and dark leafy vegetables like spinach
The nurse explains to the parents of a 1-year-old child admitted to the hospital in a sickle cell crisis that the local tissue damage the child has on admission is caused by which of the following?
Autoimmune reaction complicated by hypoxia
Lack of oxygen in the red blood cells
Obstruction to circulation
Elevated serum bilirubin concentration.
c. Obstruction to circulation
Characteristic sickle cells tend to cause "log jams" in capillaries. This results in poor circulation to local tissues, leading to ischemia and necrosis. The basic defect in sickle cell disease is an abnormality in the structure of RBCs. The erythrocytes are sickle-shaped, rough in texture, and rigid. Sickle cell disease is an inherited disease, not an autoimmune reaction. Elevated serum bilirubin concentrations are associated with jaundice, not sickle cell disease.
A client with anemia may be tired due to a tissue deficiency of which of the following substances?
Anemia stems from a decreased number of RBCs and the resulting def in O2 and body tiss. Clotting factors, such as 8 relate to the bodies ability to form blood clots and arnt related to anemia, not is carbon dioxide of T antibodies
From the following teaching tips, choose all that are appropriate for a client with thrombocytopenia.
Use an electric razor for shaving
Avoid becoming chilled
Avoid all skin or body punctures
Do not scrub skin during bathing
Eat low-roughage foods
Avoid use of all aspirin products
Avoid vigorous blowing of nose
Use only a soft toothbrush
a. Use an electric razor for shaving
c. Avoid all skin or bod punctures
e. Eat low-roughage foods
f. Avoid use of all aspirin products
g. Avoid vigorous blowing of nose
h. use only a soft toothbrush
A client with pernicious anemia asks why she must take vitamin B12 injections for the rest of her life. What is the nurse's best response?
"The reason for your vitamin deficiency is an inability to absorb the vitamin because the stomach is not producing sufficient acid."
"The reason for your vitamin deficiency is an inability to absorb the vitamin because the stomach is not producing sufficient intrinsic factor."
"The reason for your vitamin deficiency is an excessive excretion of the vitamin because of kidney dysfunction."
"The reason for your vitamin deficiency is an increased requirement for the vitamin because of rapid red blood cell production."
b. "The reason for your vitamin deficiency is an inability to absorb the vitamin because the stomach is not producing sufficient intrinsic factor."
Most clients with pernicious anemia have deficient production of intrinsic factor in the stomach. Intrinsic factor attaches to the vitamin in the stomach and forms a complex that allows the vitamin to be absorbed in the small intestine. The stomach is producing enough acid, there is not an excessive excretion of the vitamin, and there is not a rapid production of RBCs in this condition.
The nurse would instruct the client to eat which of the following foods to obtain the best supply of vitamin B12?
Green leafy vegetables
Meats and dairy products
Broccoli and Brussel sprouts
c. Meats and dairy products
Good sources of vitamin B12 include meats and dairy products. Whole grains are a good source of thiamine. Green leafy vegetables are good sources of niacin, folate, and carotenoids (precursors of vitamin A). Broccoli and Brussels sprouts are good sources of ascorbic acid (vitamin C).
When planning discharge teaching for the patient who was admitted with a sickle cell crisis, which information will the nurse include?
Drink only one or two caffeinated beverages daily.
Take a daily multivitamin with iron.
Limit fluids to 2 to 3 quarts a day.
Avoid exposure to crowds as much as possible.
d. Avoid exposure to crowds as much as possible
Exposure to crowds increases the patient's risk for infection, the most common cause of sickle cell crisis. There is no restriction on caffeine use. Iron supplementation is generally not recommended. A high-fluid intake is recommended.
When comparing the hematocrit levels of a post-op client, the nurse notes that the hematocrit decreased from 36% to 34% on the third day even though the RBC and hemoglobin values remained stable at 4.5 million and 11.9 g/dL, respectively. Which nursing intervention is most appropriate?
Check the dressing and drains for frank bleeding
Call the physician
Continue to monitor vital signs
Start oxygen at 2L/min per NC
c. Continue to monitor vital signs
The nurse should continue to monitor the client, because this value reflects a normal physiologic response. The physician does not need to be called, and oxygen does not need to be started based on these laboratory findings. Immediately after surgery, the client's hematocrit reflects a falsely high value related to the body's compensatory response to the stress of sudden loss of fluids and blood. Activation of the intrinsic pathway and the renin-angiotensin cycle via antidiuretic hormone produces vasoconstriction and retention of fluid for the first 1 to 2 day post-op. By the second to third day, this response decreases and the client's hematocrit level is more reflective of the amount of RBCs in the plasma. Fresh bleeding is a less likely occurrence on the third post-op day but is not impossible; however, the nurse would have expected to see a decrease in the RBC and hemoglobin values accompanying the hematocrit.
While obtaining a health history from a patient with numerous petechiae on the skin, the nurse asks the patient specifically about the patient's use of
c. aspirin meds
Salicylates interfere with platelet function and can lead to petechiae and ecchymosis. Anticonvulsants may cause anemia, but not bleeding. Oral contraceptives increase clotting risk. Antihypertensives do not commonly cause problems with decreased clotting.
A client comes into the health clinic 3 years after undergoing a resection of the terminal ileum complaining of weakness, shortness of breath, and a sore tongue. Which client statement indicates a need for intervention and client teaching?
"I have been drinking plenty of fluids."
"I have been gargling with warm salt water for my sore tongue."
"I have 3 to 4 loose stools per day."
"I take a vitamin B12 tablet every day."
d. I take a vitamin B12 tablet every day
Vitamin B12 combines with intrinsic factor in the stomach and is then carried to the ileum, where it is absorbed in the bloodstream. In this situation, vitamin B12 cannot be absorbed regardless of the amount of oral intake of sources of vitamin B12 such as animal protein or vitamin B12 tablets. Vitamin B12 needs to be injected every month, because the ileum has been surgically removed. Replacement of fluids and electrolytes is important when the client has continuous multiple loose stools on a daily basis. Warm salt water is used to soothe sore mucous membranes. Crohn's disease and small bowel resection may cause several loose stools a day.
Which of the following would the nurse identify as the priority nursing diagnosis during a toddler's vaso-occlusive sickle cell crisis?
Ineffective coping related to the presence of a life-threatening disease
Decreased cardiac output related to abnormal hemoglobin formation
Pain related to tissue anoxia
Excess fluid volume related to infection
c. pain related to tissue anoxia
For the child in a sickle cell crisis, pain is the priority nursing diagnosis because the sickled cells clump and obstruct the blood vessels, leading to occlusive and subsequent tissue ischemia. Although ineffective coping may be important, it is not the priority. Decreased cardiac output is not a problem with this type of vaso-occlusive crisis. Typically, a sickle cell crisis can be precipitated by a fluid volume deficit or dehydration.
A client with iron deficiency anemia is scheduled for discharge. Which instruction about prescribed ferrous gluconate therapy should the nurse include in the teaching plan?
"Take the medication with an antacid."
"Take the medication with a glass of milk."
"Take the medication with cereal."
"Take the medication on an empty stomach."
d. Take the meds on an empty stomach
Preferably, ferrous gluconate should be taken on an empty stomach. Ferrous gluconate should not be taken with antacids, milk, or whole-grain cereals because these foods reduce iron absorption.
The physician has ordered several laboratory tests to help diagnose an infant's bleeding disorder. Which of the following tests, if abnormal, would the nurse interpret as most likely to indicate hemophilia?
Clot retraction test
Partial thromboplastin time (PTT)
PTT measures the activity of thromboplastin, which is dependent on intrinsic clotting factors. In hemophilia, the intrinsic clotting factor VIII (antihemophilic factor) is deficient, resulting in a prolonged PTT. Bleeding time reflects platelet function; the tourniquet test measures vasoconstriction and platelet function; and the clot retraction test measures capillary fragility. All of these are unaffected in people with hemophilia.
The mother asks the nurse why her child's hemoglobin was normal at birth but now the child has S hemoglobin. Which of the following responses by the nurse is most appropriate?
"The placenta bars passage of the hemoglobin S from the mother to the fetus."
"The red bone marrow does not begin to produce hemoglobin S until several months after birth."
"Antibodies transmitted from you to the fetus provide the newborn with temporary immunity."
"The newborn has a high concentration of fetal hemoglobin in the blood for some time after birth."
d. The newborn as a high concentration of fetal hgb in the blood for some time after birth.
Sickle cell disease is an inherited disease that is present at birth. However, 60% to 80% of a newborns hemoglobin is fetal hemoglobin, which has a structure different from that of hemoglobin S or hemoglobin A. Sickle cell symptoms usually occur about 4 months after birth, when hemoglobin S begins to replace the fetal hemoglobin. The gene for sickle cell disease is transmitted at the time of conception, not passed through the placenta. Some hemoglobin S is produced by the fetus near term. The fetus produces all its own hemoglobin from the earliest production in the first trimester. Passive immunity conferred by maternal antibodies is not related to sickle cell disease, but this transmission of antibodies is important to protect the infant from various infections during early infancy.
Which of the following assessments in a child with hemophilia would lead the nurse to suspect early hemarthrosis?
Child's reluctance to move a body part
Cool, pale, clammy extremity
Ecchymosis formation around a joint
Instability of a long bone in passive movement
a. Childs reluctance to move a body part
Bleeding into the joints in the child with hemophilia leads to pain and tenderness, resulting in restricted movement. Therefore, an early sign of hemarthrosis would be the child's reluctance to move a body part. If the bleeding into the joint continues, the area becomes hot, swollen, and immobile—not cool, pale, and clammy. Ecchymosis formation around a joint would be difficult to assess. Instability of a long bone on passive movement is not associated with joint hemarthrosis.
Which statements by the mother of a toddler would lead the nurse to suspect that the child has iron-deficiency anemia? Select all that apply.
"He drinks over 3 cups of milk per day."
"I can't keep enough apple juice in the house; he must drink over 10 ounces per day."
"He refuses to eat more than 2 different kinds of vegetables."
"He doesn't like meat, but he will eat small amounts of it."
"He sleeps 12 hours every night and takes 2 naps."
a He drinks over 3 cups of milk per day
b. I cant keep enough apple juice in the house; he must drink over 10 oz per day
Toddlers should have between 2 and 3 cups of milk per day and 8 ounces of juice per day. If they have more than that, then they are probably not eating enough other foods, including iron-rich foods that have the needed nutrients
A client is to receive epoetin (Epogen) injections. What laboratory value should the nurse assess before giving the injection?
Partial thromboplastin time
Epogen is a recombinant DNA form of erythropoietin, which stimulates the production of RBCs and therefore causes the hematocrit to rise. The elevation in hematocrit causes an elevation in blood pressure; therefore, the blood pressure is a vital sign that should be checked. The PTT, hemoglobin level, and PT are not monitored for this drug.
The nurse writes a dx of altered tissue perfusion for a client diagnosed with anemia. Which interventions should be included in the plan of care? Select all that apply.
A.Monitor the clients hemoglobin and hematocrit
B.Move the client to a room near the nurses desk
C.Limit the clients dietary intake of green vegetables
D.Assess the client for numbness and tingling
E.Allow for rest periods during the day for the client
The client was dx with iron-deficiency anemia is prescribed ferrous gluconate orally. Which should the nurse teach the client?
A.Take Imodium, and anti diarrheal, OTC for diarrhea
B.Limit exercise for several weeks until a tolerance is achieved
C.The stools may be very dark, and this can mask blood
D.Eat only red meats and organ meats for protein
The nurse is admitting a 24 year old American American female client with a dx of rule-out anemia. The client has a hx of gastric bypass surgery for obesity 4 years ago. Current assessment findings include height 5'5, wt. 75 kg, P 110, R 27, and BP 104/66; pale mucous membranes and dyspnea on exertion. Which type of anemia would the nurse suspect the client has developed?
A.Vitamin B12 deficiency
B.Folic acid deficiency
D.Sickle cell anemia
The nurse and AP are caring for clients on a medical unit. Which task should the nurse delegate to the AP?
A.Check on the bowel movements of a client dx with melena
B.Take vital signs if a client who received blood the day before
C.Evaluate the dietary intake of a client who has been noncompliant with eating
D.Shave the client dx with severs hemolytic anemia
The client is being admitted with Folic acid deficiency anemia. Which would be the most appropriate referral?
B.Leukemia society of America
D.A social worker
The charge nurse is making assignments on a medical floor. Which client should be assigned to the most experienced nurse?
A.The client dx with iron-deficiency anemia who is prescribed iron supplements
B.The client dx with pernicious anemia who is receiving vitamin B12 IM
C.The client dx with aplastic anemia who has developed pancytopenia
D.The client dx with renal disease who has deficiency of erythropoietin
The client dx with anemia begins to complain of dyspnea when ambulating in the hall. Which intervention should the nurse implement first?
A.Apply oxygen via nasal cannula
B.Get a wheelchair for the client
C.Assess the clients lung fields
D.Assist the client when ambulating in the hall
The nurse is discharging a client dx with anemia. Which discharge instruction should the nurse teach?
A.Take prescribed iron until it is completely gone
B.Monitor P and BP at local pharmacy weekly
C.Have complete blood count checked at the HCP's office
D.Perform isometric exercise three times a week
The nurse writes a client problem of "activity intolerance" for a client dx with anemia. Which intervention should the nurse implement?
A.Pace activities according to tolerance
B.Provide supplements high in iron and vitamins
C.Administer packed red blood cells
D.Monitor vital signs q4h
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