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Nclex questions...good...Hematology Nursing III sickle cell anemia, anemia, thrombocytopenia, IVS
Terms in this set (129)
A child is suspected of having sickle cell disease is seen in a clinic, and laboratory studies are performed. A nurse checks the laboratory results, knowing that which of the following would be increased in this disease?
1. platelet count
2. hematocrit level
3. reticulocyte count
4. Hemoglobin level
Rationale: A diagnosis is established based on a complete blood count, examination for sickled red blood cells in the peripheral smear, and hemoglobin electrophoresis. Laboratory studies will show decreased hemoglobin and hematocrit levels and a decreased platelet count, an INCREASED reticulocyte count and the presence of nucleated red blood cells. Increased reticulocyte counts occur in children with sickle cell disease because the life span of their sickled red blood cells is shortened.
A pediatric nursing instructor asks a nursing student to describe the cause of the clinical manifestations that occur in sickle cell disease. The student responds correctly by telling the instructor that
1. Sickled cells increase the blood flow through the body and cause a great deal of pain.
2. sickled cells mix with the unsickled cells and cause the immune system to become depressed.
3. bone marrow depression occurs because of the development of sickled cells.
4. sickled cells are unable to flow easily through the microvasculature and their clumping obstructs blood flow.
Rationale: all of the clinical manifestations of sickle cell disease result from the sickled cells being unable to flow easily through the microvasculature, and their clumping obstructs blood flow. With re-oxygenation, most of the sickled red blood cells resume their normal shape. Options 1, 2, and 3 are incorrect statements.
A 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 e precipitating factor, indicates the need for further instructions?
3. 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 1.5-2 times the daily requirement to prevent dehydration!
Laboratory studies are performed for a child suspected of having iron deficiency anemia. THe nurse reviews the laboratory results, knowing that which of the following results would indicate this type of anemia?
1. An elevated hemoglobin level
2. a decreased reticulocyte count
3. an elevated rbc count
4. rbc that are microcytic and hypochromic
The results of a cbc in children with iron deficiency anemia will show a decreased hemoglobin level and and microcytic and hypochromic rbc the rbc count is decreased, the reticulocyte count is usually normal or elevated.
A home care nurse is instructing the parents of a child with iron deciciency anemia regarding the administration of a liquid oral iron supplement. The nurse tells the mother to
1. administer the iron through a straw
2. administer iron at meal times
3. add the iron to the formula for easy administration
4. mix the iron with cereal to administer
Iron should be administered through the straw or with a medicine dropper placed at the back of the mouth because the iron will stain the teeth. the parent should be instructed to brush or wipe the teeth after administration. Iron is administered between meals because absorption is decreased if there is food in the stomach. Iron requires an acid environment to facilitate its absorption in duodenum. Iron is not added to formula or mixed with cereal or other food items.
A client with anemia has a nursing diagnosis of activity intolerance. Which of the following interventions will the nurse plan for this client?
1.Promote active and passive range-of-motion activities.
2.Space activities and plan rest periods.
3.Teach the client to change position slowly to prevent dizziness.
4. Teach the client the basics of good nutrition.
answer: Space activities and plan rest periods.
The client with activity intolerance tires easily, so it is best for the nurse to plan care and activities around periods of rest. Teaching good nutrition will not help the client to be less tired. Promoting range of motion does not address the issue of fatigue, nor does teaching the client to change position slowly.
The nurse notes that the client has a low red blood cell count and anticipates which of the following subjective manifestations on assessment?
Fatigue would signify that the body's tissues are not receiving enough oxygenation. Sore throat is a sign of infection. Chest pain may indicate an impending myocardial infarction. Nausea is a symptom for many disease processes, but is not typical for anemia.
The nurse is reviewing laboratory findings for a 2-year-old being treated for anemia. Which of the findings is the best indication that goals for this client have been met?
1.The child is no longer cyanotic.
2.The reticulocyte count is rising.
3.The child is more active.
4.Stools are black, indicating iron intake.
The reticulocyte count is rising.
An increase in the reticulocyte number means that the body is producing new RBC's. While improved oxygenation, increased activity, and indications of iron intake are desirable outcomes for the child with anemia, they are not laboratory data.
The nurse has admitted a child newly diagnosed with anemia of unknown origin. Which of the following is a priority intervention for the nurse to initiate?
1. Administer fluids to increase cardiac output.
2. Plan for safe care due to weakness.
3.Teach the client about foods with iron.
4. Assess pain level.
Answer:Plan for safe care due to weakness.
The client with anemia is weak and the nurse would address safe care due to weakness. Since the cause of the anemia is undetermined, the nurse would not administer fluids or complete nutritional teaching without additional information. Clients with anemia do not normally have pain; pain is assessed in every client, but is not the priority of care in this client.
The nurse following a client after a gastric resection observes carefully for evidence of nutritional deficiency anemia related to malabsorption including which of the following?
2.Dark yellow or bronze skin
3.Numbness and tingling of extremities
Numbness and tingling of extremities
The client who has had a gastric resection is at risk for anemia because intrinsic factor may decrease, leading to vitamin B12 deficiency anemia with associated neurologic deficits such as numbness and tingling of extremities. The other symptoms are not related to nutritional deficiency anemia.
The nurse is caring for a 78-year-old client with active alcoholism who has a vitamin B12 deficiency. The nurse plans to teach the client to select which of the following food choices? (Select all that apply)
Clients with vitamin B12 deficiency would be encouraged to eat spinach, oranges, and liver as good sources of the vitamin. Apples and carrots are not good sources for vitamin B12.
A client with iron deficiency anemia has been placed on an iron supplement. Which of the following would the nurse include in the teaching plan about this form of therapy?
1.Iron may cause the stools to be tarry.
2.Iron should be taken in the afternoon.
3.Iron can cause severe headaches.
4.Iron can cause the urine to be orange.
Your Answer:Iron may cause the stools to be tarry.
The client is taught that stools may be black and tarry while taking iron. Orange urine and headaches are not associated with taking iron. Iron should be taken with food to reduce gastric distress.
The nurse is working with a woman who is pregnant and her husband. The husband asks the nurse why his wife has a folic acid deficiency when she eats healthy meals. The nurse best responds with which of the following?
1.Pregnancy increases metabolic requirements for folic acid.
2.There is inadequate dietary intake of folic acid.
3.Pregnancy causes malabsorption of folic acid.
4.The client has some form of impaired metabolism
Answer:Pregnancy increases metabolic requirements for folic acid.
Pregnancy increases the metabolic requirements for folic acid. Since the husband states that they eat healthy meals, inadequate intake of folic acid is a less likely cause of the deficiency. Malabsorption and impaired metabolism are causes of folic acid deficiency that are not associated with pregnancy.
The nurse is teaching a group of parents whose children have sickle cell anemia. When a parent asks the cause of the symptoms, the nurse responds with which of the following?
1."Sickled cells clump in the smaller blood vessels and obstruct blood flow."
2."Sickled cells cause bone marrow depression."
3."The sickled cells mix with normal cells, which causes the immune system to be depressed."
4."Sickled cells increase the blood flow through the body, which causes pain."
"Sickled cells clump in the smaller blood vessels and obstruct blood flow."
All the symptoms of sickle cell are a result of the clumping of the sickled cells in the microvasculature, causing obstruction of blood flow. The other statements are inaccurate.
A child with suspected sickle cell disease (SCD) is in the clinic for laboratory studies. The parents ask the nurse what results will tell the physician that their child has SCD. The nurse responds that which of the following is increased in this disease?
The reticulocyte count will be increased because the life span of sickled red blood cells is shortened. Hemoglobin, hematocrit, and platelet levels will be decreased.
The nurse is instructing the mother of a child with sickle cell disease about the risk factors for precipitation of sickle cell crisis. Which of the following, if identified by the mother as a precipitating factor, indicates the need for further teaching?
Sickle cell crisis may be precipitated by dehydration, not fluid overload. Infection, trauma, and stress are all factors that may cause sickle cell crisis.
A pregnant woman tells the nurse that there is a history of sickle cell disease in her family and she is afraid that the baby will have the disease. The nurse provides the client with which of the following information?
1.Sickle cell is a male disease and would be passed on by the baby's father.
2.The baby needs only one parent to be a carrier to be affected.
3.Both the mother and father must carry the gene for the baby to be affected.
4.Genetic testing will be needed to determine if the baby is affected.
Both the mother and father must carry the gene for the baby to be affected.
Sickle cell is inherited as an autosomal recessive disorder. Both parents must carry the gene for the baby to be affected. The other statements are inaccurate.
The nurse is caring for a child who is in the hospital experiencing sickle cell crisis. The parents are asking the nurse which treatment will help cure the child. The nurse responds with which of the following?
1. Treatment with an exchange transfusion of blood will cure the child.
2. Treatment with morphine will cure sickle cell disease.
3. There is no treatment for sickle cell crisis.
4. Treatment is aimed at pain control, oxygen therapy, and hydration, but does not provide a cure.
Treatment is aimed at pain control, oxygen therapy, and hydration, but does not provide a cure.
Treatment for sickle cell crisis is pain control, oxygenation, and fluid resuscitation. There is no cure for sickle cell disease. The nurse teaches families how to prevent sickle cell crisis.
The nurse is admitting a 7-year-old client who is experiencing sickle cell crisis and plans care based on which of the following nursing diagnoses?
1. Risk for Bleeding
2. Ineffective Airway Clearance
3.Risk for Constipation
4. Delayed Growth and Development
Delayed Growth and Development
The child with sickle cell disease is often developmentally delayed due to the effects of physical disability, pain, and inpatient hospital stays. The nurse would plan activities that help maintain developmental levels the child has reached. The child in sickle cell crisis does not experience ineffective airway clearance, bleeding, or constipation as a result of sickle cell disease. The child may have an illness that could cause one of these symptoms, but they are not common to children with sickle cell disease.
The nurse is evaluating a child in sickle cell crisis who was at risk for a cerebrovascular accident. The nurse monitors the child by evaluating which of the following?
Symptoms of a cerebral vascular accident (CVA) are best noted with an assessment of the neurovascular system. While the other systems may provide some evidence of a CVA, it is the neurovascular system that gives the best informatio
The nurse is planning care for a child who is newly diagnosed with sickle cell disease. Which of the following would the nurse plan with the family to best promote the child's growth and development?
1.Renal health plan
2.Emergency care in the school setting
3.Nutritional support during hospitalizations
4. Individualized school health plan
Individualized school health plan
Children with sickle cell disease will have sickle cell crises no matter how well the child is protected, and may miss a great deal of school. Planning ahead with the school system and parents to continue schooling during recuperation can help the child maintain developmental progress. Most schools are equipped to deal with emergencies that children have. Nutrition is important to development, but a long-range plan with the school will better promote development and learning. Renal health plan is not an appropriate answer.
A nurse is planning care for a client who has a Hgb of 7.5 and a Hct of 21.5. Which of the following should the nurse include in the plan of care? select all that apply
a. provide assistance with ambulation
monitor oxygen saturation
c. weigh client weekly
d. obtain stool specimen for occult blood
e. schedule daily rest periods
rationale: a client with anemia may be dizzy and should be assisted to prevent falls, o2 should be monitored due to decreased o2 carrying capacity in the blood, they should be weight dialy, stool testing is performed to id cause of anemia due to gi bleeding, a client may experience fatigue so rest period should be planned to conserve energy
A nurse is teaching a client who has a new script for ferrous sulfate. Which of the following should be included in the teaching?
a. stools will be dark red in color
b. take with milk if gi distress occurs
c. foods high in vitamin c will promote absorption
d. take for 14 days
C. Vitamin c enhances the absorption of iron by the intestinal trat, stools will be dark green to black, milk binds with iron and decreases absorption, iron therapy can take 4-6 weeks for hgb and hct to return to normal referene range
A nurse is providing discharge teaching to a chilent who has a gastrectomy for stomach cancer. Which of the following information should be included in the teaching? select all that apply
a. you will need a monthly injection of vitamin b12 for the rest of your life
b. using nasal spray of vitamin b12 may be an option daily
c. an oral supplement of vitamin b12 may be taken as an option daily
d. u should increase animal proteins, legumes, dairy to increase vitamin b12
e. add soy milk with vitamin b12 to your diet to decrase risk of pernisious anemia
answer a and b
a client with gastrectomy will require monthly injections of vitamin b12 for the rest of his life, cyanocoblamin nasal spray is an option for a client with gastrectomy. the rest will not be absorbed due to lack of intrinisctfactor produced by stomach
A nurse is completing an integumentary assessment of a client who has anemia. which of the following is an expected finding
a. absent turgor
b. sppon shaped nails
c. shiny, hairless legs,
d. yellow mucous membranes
answer: b spoon shaped nails, pail nail beds and mucous membranes are all present iwithin these patients
A nurse in a clinic receives a phone call form a client seeking info about his new prescription for erythropoietin (epogen) which of the following inf o should be reviewed with the client.
a. the client needs an erythrocyte sedimentation rate test weekly (esr)
b. the client should have his hemoglobin checked twice a week
c. o2 saturation levels should be monitored
d. folic acid production will increase.
answer: hemoglobin/ hematocrit will be measured twice a week
bp is monitored for an increase, erythropoietin promotes increased production of rbc, it is evaluated by changes in hematocrit
During the nursing assessment of a patient with anemia, the nurse notes ad significant the patients history of...
a. reurring infections
b. partial gastrectomy
c. corticosteroid therapy
d. oral contraceptive use
the parietal ells of the stomach secrete intrinsic factor, a substance necessary for absorption of viam b 12 and if all or part of stomach is removed the lack of intrinsic factor can lead to impaired rbc production and perniscuous anemia
During assessment of a patient with thrombocytopenia, the nurse would expet to find?
a. sternal tenderness
b. petechial and purpura
c. jaundiced sclera and skin
d. tender enlarged lymph nodes.
answer: b. petachiae and purpura
rationale: petechiae are small, flat, red, or red brown pinpoint microhemorrhages that occur ont eh skin when platelet levels are low and when they are numerous, they group causing reddish bruises known as purpura. jaundice occurs when anemias are of a hemolytic origin, resulting in accumulation of bile pigments from rbc, enlarged lymph nodes are associated with infection, sternal tendernesss w leukemias
Match each of the anemic states with etiologic and morphologic classification systems
etiologic: 1. decreased rbc production
2. blood loss
3. increased rbc destruction
5. macrocytic, normochromic
6. microcytic, hypochromic
a. acute trauma ___ _____
b. iron deficiency anemia
c. sickle cell anemia _____ ________
answers: a 2,4
b. 1, 6
On physical assessment of the patient with severe anemia the nurse would expect to fin?
a. nervousness and agitiation
b. fever and tenting of the skin
c. systolic murmur and tachycardia
d. bluish mucous membranes and reddened
answer: c. systolic murmors and tachycardia
tachycardia occurs in severe anemia as the body compensates for hypoxemia and the low viscosity of the blood contributes to the development of systolic murmurs and bruits. depression of the cns is common with fatigue, lethargy, and malaise, poor skin turgor may be present, but fever is not associated with anemia. skin and membranes ar pale with blue tinged to sclera
a nursing diagnosis that is appropriate for patients with moderate to sever anemia of any etiology is
a. impaired skin integrity related to edema and pruiortos b. disturbed body image related to changes in appearance and body function
c. imbalanced nutrition less than body requirements related to lack of knowledge of adequate nutrition
d. activity intolerance related to decreased hemoglobin and imbalance between o2 supply and demand
pts with anemia have decreased hemoglobin and symptoms of hypoxemia, leading to activity intolerance. impaired skin integrity and body image disturbance may be appropriate for patients with jaundice from hemolytic anemias, and altered nutrition is indicated whn iron, folic acid, or vitamin b intake is deficint
Match the following terms with the correct anemia:
1. iron deficiency
2. sickle cell
a. hypoxia induced change in rbc
b. most common type of anemia
c. may occur with removal of duodenum
d. associated with vascular occlusion and tissue infarction
e. associated with chronic blood loss
1.b. c, e
2. a. d
To prevent a common side effect of oral iron supplements, the nurse teaches the patient to
a. take the iron preperations with meals
b. increase fluid and dietary fiber intake
c. report presence of black stools to physician
d. use enteric coated preps taken with oj
answer: B rationale constipation is a common side effet of oral iron supplementation. should be taken before meals, stools are expected to be blak, taking with oj enhances absorption but enteric coated are ineffective because of unpredicatable release of iron in area of gi tract where it can be absorbed
Lab and diagnostic test findings would expect in an anemic pateitn with alcoholism include
decreased serum folate and increased mchc
The anemia that follows aute blood loss is morst frequently treated with increased dietary iron intake, true or false?
false- blood transfusions or iron supplements
The anemia of sickle cell disease is caused by
a. intravascular hemolysis of sickled rbc
b. accelerated breakdown of abnormal rbc
c. autoimmune antibody destruction of rbc
d. isoimmune antibody antien reactions with rbc
a pt with sickle cell anemia asks the nurse why the sickling crisis does not stop when o2 therapy is started. the nurse explains that
a. sickling occurs in response to decreased blood viscosity, which os not affected by o2 therapy
b. when rbc sickle, they occlude small vessels, which cause more local hypoxia and more sickling
c. destruction of abnormal cells results in fewer rbc to carry o2
d. o2 therapy does not alter shape of abnormal erythrocytes, but allows increased o2 concentration in hemoglobin
answer b: during a crisis sickling cells clog small capillaries and resulting hemostasis promotes self perpetuating cycle of local hypoxia, deoxygenation, or more erythrocytes and more sickling. administration of o2 mau help further sickling, but additional o2 does not reach areas of local hypoxia caused by occluded vessels
a nursing intervention indiated for pt during a sickle cell crisis is
b. antiembolism hose
. restriction of sodium and oral fluids
d. administration of large doses of continuous narcotic analgesics
True or false
a. thrombotic thrombocytopenic purpura is characterized by decreased platelets, decreased rbc, and decreased agglutination function of platelets
b, a classic manifestation of thrombocytopenia that the nurse would expect to find is ecchymosis
c. The nurse suspects heparin induced thrombocytopenia and thrombosis syndrome when a patient receiving heparin induced thrombocytopenia nad thrombosis syndrome when a patient receiving heparin requires dereased heparin to maintain therapeutic activated thromboplastin times
a. false, there is increased agglutination function of platelets
b. false, the nurse would find petachia
c. false, increased heparin
A patient has a platelet count of 50,000 and is diagnosied with immune thrombocytopenic purpura. the nurse would expect initial treatment to include
c. administration of platelets
d immunosyppressive therapy
answer b. corticosteroids
They suppress phagocytic response of splenic macrophages, decreasing platelet function they also depress autoimmune antibody formation and reduce capillary fragility and bleeding time.
During care for patient with thrombocytopenia, the nurse
a. takes frequent temperatures to assess for fever
b. maintains the patient on strict bed rest to prevent injury
c. monitors patient for headaches, vertigo, or confusion
d. removes oral crusting and scabs with firm friction every two hours
Rationale: the major complication of thrombocytopenia is hemorrhage, and it may occur in any area of the body. cerebral hemorrhage may be fatal and evaluation of mental status for cns alteration to id cns bleeding is very important. fever is not a common finding in thrombocytopenia. protection from injury to prevent bleeding is an important nursing intervention, but strict bed rest is not indicated. oral care is performed very gently with minimum friction and soft swabs
Following a splenetomy for treatment of immune thrombocytopenic purpura, the nurse would expect the patients lab results to reveal
a. decreased rbc
b. decreased wbc
c. increased platelets
d. increased immunoglobulin's
answer: c. increased platelets
splenectomy may be indicated for treatment of itp, and when spleen is removed platelet counts increase significantly in most patients in any of the disorders in which spleen removes excessive blood cells, splenectomy will most often increase peripheral rbc, wbc, and platelet counts
While receiving a unit of packed rbc, the pt develops chills and a temp of 102.2. The nurse
a. notifies physician and blood bank
b. stops transfusion and removes iv catheter
c. adds a leukocyte reduction filter to the blood administration set
d. recognizes this as a mild allergic transfusion reaction and slows the transfusion
chills and fever are symptoms of an acute hemolytic or transfusion reaction if these develop the transfusion should be stopped, saline infused through the iv line, the physician and blood bank notified immediately, the id tags rechecked and vital signs and urine output monitored. addition of a leukocyte reduction filter may prevent a febrile reaction but is not helpful once the reaction has occurred. mild and transient allergic reactions indicated by itching and hives might permit restarting of transfusion after treatment with antihistamines.
A patient with thrombocytopenia with active bleeding has 2 units of platelets prescribed. To administer the platelets the nurse
a. checks for abo compatibility
b. agitates the bag periodically during the transfusion
c. takes vital signs every 15 minutes during the procedure
d. refrigerates the second unit until the first unit has transfused
answer: b agitates the bag periodically during the transfusion
platelets adhere to plastic bags and should be gently agitated throughout the transfusion. platelets do not have a b or rh antibodies and abo compatibility is not a consideration. baseline vital signs should be taken before the transfusion is started and the nurse should stay with patient during first 15 minutes platelets are stored at room temp and should not be refrigerated
What nursing care intervention should we implement for nutrition and hydration in cancer patients?
ongoing assessments, client teaching, initiating interventions to improve nutrition and hydration, antiemetic medications
How do we manage treatment side effets in cancer patients?
know side effets of medications you are administering and monitor for them for example myelosuppresion or suppression of blood cell production in the bone marrow
How many erythrocytes do we have and how long do they live
4.5-5.8 million per micro liter of blood and they last 120 days
Age-related changes that affect the hematologic system include: (Select all that apply.)
1.Bone marrow in the long bones decline.
2.The number of stem cells in the marrow increases.
3.Lymphocyte function, especially cellular immunity, decreases.
4.Platelet adhesiveness decreases.
Answer: 1. 3.
At about age 70, the amount of bone marrow in the long bones declines steadily; the number of stem cells in the marrow decreases; and lymphocyte function, especially cellular immunity, declines.
Anemia or insufficient hemoglobin content is common in older persons. The client's body compensates for the deficiency by:
1.Decreasing the respiratory and heart rates.
2.Increasing the heart and respiratory rates.
3.Shunting blood away from vital organs and skin.
4.Decreasing blood viscosity in order to supply oxygen to hypoxic tissues.
All anemias result in a loss of oxygen-carrying capacity of the blood, and produce generalized hypoxia. The body tries to compensate by raising the heart and respiratory rates, shunting blood to vital organs away from the skin, and increasing blood viscosity in order to supply oxygen to hypoxic tissues.
Which of the following statements accurately describes normocytic anemia? Normocytic anemia usually is caused by:
1.Iron deficiency and inadequate globin synthesis.
2.Acute or chronic blood loss or inadequate dietary intake of iron.
3.Concurrent chronic illness, such as chronic heart disease.
4.A deficiency in vitamin B12 or gastric surgery.
Rationale: Normocytic anemia usually is caused by concurrent chronic illness such as chronic heart, respiratory, or renal disease or malignancy. Hemolytic anemia also is a normocytic 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?
a.Liver and dark green leafy vegetables
b.Whole milk and eggs
c.Potatoes and carrots
d.Bread and fish
Foods high in folate are liver, orange juice, cereals, whole grains, beans, nuts, and dark leafy vegetables like spinach.
Because older persons can have severe anemia for a long period of time without detection, when diagnosed, quick reversal is warranted. Which of the following orders most likely would be prescribed at this time
a.Platelet transfusion and osmotic diuretic
b.Ferrous sulfate 325 mg orally three times a day
c. Packed red blood cells followed by oral furosemide (Lasix)
d. Erythropoietin (Procrit) injection twice per week
Older persons might have heart problem that are compounded by severe anemia. The physician can prescribe blood transfusions to reverse the severity of the anemia, and a diuretic such as furosemide (Lasix) orally between units to prevent fluid overload and the development of congestive heart failure (CHF).
An elderly client is admitted to the hospital Emergency Department (ED) with complaints of headache, visual disturbances, and burning pain, and erythema of the hands and feet. To accurately diagnose thrombocytopenia, the physician most likely will order:
a.Peripheral blood smear.
b.Allogenic bone marrow transplant.
c.Bone marrow aspiration.
Thrombocytopenia is characterized by an increased number of circulating platelets in the blood. Accurate diagnosis requires bone marrow aspiration. Allogenic bone marrow transplantation is prescribed for younger persons with myelofibrosis. A splenectomy may be prescribed for persons with myelofibrosis
When caring for a client with a diagnosis of thrombocytopenia, the nurse should plan to:
a.Discourage the use of stool softeners.
b.Assess temperature readings every six hours.
c.Avoid invasive procedures.
d. Encourage the use of a hard, brittle toothbrush.
Thrombocytopenia is characterized by an increased number of circulating platelets in the blood. Older persons with thrombocytopenia are at significantly increased risk of thrombosis, and careful monitoring of platelet levels and symptoms is indicated.
A client with thrombocytopenia presents to the primary care center. During assessment, the nurse notices petechiae. The nurse anticipates that which of the following laboratory results would support the presence of a hemostatic disorder?
a. Decreased erythrocyte count
b. A platelet count that is less than 150,000 uL
c. An elevated lymphocyte count
d. A hemoglobin value of 14 or more
1. Which of the following blood components is decreased in anemia
ANswer a: anemia is defined as a decreased number of erythrocytes rbc, leukopenia ia decreased wbc, thrombocytopenia is decreased number of platelets
2.A client with anemia may be tired due to a tissue deficiency of which of the following substances
a. carbon dioxide.
b factor viiii
d. t cell antibodies
Answer c: anemia stems from a decreased numbe rof rbc and the resulting deficiency in oxygen and body tissues. Clotting factors such as factor VIII relate to the bodys ability to form blood clots and aren't related to anemia, not is carbon dioxide of t antibodies.
3.which of the following ells is the precursor to the rbc
a. b cell
c. stem cell
d. t cell
The precursor to rbc is the stem cell. b cells, macrophages and t cells and lymphocytes are not rbc precursors
4.which of the following symptoms is expected with hemoglobin of 10 g/dl?
answer: a mild anemia usually has no clinical signs. Palpitations, shortness of breath, pallor are all associated with severe anemia
6. A client with iron deficiciency anemia is scheduled for discharge. which instruction should be prescribed about ferrous glsonate therapy should the nurse include in the teaching plan?
a. take with an antacid
b. take with milk
c. take with cereal
d. take on an empty stomach
answer d: ferrous gluconate should be taken on an empty stomach not with antacids, milk or whole grain cereals because they reduce iron absorption
8.The nurse explains ot the parent of a 1 year old child admitted ot the hospital in a sickle cell crisis that the local tissue damage the child has on admission is caused by which of the following?
a. autoimmune reaction complicated by hypoxia
b. lack of o2 in the red blood cells
c. obstruction of circulation
d. elevated serum bilirubin concentration
answer c: characteristic sicle cells tend to cause log jams in capillaries. this results in poor circulation to local tissues, leading to ischemia and necrosis. The basic dfect in sickle cell disease is an abnormality in the structure of rbcs. the erythrocytes are sickle shaped, rough in texture, and rigid. sickle ell disease is an inherited disease not an autoimmune reaction. elevated serum bilirubin concentrations are assoiated with jaundice not insickle cell disease
12. 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
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 ounces a day
c. he refuses to eat more than 2 different kinds of vegetables
d. he doesn't like meat but he will eat small amounts of it
e. he sleeps 12 hours every night and takes a 2 hour nap
answers: a and B
toddlers should have between 2 and 3 cups of milk a day and 8 ounces of juice per day if they have more than that they are probably not eating enough other foods including iron rich food sthat have needed nutrients
13.Which of the following foods would the nurse encourage the mother to offer to her child with iron deficiency anemia?
a. rice cereal, whole milk, and yellow vegetables
b. potato, peas and chicken
c. macaroni, cheese, and ham
d. pudding, green vegetables, and rice
Potato, peas, hiken, green vegetables, rice ceareal 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
17. A child suspected of having sickle cell disease is seen in a clinic, and lab studies are performed. a nurse checks the lab results knowing what would be increased in this disease.
a. platelet count
b. hematocrit level
c. reticulocyte count
d. hemoglobin level
diagnosis is established based on a cb, examination for sickled rb appear in peripheral smear, and hemoglobin electrophoresis. lab studies will show decreased hemoglobin and hematocrit levels and a decreased platelet count and increased reticulocyte count and presence of nucleated rbc, increased reticulocyte counts occur in children with sickle cell disease because the life span of their sickled rbc is shortned.
19. Lab studies are performed for a child suspected of having iron deficiency anemia. THe nurse reviews the lab results knowing which of the following results would indicate this type of anemia.
a. an elevated hemoglobin level
b. a decreased reticulocyte count
c. an elevated rbc count
d. rbc that are microcytic and hypochromic?
answer d: results of cbc in children with iron deficiency anemia will show decreased hemoglobin levels and microcytic and hypochromic rbc. rbc count is decreased, reticulocyte count is normal or slightly elevated
1. T he nurse is admitting a client suspected of
having sickle cell anemia. The client has a fever
of 38.9°C or 102°F, faint yellow-tinged sclera,
and is complaining of abdominal pain. Which
of the following clinical manifestations further
support this diagnosis? select all that apply.
1. R apid but regular breathing
2. P ale, dilute urine
3. S kin ulcers on the lower extremities
4. S wollen fingers
answers: 3,4,5, 6 the lient with sickle cell anemia develops skin ulcers on the lower extremities form vaso-occlusive aspects of the disease. the client would have shortness of breath, and be fatigued and pale. they may have swollen fingers, hemolysis of rbc results in billrubinuria. the clients urine is dark olored
T he nurse making a care plan for a client with
severe thrombocytopenia should include which
of the following?
1. C areful examination of spinal fluid obtained
by lumbar puncture
2. A private room with reverse isolation
3. A void intramuscular administration of
4. C areful monitoring of urinary output while
titrating the dosage of furosemide (Lasix)
S evere thrombocytopenia is a platelet count of
, 10,000 to 20,000/mm3. The client with this
low number of platelets is at great risk of
bleeding from any invasive procedure.
Intramuscular injections can cause a hematoma
in the muscle and should be avoided if
possible. A lumbar puncture would put the
client at an unnecessary risk of bleeding.
A private room is not indicated unless there are
other reasons for isolation (infection,
neutropenia). Furosemide is a diuretic and not
used as therapy for thrombocytopenia.
7. A client with a chronic bleeding duodenal ulcer
is admitted to the hospital. What clinical
manifestations should the nurse assess for in a
client with a 30% blood volume loss?
S elect all that apply:
[ ] 1. P ostural hypotension
[ ] 2. Dizziness
[ ] 3. T achycardia with activity
[ ] 4. Swelling
[ ] 5. B lood pressure below normal at rest
[ ] 6. Pain
answers 1 and 3
An acute blood loss of 30% may appear more
severe than a slower rate of blood loss. The
client would not be showing signs of shock
(clammy skin) and the vital signs would not be
completely normal. It is important for the nurse
to assess the client in various positions and
states of activity in order to elicit the signs of
significant blood loss. Pain, dizziness, and
swelling occur with a 50% blood loss.
W hich of the following should the nurse
include in the instructions provided to a client
with sickle cell anemia?
S elect all that apply:
[ ] 1. A dminister pain medications
[ ] 2. E ncourage fluids
[ ] 3. T reat the presence of infection
[ ] 4. A void informing others of the condition
[ ] 5. V igorous exercise is permitted
[ ] 6. I nform the client that the disorder is not
answers. 1. 2. 3.
Recognition of the signs of a vaso-occlusive
crisis and knowledge of the measures to
prevent it are very important in keeping the
health of a client with sickle cell anemia in
control. It is essential to administer pain
medications, encourage fluids, and treat
infections. Individuals may fear the disease, but
educating friends of the client is a healthy
approach to the disease. Dehydration from
excessive exercise or heat can precipitate a
cycle of pain. Sickle cell anemia is a genetic
disorder, and counseling of couples before they
have offspring is recommended.
T he nurse has started a transfusion of packed
red blood cells. The nurse should immediately
stop the transfusion when which of the
1. Fever and back pain
2. D ry mouth
3. H ypothermia and pallor
4. H eart rate of 74 beats per minute
Fever and back pain can occur in hemolytic
blood transfusion reaction caused by the
mismatch of blood types. If the transfusion is
not stopped immediately, the client could go
into shock and die. Dry mouth could be caused
by an antihistamine given as a premedication
or from dehydration, but it is not a reason to
stop the transfusion. Blood products expire in a
few hours and interruptions should be
minimized. A heart beat of 74 beats per minute
is not too high or too low. The client may also
spike a temperature and have flushed skin.
. A client with iron deficiency anemia is very
pale, has shortness of breath, and records a
hemoglobin level of 7.5 grams. Which of the
following is a priority for the nurse to
1. A dminister an iron supplement
2. I nstruct the client on a diet high in iron
3. A dminister packed red blood cells
4. I nstruct the client to conserve energy
A client with a hemoglobin of 7.5 grams
classifies as severe anemia. The client is
symptomatic and the administration of packed
red blood cells is the priority. Administering an
iron supplement, instructing the client on a
diet high in iron, and conserving energy are all
important interventions but not the priority.
A client is experiencing blood loss from anemia
and is exhibiting rapid and thready pulse, cold
and clammy skin, and a blood pressure below
normal at rest. The nurse anticipates what
percent of blood loss?________
A rapid and thready pulse, cold and clammy
skin, and a blood pressure below normal at rest
are the result of anemia from a 40% blood loss
A nurse is reviewing the serum laboratory test
results for a client with sickle cell anemia.
Which parameter does the nurse anticipate
will be elevated?
3 Hemoglobin A1c
4 Prothrombin time
Sickle cell anemia is a severe anemia that affects African
Americans predominantly and is characterized by sickled hemoglobin,
or Hgb-S. The client must have two abnormal genes yielding hemoglobin-
S to have sickle cell anemia. A client could have sickle cell trait by
carrying one hemoglobin-A gene and one hemoglobin-S gene; then, the
client has a less severe form of sickle cell anemia. Options 1, 3, and 4
are unrelated to sickle cell anemia
A client is admitted to the hospital in sickle cell
crisis. The nurse monitors the client for which
clinical indicator of the disorder?
4 Blurred vision
answer: 1 pain
Sickle cell crisis usually causes severe pain in the bones and
joints along with joint swelling. The pain develops as a result of microvascular
occlusion from abnormal sickled hemoglobin that occurs with
hypoxia. Therapy includes pain management with opioid analgesics,
supplemental oxygen, and intravenous fluids. The remaining options
are not associated with sickle cell crisis.
A client in labor has a concurrent diagnosis of
sickle cell anemia. Which action has priority
to assist in preventing a sickling crisis from occurring
1 Reassuring the client
2 Administering oxygen
3 Preventing bearing down
4 Maintaining strict asepsis
During the labor process, the client with sickle cell anemia is at
high risk for being unable to meet the oxygen demands of labor. Administering
oxygen will prevent sickle cell crisis during labor. Options 1 and 4
are appropriate actions but are unrelated to sickle cell crisis. Option 3 is
A nurse is planning interventions for counseling
a maternal client who has been newly
diagnosed with sickle cell anemia. Which of
the following would be the most important psychosocial
intervention at this time?
1 Provide emotional support.
2 Avoid the topic of the disease at all costs.
3 Allow the client to be alone if she is crying.
4 Provide the client with all of the information
one of the most important roles as a nurse is providing emotional support to the clients and their family during the counseling pr0cess
Option 4 overwhelms the client with information while she is trying to
cope with the news of the disease. Option 3 is only appropriate if the client
requests to be alone; if this is not requested, the nurse is abandoning the
client in a time of need. Option 2, like option 4, is nontherapeutic.
A nurse is reviewing the physician's prescriptions
for a child who was admitted to the hospital
with vaso-occlusive pain crisis from
sickle cell anemia. Which of the following
physician prescriptions would the nurse
2 Intravenous fluids
3 Supplemental oxygen
4 Meperidine hydrochloride (Demerol) for
Rationale: Meperidine hydrochloride is contraindicated for ongoing pain
management because of the increased risk of seizures associated with the
use of the medication. The management of vaso-occlusive pain generally
includes the use of strong opioid analgesics such as morphine sulfate or
hydromorphone (Dilaudid). These medications are usually most effective
when given as a continuous infusion or at regular intervals around the
clock. Options 1, 2, and 3 are appropriate prescriptions for treating
vaso-occlusive pain crisis.
The nurse cares for a client who is pale and
complains of fatigue, weakness, and dizziness.
Which serum laboratory test result is the
nurse's priority for planning care?
1 Hematocrit 43%
2 Sodium 130 mEq/L
3 Potassium 4.8 mEq/L
4 Hemoglobin of 7 g/dL
Rationale: The client's hemoglobin level and sodium level are low; however,
the nurse uses the hemoglobin results to plan care because the client's
clinical indicators are consistent with anemia. The client is pale
because the serum hemoglobin is low; thus the client's tissues are perfused
with blood that has a low oxygen-carrying capacity. The client is weak and
dizzy because the blood does not carry enough oxygen to meet tissue
oxygen demands. While a client who is hyponatremic can also feel weak
and dizzy, a hyponatremic client is unlikely to be pale. The hematocrit and
the potassium levels are within normal limits.
A client experiences postoperative blood loss.
Which does the nurse assess to determine that
the client is anemic?
4 Muscle cramps
Rationale: The client with anemia is likely to complain of fatigue caused by
deficient hemoglobin leading to a decreased oxygen-carrying capacity of
the blood and ability to meet tissue oxygen demands. The respiratory rate
can increase to improve oxygenation, but dyspnea (option 2) related to
anemia is uncommon. The client is more likely to have tachycardia than
bradycardia (option 3), because the heart beats faster to deliver the same
amount of oxygen to tissues in compensation for less oxygen in the blood.
Muscle cramps (option 4) are an unrelated finding.
A prenatal client is suspected of having iron deficiency
anemia. Which finding should the nurse
expect to note regarding the client's status?
1 Excess fluid volume
2 Deficient fluid volume
3 A low hemoglobin and hematocrit level
4 A high hemoglobin and hematocrit level
Rationale: Pathological anemia of pregnancy is primarily caused by iron
deficiency. When the hemoglobin level is below 11 mg/dL, iron deficiency
is suspected. An indirect index of the oxygen-carrying capacity is determined
via a packed red blood cell volume or hematocrit level. Options 1
and 2 are nursing diagnoses that are not noted in iron deficiency anemia.
A clinic nurse provides home care instructions
to an adolescent with iron deficiency anemia
about the administration of oral iron preparations.
The nurse tells the adolescent that it is
best to take the iron with:
4 Tomato juice
Rationale: Iron should be administered with vitamin C-rich fluids, because
vitamin C enhances the absorption of the iron preparation. Tomato
juice has a high ascorbic acid (vitamin C) content, whereas water, soda,
and cola do not contain vitamin C.
Priority Nursing Tip: Liquid iron preparations stain the teeth. Teach the
child and parents that liquid iron should be taken through a straw and the
teeth should be brushed after administration.
Which of the following instructions should the
nurse include in the teaching plan for a client
taking iron supplements to correct iron deficiency
1 Eat a low-fiber diet.
2 Limit the intake of fluids.
3 Limit the intake of meat, fish, and poultry.
4 Avoid taking the iron supplements with milk
Rationale: The client should avoid taking the iron supplements with milk
or antacids, because these items decrease the absorption of iron. The client
should also avoid taking the iron with food, if possible. The client should
increase the intake of natural sources of iron, such as meats, fish, and poultry.
Finally, the client should take in sufficient fiber and fluids to prevent
constipation as a side effect of iron therapy.
A nurse is preparing to teach the parents of a
child with anemia about the dietary sources
of iron that are easy for the body to absorb.
Which food item should the nurse include
in the teaching plan?
Rationale: Dietary sources of iron that are easy for the body to absorb include
meat, poultry, and fish. Vegetables, fruits, cereals, and breads are
also dietary sources of iron, but they are harder for the body to absorb.
A child is admitted to the hospital with a suspected
diagnosis of idiopathic thrombocytopenic
purpura (ITP), and diagnostic studies
are performed. Which of the following diagnostic
results are indicative of this disorder?
1 An elevated platelet count
2 Elevated hemoglobin and hematocrit levels
3 A bone marrow examination showing an
increased number of megakaryocytes
4 A bone marrow examination indicating an
increased number of immature white blood
Rationale: The laboratory manifestations of ITP include the presence of a
low platelet count of usually less than 20,000 cells/mm3. Thrombocytopenia
is the only laboratory abnormality expected with ITP. If there has
been significant blood loss, there is evidence of anemia in the blood cell
count. If a bone marrow examination is performed, the results with ITP
show a normal or increased number of megakaryocytes, which are the precursors
of platelets. Option 4 indicates the bone marrow result that would
be found in a child with leukemia.
The nurse admits a client who is in sickle cell
crisis to the hospital. Which does the nurse prepare
as the priority in the management of the
1 Pain management
2 Fluid administration
3 Oxygen administration
4 Red blood cell transfusion
Rationale: The priority nursing intervention for a client in sickle cell crisis
is to administer supplemental oxygen because the client is hypoxemic, and
as a result, the red blood cells change to the sickle shape. In addition,
oxygen is the priority because airway and breathing are more important
than circulatory needs. The nurse also plans for fluid therapy to promote
hydration and reverse the agglutination of sickled cells, opioid analgesics
for relief from severe pain, and, blood transfusions to increase the blood's
1. The home health nurse is visiting a client with autoimmune thrombocytopenic purpura (ATP). The client's platelet count currently is 80, It will be most important to teach the client and family about:
A. Bleeding precautions
B. Prevention of falls
C. Oxygen therapy
D. Conservation of energy
2. A client has autoimmune thrombocytopenic purpura. To determine the client's response to treatment, the nurse would monitor:
A. Platelet count
B. White blood cell count
C. Potassium levels
D. Partial prothrombin time (PTT)
3. The nurse is conducting a physical assessment on a client with anemia. Which of the following clinical manifestations would be most indicative of the anemia?
A. BP 146/88
B. Respirations 28 shallow
C. Weight gain of 10 pounds in 6 months
D. Pink complexion
4. Clients with sickle cell anemia are taught to avoid activities that cause hypoxia and hypoxemia. Which of the following activities would the nurse recommend?
A. A family vacation in the Rocky Mountains
B. Chaperoning the local boys club on a snow-skiing trip
C. Traveling by airplane for business trips
D. A bus trip to the Museum of Natural History
5. The nurse is instructing a client with iron-deficiency anemia. Which of the following meal plans would the nurse expect the client to select?
A. Roast beef, gelatin salad, green beans, and peach pie
B. Chicken salad sandwich, coleslaw, French fries, ice cream
C. Egg salad on wheat bread, carrot sticks, lettuce salad, raisin pie
D. Pork chop, creamed potatoes, corn, and coconut cake
6. A newly admitted client has sickle cell crisis. The nurse is planning care based on assessment of the client. The client is complaining of severe pain in his feet and hands. The pulse oximetry is 92. Which of the following interventions would be implemented first? Assume that there are orders for each intervention.
A. Adjust the room temperature
B. Give a bolus of IV fluids
C. Start O2
D. Administer meperidine (Demerol) 75mg IV push
1. Which of the following foods would the nurse encourage the client in sickle cell crisis to eat?
B. Cottage cheese
D. Lima beans
2. A 25-year-old male is admitted in sickle cell crisis. Which of the following interventions would be of highest priority for this client?
A. Taking hourly blood pressures with mechanical cuff
B. Encouraging fluid intake of at least 200mL per hour
C. Position in high Fowler's with knee gatch raised
D. Administering Tylenol as ordered
1. A 30-year-old male from Haiti is brought to the emergency department in sickle cell crisis. What is the best position for this client?
A. Side-lying with knees flexed
C. High Fowler's with knees flexed
D. Semi-Fowler's with legs extended on the bed
2. A 43-year-old African American male is admitted with sickle cell anemia. The nurse plans to assess circulation in the lower extremities every 2 hours. Which of the following outcome criteria would the nurse use?
A. Body temperature of 99°F or less
B. Toes moved in active range of motion
C. Sensation reported when soles of feet are touched
D. Capillary refill of < 3 seconds
The nurse is preparing to administer iron
dextran (Imferon) to a client with iron deficiency
anemia. Which action is appropriate?
1. Using a 25G needle
2. Administering a Z-track injection
3. Using the same needle to draw up
the solution and to administer the
4. Preparing the deltoid site for injection
Answer: 2. A Z-track or zig-zag technique
should be used to administer an iron injection.
This prevents iron from leaking into and irritating
the subcutaneous tissue. A 25G needle
is used for a subcutaneous injection, not for
a deep I.M. injection (such as that needed
to administer iron). The needle should be
changed after drawing up the iron solution
to avoid staining and irritating the tissues.
A deep I.M. site such as the upper outer quadrant
of the buttocks should be used to administer
iron; the deltoid site doesn't provide
enough muscle mass for an iron injection.
A nurse is documenting her care for
a client with iron deficiency anemia. Which
nursing diagnosis is most appropriate?
1. Impaired gas exchange
2. Deficient fluid volume
3. Ineffective airway clearance
4. Ineffective breathing pattern
Answer: 1. Hemoglobin is responsible
for oxygen transport in the body. Iron is
necessary for hemoglobin synthesis. Iron deficiency
anemia causes subnormal hemoglobin
levels, which impair tissue oxygenation and
impair gas exchange. Iron deficiency anemia
doesn't cause deficient fluid volume and is
less directly related to ineffective airway
clearance and breathing pattern than it is to
impaired gas exchange.
A nurse is providing dietary teaching
for the mother of a child with iron deficiency
anemia. Which iron-rich foods should the
nurse instruct the mother to include in her
1. Liver, dark leafy vegetables, and
2. Dark leafy vegetables, chicken, and
3. Whole grains, citrus fruit, and yogurt
4. Citrus fruit, liver, and whole grains
Answer: 1. The mother should be instructed
to give her child iron-rich foods, such as
liver, dark leafy vegetables, and whole grains.
Chicken is a good source of protein, but it
isn't high in iron. Citrus fruits aid iron
absorption but aren't high in iron. Yogurt is
a good source of calcium but
A client with thrombocytopenia,
secondary to leukemia, develops epistaxis.
The nurse should instruct the client to:
1. lie supine with his neck extended.
2. sit upright, leaning slightly forward.
3. blow his nose and then put lateral
pressure on his nose.
4. hold his nose while bending forward
at the waist.
Answer: 2. The upright position, leaning
slightly forward, avoids increasing the
vascular pressure in the nose and helps the
client avoid aspirating blood. Lying supine
won't prevent aspiration of the blood. Nose
blowing can dislodge any clotting that has
occurred. Bending at the waist increases
vascular pressure in the nose and promotes
bleeding rather than halting it.
Before performing a venipuncture to initiate
continuous intravenous (IV) therapy, a nurse
1 Inspect the IV solution and expiration date.
2 Apply a cool compress to the affected area.
3 Secure a padded armboard above the IV site.
4 Apply a tourniquet below the venipuncture
Rationale: IV solutions should be free of particles or precipitates to prevent
trauma to veins or a thromboembolic event; in addition, the nurse avoids
administering IV solutions whose expiration date has passed to prevent
infection. Cool compresses cause vasoconstriction, making the vein less
visible, smaller, and more difficult to puncture. Arm boards are applied
after the IV is started and are used only if necessary. A tourniquet is applied
above the chosen vein site to halt venous return and engorge the vein; this
makes the vein easier to puncture.
A nurse has just finished assisting the physician
in placing a central intravenous (IV) line. Which
of the following is a priority intervention after
central line insertion?
1 Prepare the client for a chest radiograph.
2 Assess the client's temperature to monitor for
3 Label the dressing with the date and time of
4 Monitor the blood pressure (BP) to assess for
fluid volume overload.
Rationale: A major risk associated with central line placement is the possibility
of a pneumothorax developing from an accidental puncture of the
lung. Assessing the results of a chest radiograph is one of the best methods
to determine if this complication has occurred and verify catheter tip
placement before initiating intravenous (IV) therapy. A temperature elevation
related to central line insertion would not likely occur immediately
after placement. Labeling the dressing site is important but is not the priority.
Although BP assessment is always important in assessing a client's
status after an invasive procedure, fluid volume overload is not a concern
until IV fluids are started.
A nurse evaluates the patency of a peripheral intravenous
(IV) site and suspects an infiltration.
Which does the nurse implement to determine
if the IV has infiltrated?
1 Strips the tubing and assesses for a blood
2 Checks the regional tissue for redness and
3 Increases the infusion rate and observes for
4 Gently palpates regional tissue for edema
Rationale: When assessing an IV for clinical indicators of infiltration, it is
important to assess the site for edema and coolness, signifying leakage of
the IV fluid into the surrounding tissues. Stripping the tubing will not
cause a blood return but will force IV fluid into the surrounding tissues,
which can increase the risk of tissue damage. Redness and warmth are
more likely to indicate infection or phlebitis. Increasing the IV flow rate
can further damage the tissues if the IV has infiltrated. Additionally, a physician's
prescription is needed to increase an IV flow rate
The nurse assesses a peripheral intravenous (IV)
dressing and notes that it is damp and the tape
is loose. The best nursing action is to:
1 Stop the infusion immediately.
2 Apply a sterile, occlusive dressing.
3 Ensure tight IV tubing connections.
4 Remove the IV and insert a new IV.
Rationale: To determine subsequent nursing interventions, the nurse
checks all connections to ensure tight seals while the IV infuses to help
locate the source of the leak. If the leak is at the insertion site, the nurse
stops the infusion, removes the IV, and inserts a new IV catheter. The nurse
applies a new sterile occlusive dressing after resolving the source of the
The nurse understands that which of the following
are clinical indicators for intravenous (IV)
fluids? Select all that apply.
r 1 Syncope episodes
r 2 Bounding pulse rate
r 3 Chronic renal failure
r 4 Rapid, weak, and thready pulse
r 5 Serum electrolyte abnormalities
r 6 Abnormal serum and urine osmolality
Answer: 4, 5, 6
Rationale: Common abnormal assessment findings of major body systems
offer clues to fluid and electrolyte imbalances. Intravenous fluid
and electrolyte therapies are commonly used to correct many fluid and
electrolyte imbalances in the body. Rapid, weak, and thready pulse is a
common assessment abnormality found with fluid and electrolyte imbalances.
Abnormal serum and urine osmolality are laboratory tests that are
helpful in identifying the presence of or risk of fluid, electrolyte, and acidbase
imbalances. Isolated episodes of syncope are not indicators for intravenous
therapy unless fluid and electrolyte imbalances are identified. A
bounding pulse rate is a manifestation of fluid volume excess; therefore
IV fluids are not indicated. Clients with chronic renal failure experience
the inability of the kidneys to regulate the body's water balance; fluid
restrictions may be used.
The nurse caring for a client receiving intravenous
therapy monitors for which signs of infiltration
at the catheter site of an intravenous (IV)
infusion? Select all that apply.
r 1 Slowing of the IV rate
r 2 Tenderness at the insertion site
r 3 Edema around the insertion site
r 4 Skin tightness at the insertion site
r 5 Warmth of skin at the insertion site
r 6 Fluid leaking from the insertion site
Answer: 1, 2, 3, 4, 6
Rationale: Infiltration is the leakage of an IV solution into the extravascular
tissue. Signs and symptoms include slowing of the IV rate; increasing
edema in or around the catheter insertion site; complaints of skin tightness,
burning, tenderness, or general discomfort at the insertion site;
blanching or coolness of the skin; and fluid leaking from the insertion site.
Priority Nursing Tip: Infiltration at an intravenous site produces coolness
of the skin, whereas phlebitis at an intravenous site produces warmth of
The nurse prepares to administer an intravenous
(IV) medication when the nurse notes that
the medication is incompatible with the IV solution.
Which is the best intervention for the
nurse to implement for safe medication
1 Ask the provider to prescribe a compatible
2 Start a new IV catheter for the incompatible
3 Collaborate with the provider for a new administration
4 Flush tubing before and after administering
the medication with normal saline.
Rationale: When giving a medication intravenously, if the medication is
incompatible with the IV solution, the tubing is flushed before and after
the medication with infusions of normal saline to prevent in-line precipitation
of the incompatible agents. Starting a new IV, changing the solution,
or changing the administration route are unnecessary because a
simpler, less risky, viable option exists.
The nurse prepares a client for discharge from
the hospital with a peripheral intravenous
(IV) site for home IV therapy. Which should
the nurse teach the client to help prevent phlebitis
1 Massage the IV site daily.
2 Immobilize the extremity.
3 Stabilize the cannula with tape.
4 Cleanse the site daily with alcohol.
Rationale: Providing IV therapy at home involves the same principles as
are used in the hospital. Protecting the IV site and securing it with tape
are extremely important to ensure that the IV site remains immobile to
reduce the risk of phlebitis and infiltration; however, the extremity does
not need to be immobilized. Massaging the site potentially contributes
to catheter movement and tissue damage. Alcohol skin preparation is used
during the catheter insertion; because of the potential for excessive drying
and client discomfort, alcohol is not used in IV site care. Immobilization
devices such as arm boards are used if a site is near a joint and the IV flow
rate is affected by joint movement.
The nurse assesses the client's peripheral intravenous
(IV) site and notes that it is cool, pale,
swollen, and not infusing. The nurse should
document in the client's record that which
of the following has probably occurred?
Rationale: The infusion stops when the pressure in the tissue exceeds
the pressure in the tubing. The pallor, coolness, and swelling of the IV site
are the result of IV fluid infusing into the subcutaneous tissue. An IV site is
infiltrated when it becomes dislodged from the vein and is lying in
subcutaneous tissue, so the nurse concludes that the IV is infiltrated.
The nurse needs to remove the infiltrated catheter and insert a new IV.
The remaining options are likely to be accompanied by warmth at the site.
Options 1 and 2 also involve the site appearance as reddened.
The nurse prepares to access an implanted vascular
access port. Which should the nurse implement
1 Palpate the vascular port.
2 Anchor the vascular port.
3 Cleanse the site with alcohol.
4 Apply a cool compress to the site.
Rationale: Before accessing an implanted vascular access port, the nurse
must palpate the port to locate the center of the septum because the
nurse needs to know where to insert the needle to avoid more than
one needle stick for the client. The nurse then applies the cool compress
to the insertion site to ease any discomfort that occurs from the needle
stick, cleanses the site with alcohol, anchors the port with the nondominant
hand avoiding contamination of the septum, and accesses the site.
A client receiving parenteral nutrition (PN) via
a central venous catheter (CVC) is scheduled to
receive an intravenous (IV) antibiotic. Which
should the nurse implement before administering
1 Turn off the PN for 30 minutes.
2 Check for compatibility with PN.
3 Ensure a separate IV access route.
4 Flush the CVC with normal saline.
Rationale: The PN line is used only for the administration of the PN solution
to prevent crystallization in the CVC tubing and disruption of
the PN infusion. Any other IV medication must be administered through
a separate IV access site, including a separate infusion port of the CVC
catheter. Therefore options 1, 2, and 4 are incorrect actions.
Priority Nursing Tip: Parenteral nutrition solutions that are cloudy or
darkened should not be used for administration and should be returned
to the pharmacy.
A nurse is planning client and unit activities for
the day. Select the activities that the nurse
should delegate to the nursing assistant. Select
all that apply.
r 1 Deliver fresh water to clients.
r 2 Empty urine out of Foley bags.
r 3 Take temperatures, pulses, respirations,
and blood pressures.
r 4 Count the substance control medications
in the opioid medication supply.
r 5 Check the crash cart (cardiopulmonary resuscitation
cart) for necessary supplies
using a checklist.
r 6 Check all intravenous (IV) solution bags
on clients receiving IV therapy for the
remaining amounts of solution in the
Answer: 1, 2, 3
Rationale: Delegation is the transfer of responsibility for the performance
of an activity or task while retaining accountability for the outcome. When
delegating an activity, the nurse must consider the educational preparation
and experience of the individual. A nursing assistant is trained to perform
noninvasive tasks and those that meet basic client needs. The nursing
assistant is also trained to take vital signs. Therefore the appropriate activities
to assign to the nursing assistant would be to empty urine out of Foley
bags; deliver fresh water to clients; and take temperatures, pulses, respirations,
and blood pressures. Any activities related to medications and IV
therapy must be delegated to a licensed nurse. Although a nursing assistant
is trained in performing cardiopulmonary resuscitation, he or she
is not trained to check a crash cart, and this activity must be assigned to
a licensed nurse.
A nurse is preparing to administer heparin
sodium 5000 units subcutaneously. The nurse
should take which action to safely administer
1 Inject via an infusion device.
2 Inject within 1 inch of the umbilicus.
3 Massage the injection site after administration.
4 Change the needle on the syringe after withdrawing
the medication from the vial.
Rationale: The injection site is located in the abdominal fat layer. Heparin
administered subcutaneously does not require an infusion device. It is not
injected within 2 inches of the umbilicus or into any scar tissue. The needle
is withdrawn rapidly, pressure is applied, and the area is not massaged.
Injection sites are rotated. After withdrawal of heparin from the vial, the
needle is changed before injection to prevent leakage of medication along
the needle tract.
If we had no cell membrane what would happen?
There would be infiltration of good and bad things and eventually the cell would be depleted of all of its resources and die.
Example: border control in this country
If your patient is showing signs and symptoms of stress or crashing, according Miss.Liss what would be one of the first things you do?
Apply oxygen, and call a rapid response.
In which phase of cell division occurs the longest?
interphase cells spend about 90% of their time in interphase. 10% of their time in mitosis depending on the cell
Fact: In cancer cells are flying pass check points and dividing in _______ very often and this can cause tumors
One example where hyperplasia occurs is when a patient is ________ . Is there dna control when this occurs?
Pregnant. During this time women have a release of estrogen which causes the ells of the uterine to multiply at a tremendous rate. Some documents indicate the uterine can increase 500xs in size in order to house a baby
Yes, this means it is typically reversible
Increase in number or density of normal cells.
Response to stress, increased metabolic demands, or elevated levels of hormones.
Cells are under "normal" DNA control.
Cells differentiate into cell types not normally found at that location in the body.
Cells are under normal DNA control and are reversible when the stressor or disruptive condition ceases.
One example where metaplasia occurs is with _____ _______.
Barrettes esophagus. The condition that often starts out with patients who have chronic heart burn that does not get treated. Hydrochloric acid is spilled into the esophagus and the cells are not able to handle the stress that is put on them.
Loss of DNA control over differentiation.
Cells show abnormal variations in size, shape and appearance and arrangement.
An example of this is when a patient first gets diagnosed with cervical cancer but we are able to go in and cut off the cancerous portion
Regression of cell to immature or undifferentiated cell type.
No DNA control
example: full blown cervical cancer. Cells will grow on top of each other and are very unorganized. They defy laws of physics as a cell
In iron deficiency cells will be ______ and _______. where as in vitamin b12 or folic acid deficiency cells will be _____.
hematocrit levels indicate the amount of plasma to red blood cells. What are the normal values for females and males?
(f) 34.9-44.5% ; (m) 38.8-50 %
If a patient is dehydrated what will the hematocrit levels look like? Is this appearance false?
They will look normal or low and this is a false appearance. If they are too hydrated it will be diluted and hematocrit will appear increased
Accepted values of hemoglobin
Adult males: 13.8-18 g/dL
Adult females 12-15 g/dL
When the body senses a decreased level of oxygen where is the blood distributed and why?
To the core and because the sympathetic nervous system kicks in. Heart rate increases. You vaso constrict peripherally causing the patient to feel cool and clammy
due to inadequate pulmonary gas exchange due to high altitudes, drowning, aspiration, respiratory arrest, degenerative lung disease, CO poisoning.
An insufficiency of oxygen in the body's tissues
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