Chapter 33 Flashcards
The nurse is caring for a client with anemia who is experiencing increased fatigue and occasional palpitations at rest. Which of the following laboratory findings should the nurse expect?
a. Normal red blood cell (RBC) indices
b. Hematocrit (Hct) of 38%
c. Hemoglobin (Hb) of 86 g/L
d. RBC count of 4.5 ́ 1012/L
C
The client’s clinical manifestations indicate moderate anemia, which is consistent with an Hb of 60–100 g/L. The other values are all within the range of normal.
Which of the following menu choices indicate that the client understands the nurse’s teaching about best dietary choices for iron-deficiency anemia?
a. Omelette and whole wheat toast
b. Cantaloupe and cottage cheese
c. Strawberry and banana fruit plate
d. Cornmeal muffin and orange juice
A
Eggs and whole grain breads are high in iron. The other choices are appropriate for other nutritional deficiencies, but are not the best choice for a client with iron-deficiency anemia.
The nurse is caring for a client who is receiving methotrexate and develops a megaloblastic anemia. Which of the following nutrients should the nurse include in the teaching plan?
a. Iron
b. Folic acid
c. Cobalamin (vitamin B12)
d. Ascorbic acid (vitamin C)
B
Methotrexate use can lead to folic acid deficiency. Supplementation with oral folic acid supplements is the usual treatment. The other nutrients would not correct folic acid deficiency, although they would be used to treat other types of anemia.
The nurse is teaching a client with a new diagnosis of pernicious anemia about the disorder. Which of the following client statements indicates that the teaching has been effective?
a. “I need to start eating more red meat or liver.”
b. “I will stop having a glass of wine with dinner.”
c. “I will need to take a proton pump inhibitor like omeprazole.”
d. “I would rather use the nasal spray than have to get injections of vitamin B12.”
D
Since pernicious anemia prevents the absorption of vitamin B12, this client requires injections or intranasal administration of cobalamin. Alcohol use does not cause cobalamin deficiency. Proton pump inhibitors decrease the absorption of vitamin B12. Eating more foods rich in vitamin B12 is not helpful because the lack of intrinsic factor prevents absorption of the vitamin.
The nurse is caring for a client who is hospitalized for treatment of severe hemolytic anemia. Which of the following actions should the nurse implement?
a. Provide a diet high in vitamin K.
b. Place the client on protective isolation.
c. Alternate periods of rest and activity.
d. Teach the client how to avoid injury.
C
Nursing care for clients with anemia should alternate periods of rest and activity to encourage activity without causing undue fatigue. There is no indication that the client has a bleeding disorder, so a high vitamin K diet or teaching about how to avoid injury is not needed. Protective isolation might be used for a client with aplastic anemia, but it is not indicated for hemolytic anemia.
The nurse has finished teaching a client about taking oral ferrous sulphate. Which of the following client statements indicates that additional instruction is needed?
a. “I will call the doctor if my stools start to turn black.”
b. “I will take a stool softener if I feel constipated occasionally.”
c. “I should take the iron with orange juice about an hour before eating.”
d. “I should increase my fluid and fibre intake while I am taking the iron tablets.”
A
It is normal for the stools to appear black when a client is taking iron and the client should not call the doctor about this. The other client statements are correct.
The nurse is caring for a client with idiopathic aplastic anemia. Which of the following collaborative problems should the nurse include when developing the care plan?
a. Potential complication: seizures
b. Potential complication: infection
c. Potential complication: neurogenic shock
d. Potential complication: pulmonary edema
B
Because the client with aplastic anemia has pancytopenia, the client is at risk for infection and bleeding. There is no increased risk for seizures, neurogenic shock, or pulmonary edema.
The nurse is caring for a client with a sickle cell crisis. While caring for the client during the crisis, which of the following actions is priority?
a. Limit the client’s intake of oral and IV fluids.
b. Evaluate the effectiveness of opioid analgesics.
c. Encourage the client to ambulate as much as tolerated.
d. Teach the client about high-protein, high-calorie food
B
Pain is the most common clinical manifestation of a crisis and usually requires large doses of continuous opioids for control. Fluid intake should be increased to reduce blood viscosity and improve perfusion. Rest is usually ordered to decrease metabolic requirements. Clients are instructed about the need for dietary folic acid, but high-protein, high-calorie diets are not emphasized.
Which of the following statements by a client with sickle cell anemia indicates good understanding of the nurse’s teaching about prevention of sickle cell crisis?
a. “Home oxygen therapy is frequently used to decrease sickling.”
b. “There are no effective medications that can help prevent sickling.”
c. “Routine continuous dosage narcotics are prescribed to prevent a crisis.”
d. “Risk for a crisis can be lowered by having an annual influenza vaccination.”
D
Since infection is the most common cause of a sickle cell crisis, influenza, Haemophilus influenzae, pneumococcal pneumonia, and hepatitis immunizations should be administered. Although continuous dose opioids and oxygen may be administered during a crisis, clients do not receive these therapies to prevent crisis. Hydroxyurea is used for many clients to decrease the number of sickle cell crises.
The nurse is planning discharge teaching for a client who was admitted with neutropenia. Which of the following instructions should the nurse include?
a. Limit fluids to 2–3 litres a day.
b. Include eggs and fish in the diet.
c. Avoid exposure to crowds as much as possible.
d. Drink only one or two caffeinated beverages daily.
C
Exposure to crowds increases the client’s risk for infection and should be avoided for the client with neutropenia. There is no restriction on caffeine use. Iron supplementation is generally not recommended. A high-fluid intake is recommended. Eggs and seafood are to be avoided.
The nurse is admitting a client with hemolytic anemia and notes jaundice of the sclerae. Which of the following laboratory results should the nurse assess?
a. Schilling test
b. Bilirubin level
c. Stool occult blood test
d. Gastric analysis testing
B
Jaundice is caused by the elevation of bilirubin level associated with red blood cell (RBC) hemolysis. The other tests would not be helpful in monitoring or treating a hemolytic anemia.
The nurse is caring for a client who has been receiving a heparin infusion and warfarin for a deep vein thrombosis (DVT) with a diagnosis of heparin-induced thrombo-cytopenia (HIT). Which of the following actions should the nurse include in the plan of care?
a. Use low-molecular-weight heparin (LMWH) only.
b. Flush all intermittent IV lines using normal saline.
c. Administer the warfarin at the scheduled time.
d. Teach the client about the purpose of platelet transfusions.
B
All heparin is discontinued when the HIT is diagnosed. The client should be instructed to never receive heparin or LMWH. Warfarin is usually not given until the platelet count has returned to 150 ́ 109/L. The platelet count does not drop low enough in HIT for a platelet transfusion, and platelet transfusions increase the risk for thrombosis.
The nurse is caring for a client with an acute exacerbation of polycythemia vera. Which of the following actions should the nurse implement during treatment?
a. Place the client on bed rest.
b. Administer iron supplements.
c. Avoid use of Aspirin products.
d. Monitor fluid intake and out
D
Monitoring hydration status is important during an acute exacerbation because the client is at risk for fluid overload or underhydration. Aspirin therapy is used to decrease risk for thrombosis. The client should be encouraged to ambulate to prevent deep vein thrombosis (DVT). Iron is contraindicated in clients with polycythemia vera.
Which of the following nursing interventions should be included in the care plan for a client with immune thrombo-cytopenic purpura (ITP)?
a. Assign the client to a private room.
b. Avoid intramuscular (IM) injections.
c. Use rinses rather than a toothbrush for oral care.
d. Restrict activity to passive and active range of motion.
B
IM or subcutaneous injections should be avoided because of the risk for bleeding. A soft toothbrush can be used for oral care. There is no need to restrict activity or place the client in a private room.
Which of the following laboratory information should the nurse monitor to detect heparin-induced thrombo-cytopenia (HIT) in a client who is receiving a continuous heparin infusion?
a. Prothrombin time
b. Erythrocyte count
c. Fibrinogen degradation products
d. Activated partial thromboplastin time
D
Platelet aggregation in HIT causes neutralization of heparin so that the activated partial thromboplastin time will be shorter and more heparin will be needed to maintain therapeutic levels. The other data will not be affected by HIT.
The nurse is admitting a client with type A hemophilia who has severe pain and swelling in the right knee. Which of the following actions should the nurse implement initially?
a. Immobilize the knee
b. Apply heat to the joint
c. Assist the client with light weight bearing
d. Perform passive range of motion to the knee
A
The initial action should be total rest of the knee to minimize bleeding. Ice packs are used to decrease bleeding. Range of motion (ROM) and weight-bearing exercise are contraindicated initially, but after the bleeding stops, ROM and physical therapy are started.
The nurse is caring for a client with von Willebrand disease who is admitted to the hospital for minor knee surgery. Which of the following laboratory information should the nurse assess?
a. Platelet count
b. Bleeding time
c. Thrombin time
d. Prothrombin time
B
The bleeding time is affected by von Willebrand disease. Platelet count, prothrombin time, and thrombin time are normal in von Willebrand disease.
A routine complete blood count indicates that a client may have myelodysplastic syndrome. At this time, which of the following information should the nurse include in the teaching plan?
a. Packed red blood cells (PRBCs) transfusion
b. Bone marrow biopsy
c. Filgrastim administration
d. Erythropoietin administration
B
Bone marrow biopsy is needed to make the diagnosis and determine the specific type of myelodysplastic syndrome. The other treatments may be necessary if there is progression of the myelodysplastic syndrome, but the initial action for this asymptomatic client will be a bone marrow biopsy.
Which of the following actions should the nurse include in the care plan for a hospitalized client who is neutropenic?
a. Avoid any IM or subcutaneous injections.
b. Check the oral temperature every 4 hours.
c. Omit all fruits or vegetables from the diet.
d. Place a “No Visitors” sign on the client door.
B
The earliest sign of infection in a neutropenic client is an elevation in temperature. Although unpeeled fresh fruits and vegetables should be avoided, fruits and vegetables that are peeled or cooked are acceptable. Injections may be required for administration of medications such as filgrastim. The number of visitors may be limited and visitors with communicable diseases should be avoided, but a “no visitors” policy is not needed.
Which of the following laboratory tests should the nurse use to determine whether the prescribed filgrastim is effective in the treatment of a client who is receiving chemotherapy for acute lymphocytic leukemia?
a. Platelet count
b. Reticulocyte count
c. Total lymphocyte count
d. Absolute neutrophil count
D
Filgrastim increases the neutrophil count and function in neutropenic clients. Although total lymphocyte, platelet, and reticulocyte counts also are important to monitor in this client, the absolute neutrophil count is used to evaluate the effects of filgrastim.
The nurse is caring for a client with acute myelogenous leukemia (AML) who has induction therapy prescribed and the client asks the nurse whether the planned chemotherapy will be worth undergoing. Which of the following responses by the nurse is best?
a. “If you do not want to have chemotherapy, there are other options for treatment such as stem cell transplantation.”
b. “The decision about chemotherapy is one that you and the doctor need to make rather than asking what I would do.”
c. “You don’t need to make a decision about treatment right now since leukemias in adults tend to progress quite slowly.”
d. “The adverse effects of the chemotherapy are difficult, but AML frequently does go into remission with chemotherapy.”
D
This response uses therapeutic communication by addressing the client’s question and giving accurate information. The other responses either give inaccurate information or fail to address the client’s question, which will discourage the client from asking the nurse for information.
The nurse is caring for a client who has a history of a transfusion-related acute lung injury (TRALI) and is to receive a transfusion of packed red blood cells (PRBCs). Which of the following actions should the nurse take to decrease the risk for TRALI for this client?
a. Infuse the PRBCs slowly over 4 hours.
b. Transfuse only leukocyte-reduced PRBCs.
c. Administer the scheduled oral diuretic before the transfusion.
d. Give the PRN dose of antihistamine before starting the transfusion.
B
TRALI is caused by a reaction between the donor and the client leukocytes that causes pulmonary inflammation and capillary leaking. The other actions may help prevent respiratory problems caused by circulatory overload or by allergic reactions, but they will not prevent TRALI.
The nurse is caring for a client with acute myelogenous leukemia (AML) who is considering the possibility of treatment with a hematopoietic stem cell transplant (HSCT). Which of the following actions is best for the nurse to implement to assist the client with treatment decisions?
a. Emphasize the positive outcomes of a bone marrow transplant.
b. Discuss the need for adequate insurance to cover post-HSCT care.
c. Ask the client whether there are any questions or concerns about HSCT.
d. Explain that a cure is not possible with any other treatment except HSCT.
C
Offering the client an opportunity to ask questions or discuss concerns about HSCT will encourage the client to voice concerns about this treatment and also will allow the nurse to assess whether the client needs more information about the procedure. Treatment of AML using chemotherapy is another option for the client. It is not appropriate for the nurse to ask the client to consider insurance needs in making this decision.
Which of the following nursing actions should the nurse include in the plan of care for a client admitted with multiple myeloma?
a. Monitor fluid intake and output.
b. Administer calcium supplements.
c. Assess lymph nodes for enlargement.
d. Limit weight bearing and ambulation.
A
A high fluid intake and urine output helps prevent the complications of kidney stones caused by hypercalcemia and renal failure caused by deposition of Bence Jones protein in the renal tubules. Weight bearing and ambulation are encouraged to help bone retain calcium. Lymph nodes are not enlarged with multiple myeloma. Calcium supplements will further increase the client’s calcium level and are not used.
