EXAM 4 Part 2

Question 1

Which clinical finding by the nurse is considered normal in the older adult client?

1. A hemoglobin of 10 g/dL two days post-joint replacement
2. Reports of the hands and feet feeling extremely warm
3. Skin tear with bruising, re-bleeding, and prolonged healing time
4. Poor or weak pulse amplitude in bilateral lower extremities

Answer 1

1

Red blood cell reserve and replacement is slower in the older adult client. Anemia after joint surgery is sometimes increased and prolonged. Transfusions are done for symptomatic clients.

Question 2

While completing an assessment the nurse is concerned that an older client is experiencing anemia. Which findings are most concerning for anemia? Select all that apply.

1. Pale, cool, and dry skin
2. Diffuse joint and bone pain
3. Decreased interest in meals
4. Heart rate 112 beats/minute
5. Dyspnea on exertion

Answer 2

2,3,4,5

Question 3

An older client with chronic renal failure and weekly dialysis has anemia. Which intervention is most important for the nurse to implement for this client?

1. Frequent blood pressure assessment
2. Erythropoietin injection
3. Administer ferrous sulfate orally
4. Monitor for hematuria

Answer 3

2

Anemia associated with renal failure is related to the loss of erythropoietin, which is produced by the healthy kidney and stimulates bone marrow to produce red blood cells. Erythropoietin is replaced via injection on a regular basis for those with renal insufficiency.

Question 4

An older client is diagnosed with hemolytic anemia. What will the nurse teach the client about this disorder?

1. It is caused by blood loss.
2. It will be treated with folic acid.
3. It causes the red blood cells to be misshaped.
4. It is associated with decreased immature red blood cells.

Answer 4

2

Question 5

Which finding most concerns the nurse that the client has pernicious anemia?

1. The client takes a daily antacid tablet.
2. Report of tingling and hand clumsiness
3. B12 level 300 pg/mL
4. Bowel movement frequency is every three days.

Answer 5

2

Symptoms of B12 (cobalamin) deficiency include neuropathies, paresthesias, and cognitive impairment. MCV will be greater than 100 fL and B12 level will be less than 150 pg/mL for most clients with pernicious anemia.

Question 6

What are the most concerning assessment findings in an older client with a suspected vitamin B12 deficiency? Select all that apply.

1. Unintentional weight loss of ten pounds in three months
2. Progressive inability to walk safely without assistance
3. Nausea that prevents eating breakfast
4. Inability to state where they are or what day it is
5. Tingling in the feet and numbness in the hands

Answer 6

2,4,5

Question 7

An older client is prescribed a blood transfusion of two units packed red blood cells. What should the nurse do when providing the blood to this client? Select all that apply.

1. Place the client on a heart monitor.
2. Administer each unit over two to four hours.
3. Provide a diuretic between the two units as prescribed.
4. Carefully assess the intravenous access site for infiltration.
5. Monitor vital signs and urine output during the transfusion.

Answer 7

2,3,4,5

Question 8

The healthcare provider determines that an older client, who takes daily aspirin, is at risk for a stroke. Which finding causes the nurse to contact the healthcare provider?

1. The client has a previously undisclosed distant history of myocardial infarction.
2. The client reports stools are occurring more frequently and are darker than normal.
3. Ferrous sulfate is on the client’s home medication list but is not currently prescribed.
4. Low-molecular-weight heparin therapy is prescribed by a different healthcare provider.

Answer 8

2

Question 9

The nurse cares for an admitted client to rule out a multiple myeloma diagnosis. Which finding does the nurse report to the healthcare provider immediately?

1. Positive Bence Jones protein
2. Bone pain in the lower ribs
3. Hemoglobin level is decreased to 11 g/dL
4. Blood Urea Nitrogen changed from 20 mg/dL to 48 mg/dL

Answer 9

4

Renal failure is a serious complication of multiple myeloma and must be treated aggressively. Initially, fluids and diuretics may be used. Dialysis may be required later.

Question 10

An older client is diagnosed with thalassemia. How will the nurse instruct the client about this diagnosis? Select all that apply.

1. There is no specific treatment.
2. Iron therapy is the best treatment.
3. A folate supplement may be prescribed.
4. Sulfonamides might need to be avoided.
5. It is an inherited disorder that can go undiagnosed until later in life.

Answer 10

1,3,5

Question 11

A client is prescribed warfarin for chronic atrial fibrillation. Which laboratory value is most concerning to the nurse?

1. Platelet count 130,000/microliter
2. Hematocrit level 31%
3. Partial thromboplastin time (PTT) 38 seconds
4. International normalized ratio (INR) 2.8

Answer 11

2

With no other obvious cause for bleeding and no relevant history, the client on an anticoagulant should not experience anemia. This finding is concerning for the possibility of unseen bleeding. The nurse assesses for other manifestations of blood loss and ensures the healthcare provider is aware.

Question 12

The nurse has completed a physical assessment on an older client. Which new assessment finding is most concerning for the presence of deep-venous thrombosis?

1. Unequal, palpable pedal pulses
2. Shortness of breath after activity
3. Swelling in one leg with pitting edema
4. Bilateral calf pain after walking up a flight of stairs

Answer 12

3

Question 13

An older client receiving warfarin, with alternating doses of 2.5 mg and 5 mg, has an INR of 6.3. What are the immediate nursing interventions for this client? Select all that apply.

1. Prepare to begin a heparin infusion.
2. Administer vitamin K as prescribed.
3. Evaluate liver function tests.
4. Withhold the next warfarin dose.
5. Determine if there is a recent type and crossmatch

Answer 13

2,4,5

Question 14

An older client is diagnosed with polycythemia vera and has a hematocrit of 58%. Which interventions are most important for the nurse to implement? Select all that apply.

1. Evaluate for activity intolerance
2. Assess for hypervolemia
3. Administer hydroxyurea
4. Assess for hypertension
5. Arrange for phlebotomy

Answer 14

2,3,4

Question 15

The client is admitted to rule out a diagnosis of non-Hodgkin’s lymphoma. Which assessment finding best indicates to the nurse that an older adult client has non-Hodgkin’s lymphoma?

1. Pitting edema bilaterally
2. Difficulty with walking
3. Severe bone pain in the lower back
4. Diffuse lymph node enlargement

Answer 15

4

Question 16

The nurse cares for a client with multiple myeloma. Which assessment finding is the priority for the nurse to report to the healthcare provider?

1. Pain 4/10 after intravenous morphine dose
2. Mild intermittent confusion and drowsiness
3. Moderate joint pain and erythema
4. Overnight diaphoresis requiring a bed change

Answer 16

4

Question 17

An older client is experiencing acute liver failure. Which laboratory findings are most closely related to this condition? Select all that apply.

1. Elevated INR
2. Decreased hematocrit and hemoglobin
3. Elevated serum ferritin
4. Decreased platelet count
5. Elevated white blood cell count

Answer 17

1,3

Question 18

The nurse is caring for an older adult client with chronic renal failure who is scheduled for dialysis in two hours. Which finding is most concerning?

1. Hematocrit 58%
2. Platelet count 99,000/microliter
3. Diffuse pulmonary crackles
4. Increased jugular venous distention

Answer 18

1

Chronic renal failure results in a two-fold increase in the chance of being diagnosed with anemia. Erythropoietin (EPO), a hormone the body normally makes with functioning kidneys, is often given for this. A hematocrit or hemoglobin above normal places the client at risk for stroke or myocardial infarction. This level is 20% above normal. The EPO injections must be temporarily held.

Question 19

The nurse provides discharge teaching to an older client diagnosed with iron deficiency anemia. Which statement by the client best indicates the client understands the teaching?

1. “I will take my ferrous sulfate tablet with lunch or dinner.”
2. “An appointment for lab work is scheduled in 2 weeks and again in 2 months.”
3. “I will eat oatmeal with milk for breakfast while I am on ferrous sulfate.”
4. “Increasing my fluid intake by drinking mostly fruit juice is helpful.”

Answer 19

2

Labs are done in 1-2 weeks and at 2 months to ensure the therapy is having the desired effect.

Question 20

The nurse is preparing an educational program on hemolytic anemia for the residents of an assisted living center. Which potential causes should the nurse include in the program? Select all that apply.

1. Chronic steroid therapy
2. Prolonged jaundice
3. Cephalosporin antibiotics
4. Exposure to toxic chemicals
5. Prosthetic heart valve placement

Answer 20

3,4,5

Question 21

An older client is prescribed warfarin. What will the nurse include when teaching the client about this medication?

1. Alcohol intake must be done on a regular basis, if at all.
2. Do not take any medications with aspirin or acetaminophen.
3. Dietary supplements can be continued when taking this medication.
4. Ensure that you have safety bars and non-skid carpeting in your home.

Answer 21

4

Clients with demonstrated fall risk must not be prescribed warfarin due to risk of brain hemorrhage. Because hepatic clearance is reduced in this client, the dose is begun slowly and titrated as needed. Additionally, the healthcare provider will continue to assess the client’s fall risk during this time.

Question 22

The nurse provides discharge teaching to an older client recovering from deep vein thrombosis. Which client statement best indicates that teaching has been effective?

1. “I will increase my fluid intake to include tea and juice.”
2. “I should wear a compression hose at all times.”
3. “I will take my medication every day as prescribed.”
4. “I will only cross my legs when reading after dinner.”

Answer 22

3

Question 23

An older client recovering from a total hip replacement is demonstrating edema and pain in the operative limb. Which intervention does the nurse perform first?

1. Assess the client’s lower extremity pulses.
2. Situate the client comfortably with pillows.
3. Evaluate the client’s respiratory status.
4. Determine if anticoagulant medication is prescribed.

Answer 23

1

Question 24

The nurse is planning an inservice for nursing assistive personnel on ways to prevent the development of deep vein thrombosis (DVT) in older clients. Which information must the nurse include in this presentation? Select all that apply.

1. Turn bed-bound clients and perform range-of-motion exercises.
2. Clients should be assisted to walk frequently when they are able.
3. Remind clients to ambulate short distances to avoid fatigue.
4. Apply fitted support stockings to older clients as prescribed.
5. Assist older clients to walk as soon as possible after surgery.

Answer 24

1,2,4,5

Question 25

An older client with a history of peptic ulcer disease is diagnosed with a vitamin B12 deficiency. What must the nurse teach the client?

1. Pay close attention when using hot water, handling hot surfaces, and while cooking.
2. Be alert to cognitive changes, memory impairment, and depression symptoms.
3. Blood work will need to be done in the doctor’s office frequently to check for anemia.
4. Medications used to treat peptic ulcer disease can block the absorption of vitamins.

Answer 25

1

Paresthesias and neuropathies can result in burns if the client is not cautious while performing cooking-related tasks in particular. This is a safety issue.