Iggy Ch 36 Questions Flashcards
Which symptom reported by a client suggests to the nurse that anemia is a possibility?
a) Chronic headaches
b) Shortness of breath
c) Cold hands and feet
d) Difficulty sleeping
b) Shortness of breath
Shortness of breath is very common with anemia because the blood is not efficient at providing enough oxygen. Thus, to maintain adequate oxygenation to tissues, the person has to increase his or her respiratory rate. Although cold hands/feet and headaches are associated with anemia, these symptoms are not specific enough to suggest anemia.
What is the nurse’s best response when a client with anemia asks “Why am I feeling tired all the time?”
a) “Your brain is not getting enough oxygen.”
b) “How many hours are you sleeping at night?”
c) “You are probably dehydrated.”
d) “When you are sick, you need to rest more.”
a) “Your brain is not getting enough oxygen.”
The nurse’s best response to the client complaining about feeling tired all the time is “Your cells are delivering less oxygen than you need.” The single most common symptom of anemia is fatigue, which occurs because oxygen delivery to cells is less than is required to meet normal oxygen needs.
Which assessment question is most relevant for the nurse to ask a client on warfarin therapy whose international normalized ratio (INR) is 0.6?
a) “What types of dairy products do you consume on a regular basis?
b) “Have you noticed any bleeding from your gums after brushing or flossing?
c) “How many salads and raw vegetables do you eat per week?
d) “Do you or any member of your family have frequent nose bleeds or bruising?
c) “How many salads and raw vegetables do you eat per week?
The normal INR ranges between 0.8 and 1.1 times the normal control. Lower INRs are associated with an increased risk for clotting. Clients on warfarin therapy, which is a vitamin K antagonist, are expected to have INRs between 2.0 and 3.0 depending on why anticoagulation is needed. Increased vitamin K intake, which is found in raw, leafy green vegetables, reduces the effectiveness of this drug.
How will the nurse interpret a client’s laboratory finding of an increased total iron-binding capacity (TIBC)?
a) Increased risk for clot formation
b) Deficient circulating and stored iron levels
c) Iron excess
d) Decreased bone marrow function
b) Deficient circulating and stored iron levels
TIBC measures how much iron could be bound to transferrin. When this value increases, a client is deficient in serum iron and stored iron levels, and less is bound to the transferrin.
Changes in TIBC do not reflect actual bone marrow function. Clot formation does not increase with higher TIBC.
Which client laboratory trend indicates to the nurse that the prescribed erythropoietin therapy is effective?
a) Rising reticulocyte count
b) Rising platelet count
c) Decreasing albumin levels
d) Decreasing white blood cell count
a) Rising reticulocyte count
Erythropoietin stimulates the bone marrow to produce more new red blood cells. A rising reticulocyte count reflects bone marrow release of new and less mature erythrocytes.
Why does an abnormally low erythrocyte count reduce gas exchange?
a) Pulmonary ventilation is reduced.
b) Circulation to the peripheral tissues is reduced.
c) Blood flow is obstructed from increased clot formation.
d) Peripheral oxygen transport is reduced.
d) Peripheral oxygen transport is reduced.
The major component of erythrocytes is hemoglobin, which is responsible for transporting oxygen through the blood to the tissues for tissue gas exchange. Fewer erythrocytes result in decreased oxygen transport although circulation to the peripheral tissues is unaffected.
Clot formation is not increased, and pulmonary ventilation (movement of atmospheric air into and out from the lungs) is not affected.
Why does an abnormally low erythrocyte count reduce gas exchange?
a) Pulmonary ventilation is reduced.
b) Circulation to the peripheral tissues is reduced.
c) Blood flow is obstructed from increased clot formation.
d) Peripheral oxygen transport is reduced.
d) Peripheral oxygen transport is reduced.
The major component of erythrocytes is hemoglobin, which is responsible for transporting oxygen through the blood to the tissues for tissue gas exchange. Fewer erythrocytes result in decreased oxygen transport although circulation to the peripheral tissues is unaffected.
Clot formation is not increased, and pulmonary ventilation (movement of atmospheric air into and out from the lungs) is not affected.
Which body area on a client with darker skin is most appropriate for the nurse to examine for indications of pallor and cyanosis?
a) Earlobes and bridge of the nose
b) Palms and soles
c) Conjunctiva of the eyes
d) Tongue
c) Conjunctiva of the eyes
Pallor and cyanosis are more easily detected in adults with darker skin by examining the oral mucous membranes and the conjunctiva of the eye, not the palms of the hands or soles of the feet (although petechiae may be more apparent there). The tongue is a poor indicator of pallor or cyanosis although changes in texture and color may indicate other hematology problems.
Which question will the nurse ask to assess a client’s endurance in performing ADLs?
a) “Do you usually eat supper at home or at a restaurant?”
b) “How would you rate your energy level compared with last year?”
c) “What medications do you take daily, weekly, and monthly?”
d) “Have you lost any weight this past year?”
“How would you rate your energy level compared with last year?”
The question the nurse needs to ask the client about endurance in performing ADLs is “How is your energy level compared with last year”? Asking the client how his or her energy level compares with last year is an activity exercise question that correctly assesses endurance compared with self-assessment in the past. None of the other questions are specific to assessment of a client’s endurance.
