Week 2 EAQ/HESI Flashcards
Working with this physician, you see many patient with anemia. The basic pathophysiology of anemia involves a reduction in:
blood volume
the total number of platelets
the total number of circulating erythrocytes
the total number of circulating leukocytes
the total number of circulating erythrocytes
Knowing that a variety of problems can contribute to the development of anemia, you ask Mrs. Byrd about any history of: Select all that apply
gastric surgery
kidney disease
childhood illnesses
poor nutrition
bleeding episodes
alcohol abuse
gastric surgery
kidney disease
poor nutrition
bleeding episodes
alcohol abuse
Most commonly, anemia is due to _____ deficiency or a result of chronic disease.
iron
An electrocardiogram (ECG) is taken. The severely anemic patient may have which of the following ECG changes?
Widened QRS complex
Sinus bradycardia
ST-segment depression
Presence of Q waves
ST-segment depression
Mrs. Byrd has iron-deficiency anemia. Which of the following questions is pertinent to her diagnosis?
“Do you use artificial sweeteners?”
“Have you ever had diabetes?”
“Are you anxious about anything?”
“Is your tongue sore?”
“Is your tongue sore?”
An inflamed, sore tongue (glossitis) is a symptom of iron-deficiency anemia. Mrs. Byrd admits that her tongue has been sore, and you note that it is red, swollen, and smooth.
Given Mrs. Byrd’s glossitis, which of the following recommendations is appropriate?
Eat soft foods
Restrict fluid intake
Avoid sweet desserts
Drink hot liquids
Eat soft foods
Glossitis is painful. Measures to promote comfort are indicated. Soft foods are non-irritating and should allow for adequate food intake despite an inflamed tongue. Fluid intake should be encouraged. Frozen desserts may offer some relief from the discomfort associated with glossitis. Hot foods and liquids can be irritating and painful on an inflamed tongue and should be avoided.
To prevent injury from dizziness when getting out of bed in the morning, you teach Mrs. Byrd to:
take some quick, deep breaths before getting out of bed
get out of bed slowly
get out of bed quickly
hold her breath when getting out of bed
get out of bed slowly
__________ is a concavity of the nails. It commonly occurs with iron-deficiency anemia.
Spooning
Feosol (ferrous sulfate) is an ______ supplement. It should increase Mrs. Byrd’s hemoglobin levels. Generally, tablets or liquid are prescribed to be taken by mouth three times a day.
iron
As expected, the physician prescribes Feosol (ferrous sulfate). You teach Mrs. Byrd about side effects. These include:
nausea
bradycardia
hypertension
epistaxis
nausea
You teach Mrs. Byrd to take Feosol (ferrous sulfate):
between meals
with an antacid
before going to bed
between meals
Between-meal dosing is preferred for best drug absorption. If GI distress occurs, Feosol (ferrous sulfate) can be taken after meals, although absorption may be decreased if the drug is taken after meals. The liquid form of the drug should be taken well-diluted with water or juice, using a straw, to avoid discoloration of the teeth. Vitamin C (ascorbic acid) found in juice will increase absorption of the Feosol (ferrous sulfate). Absorption of Feosol (ferrous sulfate) is decreased if taken with caffeinated beverages or milk.
To help meet the goal of a normal hemoglobin level, which of the following foods do you encourage Mrs. Byrd to include in her diet?
Pancakes
Eggs
Yogurt
Bananas
Eggs
Egg yolks are a good source of iron. Other sources of iron include liver, oysters, lean meats, kidney beans, spinach, kale, whole wheat bread, and carrots.
Constipation is a common adverse effect of _____ supplement therapy.
iron
It is important to assess Mrs. Byrd for signs and symptoms of iron overdose. These can include:
respiratory depression
abdominal pain
skin rash
intermittent hypertension
abdominal pain
The nurse receives shift report and proceeds to the client’s room, bringing equipment to measure his vital signs. Which vital sign should concern the nurse the most? [Pernicious anemia]
Blood pressure is 142/80 mmHg.
Respiration rate of 24 breaths/minute.
Heart rate of 98 beats/minute.
Pulse oxygenation of 94%.
Blood pressure is 142/80 mmHg.
This elevated blood pressure could indicate an underlying issue that should be addressed.
The nurse asks the client how he is feeling. He reports that he does not have time for this hospitalization. The nurse notes that he seems annoyed. He coughs as he tries to sit up. He turns on the television, focuses on a news station, and ignores the nurse.
Which type of assessment should the nurse perform on the client?
A focused assessment.
A comprehensive assessment.
An emergency assessment.
A psychosocial assessment.
A focused assessment.
This assessment is for evaluating the status of specific previously identified problems and any symptoms of new problems developing.
During the assessment, the nurse suspects that the client may have pernicious anemia. Which pathophysiological process promotes this condition?
Presence of Reed-Sternberg cells.
Diminished total iron-binding capacity.
Destruction of gastric parietal cells.
Inadequate intake of dietary folate.
Destruction of gastric parietal cells.
Pernicious anemia is often associated with chronic gastritis. This is because destruction of gastric parietal cells due to inflammation and cellular hypoxia causes gradual gastric atrophy and a reduction of available intrinsic factor, which is a transporter molecule that is required to promote the bioavailability of vitamin B12.
Which sign or diagnostic result should the nurse expect to observe in a client due to hypokalemia?
An arm tremor while taking the client’s blood pressure.
Hyperactive deep tendon reflexes.
Elevated serum glucose level.
A dampened or flattened T-wave on an electrocardiogram (ECG).
A dampened or flattened T-wave on an electrocardiogram (ECG).
A magnesium deficit is consistent with the client’s assessment findings, and it is commonly associated with chronic _________ use.
alcohol
Which laboratory values should the nurse monitor cautiously before starting (IV) magnesium sulfate 2 mg in 100 mL of 5% dextrose in water?
Blood urea nitrogen (BUN) and serum creatinine levels.
White blood cell (WBC) and red blood cell counts (RBC).
Activated partial thromboplastin time (aPTT).
Hemoglobin (Hb), hematocrit (Hct), and platelet count.
Blood urea nitrogen (BUN) and serum creatinine levels.
If doppler studies are negative and a DVT is still suspected, a ___________ may be needed to make accurate diagonis.
venogram
The incoming nurse notices which cue as the cause of observable hematuria in the client’s urinary catheter?
The IV pump infusing at a higher rate than prescribed.
The HCP prescribes a lower rate than recommended.
The day shift nurse reported lowering the rate of infusion prior to shift change.
The urinary catheter bag hangs from the side bedrail.
The IV pump infusing at a higher rate than prescribed.
After consulting with the HCP, the nurse is to administer a heparin antagonist. The nurse explains to the client that protamine sulfate is being administered to obtain which expected outcome?
Neutralize blood clots.
Reduce hematuria.
Prevent blood clots.
Avoid strokes.
Reduce hematuria.
Another less common complication of heparin therapy is Heparin Induced Thrombocytopenia (HIT). What if the client develops fever and chills? Based on these cues, the nurse recognizes that it is essential to obtain which information first?
Platelet count.
. White blood cell count (WBC).
Renal function tests.
Client’s fluid intake and output.
Platelet count.
To detect HIT, observe the client for decreasing platelet count, skin lesions at the injection site, and systemic reactions such as chills and fever.
Which action can be delegated by the nurse to the UAP?
Assess skin for bruising.
Teach the client to use a soft toothbrush.
Review the side effect of anticoagulants.
Obtain stool specimen for guaiac.
Obtain stool specimen for guaiac.
With a diagnosis of pneumonia, which assessment finding warrants immediate intervention by the nurse?
Oxygen saturation 90%.
Blood pressure (BP) 132/78 mmHg.
Heart rate 120 beats/minute.
Inelastic skin turgor.
Oxygen saturation 90%.
____ pH indicates that acidosis is present.
Low
Which nursing action should be implemented before the prescribed levofloxacin is administered?
Auscultate lung sounds.
Assess oral intake.
Obtain a sputum culture with sensitivity.
Assist client to the bathroom.
Obtain a sputum culture with sensitivity.
While the client is undergoing nebulizer treatments with albuterol, which assessment is it most important for the nurse to perform?
Monitor pulse oximeter readings.
Monitor respiratory rate.
Monitor pulse and blood pressure.
Monitor temperature.
Monitor pulse and blood pressure.
The triad of treatment for a client experiencing a ____________ crisis is: hydration, pain management, and oxygenation
sickle cell
