1.
1. Position the client in a side-lying position.
2. Clean the skin with an antiseptic solution.
4. Apply ice to the biopsy site.
3. Verify the client has signed an informed consent.
First, the nurse must verify that the client has vol- untarily signed a consent form before the procedure begins, and check that the client understands the procedure. The nurse then positions the client in a side-lying, or lateral decubitus, position with the affected side up. Then the nurse should clean the skin site and surrounding area with an antiseptic solution such as Betadine before the health care provider numbs the site and collects the specimen.
When the procedure is fi nished, the nurse must apply ice to the biopsy site to reduce pain.
CN: Management of care; CL: Synthesize
2.
1, 2, 5. Nausea and vomiting are common adverse effects of oral iron preparations. The nurse should fi rst ask the client why she does not want to take the oral medication, and then suggest ways to decrease the nausea and vomiting. Ginger may help minimize the nausea and the client can try this remedy and evaluate its effectiveness. Iron should be taken on an empty stomach but can be taken with orange juice. The client can evaluate if this helps the nausea. Stool softeners should not be used in clients with iron defi ciency anemia. Instead, constipation can be prevented by following a high-fi ber diet.Administering iron intramuscularly is done only if other approaches are not effective.
CN: Health promotion and maintenance;
CL: Synthesize
Managing Care Quality and Safety
119.
A nurse has two clients that have an order to receive a blood transfusion of packed red blood cells at the same time. The fi rst client’s blood pressure dropped from the preoperative value of 120/80 mm Hg to a postoperative value of 100/50. The second client is 58 years old and is hospitalized because he developed dehydration and anemia following pneu- monia. After checking the patency of their I.V. lines and vital signs, which should the nurse do next?■ 1. Call for both clients’ blood transfusions at the same time.
■ 2. Ask another nurse to verify the compatibility of both units at the same time.
■ 3. Call for and hang the fi rst client’s blood transfusion.
■ 4. Ask another nurse to call for and hang the blood for the second client.
120.
When a blood transfusion is terminated fol- lowing a reaction, the nurse must do which of the following? Select all that apply.■ 1. Send freshly-collected urine samples to the laboratory.
■ 2. Return the remainder of the blood component unit to the blood bank.
■ 3. Return the intravenous administration set to the blood bank.
■ 4. Alert Risk Management about the incident.
■ 5. Report the incident to the Infection Control Manager.
121.
The nurse is administering a medication to a client with myeloid leukemia and does not know the use, dose, or side effects. To obtain the most up-to-date information about this drug, the nurse should:■ 1. Check the Physician’s Drug Reference (PDR) at the nurses’ station.
■ 2. Obtain a pharmacology textbook from the hospital library.
■ 3. Consult the drug guide provided by the hos- pital on the nurses’ PDA.
■ 4. Review information at the drug manufactur- er’s website.
122.
The charge nurse on a hematology/oncology unit is reviewing the policy for using abbreviations with the staff. The charge nurse should emphasize which of the following about why dangerous abbre- viations need to be eliminated? Select all that apply.■ 1. To ensure effi cient and accurate communica- tion.
■ 2. To prevent medication errors.
■ 3. To ensure client safety.
■ 4. To make it easier for clients to understand the medication orders.
■ 5. To make data entry into a computerized health record easier.
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acid level in the presence of a normal vitamin B12 level is indicative of a primary folic acid defi ciency anemia. Factors that affect the absorption of folic acid are drugs such as methotrexate, oral contra- ceptives, antiseizure drugs, and alcohol. The total bilirubin, serum creatinine, and hemoglobin values are within normal limits.
CN: Physiological adaptation;
CL: Analyze
9.
2. The defi ning characteristic of pernicious anemia, a megaloblastic anemia, is lack of the intrinsic factor which results from atrophy of the stomach wall. Without the intrinsic factor, vitamin B12 cannot be absorbed in the small intestine and folic acid needs vitamin B12 for deoxyribonucleic acid synthesis of RBCs. The gastric analysis is done to determine the primary cause of the anemia. An elevated excretion of the injected radioactive vita- min B12, which is protocol for the fi rst and second stage of the Schilling test, indicates that the cli- ent has the intrinsic factor and can absorb vitamin B12 in the intestinal tract. A sedimentation rate of 16 mm/hour is normal for both men and women and is a nonspecifi c test to detect the presence of infl ammation; it is not specifi c to anemias. An RBC value within the normal range does not indicate an anemia.CN: Physiological adaptation;
CL: Synthesize
10.
2. Clients with aplastic anemia are severely immunocompromised and at risk for infection and possible death related to bone marrow suppression and pancytopenia. Strict aseptic technique and reverse isolation are important measures to prevent infection. Although diet, reduced stress, and rest are valued in supporting health, the potentially fatal consequence of an acute infection places it as a priority for teaching the client about health mainte- nance. Animal meat and dark green leafy vegetables, good sources of vitamin B12 and folic acid, should be included in the daily diet. Yoga and meditation are good complementary therapies to reduce stress.Eight hours of rest and naps are good for spacing and pacing activity and rest.
CN: Reduction of risk potential;
CL: Synthesize
11.
4. Vitamin B12 combines with intrinsic fac- tor in the stomach and is then carried to the ileum, where it is absorbed into the bloodstream. In this situation, vitamin B12 cannot be absorbed regardless of the amount of oral intake of sources of vitamin B12, such as animal protein or vitamin B12 tab- lets. Vitamin B12 needs to be injected every month because the ileum has been surgically removed.Replacement of fl uids and electrolytes is impor- tant when the client has continuous multiple loose
3.
1. This client is likely experiencing fatigue and should increase her periods of rest. The fatigue may be caused by anemia from depletion of red blood cells due to the chemotherapy. Asking the client to limit her activities may cause the client to become withdrawn. The information given does not support limiting activity. Increasing fl uid intake will not reduce the fatigue. The information does not indicate that the client is immunosuppressed and should avoid contact with others.CN: Physiological adaptation;
CL: Synthesize
4.
1, 2, 3. Using designated donors does not decrease the risk of contracting infectious diseases, such as the Epstein-Barr virus, HIV, or CMV. Hepa- titis A is transmitted by the oral-fecal route, not the blood route; however, hepatitis B and C can be con- tracted from a designated donor. Malaria is transmit- ted by mosquitoes.CN: Safety and infection control;
CL: Apply
5.
4. A routine serology study to confi rm com- patibility between a blood donor and recipient takes about 1 hour. In an emergency, O negative RBCs can be safely administered to most clients, which is why a person with O-negative blood is called a univer- sal donor. The other types of RBCs may cause an adverse reaction.CN: Safety and infection control;
CL: Apply
6.
1. One of the microcytic, hypochromic anemias is iron defi ciency anemia. A rich source of iron is needed in the diet, and eggs are high in iron.Other foods high in iron include organ and muscle (dark) meats; shellfi sh, shrimp, and tuna; enriched, whole-grain, and fortifi ed cereals and breads;
legumes, nuts, dried fruits, and beans; oatmeal; and sweet potatoes. Dark green, leafy vegetables and citrus fruits are good sources of vitamin C. Cheese is a good source of calcium.
CN: Reduction of risk potential;
CL: Apply
7.
3. Good sources of vitamin B12 include meats and dairy products. Whole grains are a good source of thiamine. Green, leafy vegetables are good sources of niacin, folate, and carotenoids (precursors of vitamin A). Broccoli and brussels sprouts are good sources of ascorbic acid (vitamin C).CN: Reduction of risk potential;
CL: Apply
8.
4. The normal range of folic acid is 1.8 to 9 ng/mL, and the normal range of vitamin B12 (cyanocobalamin) is 200 to 900 pg/mL. A low folicBillings_Part 2_Chap 3_Test 03.indd 381
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relaxation, which decreases the discomfort of mak- ing an injection into a tense muscle. Lying on the side with legs extended will not provide the greatest muscle relaxation. Leaning over the edge of a table with the hips fl exed and standing upright with the feet apart will increase muscular tension.
CN: Physiological adaptation; CL: Apply
16.
1, 2, 3, 4. The nurse should ask the client about symptoms related to pernicious anemia because she had her stomach stapled 2 years ago and shows no history of supplemental vitamin B12. Numbness and tingling relate to a loss of intrinsic factor from the gastric stapling. Intrinsic factor is necessary for absorption of vitamin B12. The nurse should suspect pernicious anemia if the client is not taking supplemental vitamin B12. Other signs and symptoms of pernicious anemia include cognitive problems and depression. The nurse also should ask about the client’s support at home in case the fall was not an accident. Pernicious anemia is not related to dietary intake of iron.CN: Reduction of risk potential;
CL: Analyze
17.
1. The nurse should prepare to start an intake and output record because the client is exhibiting clinical manifestations of anemia with jaundice and is demonstrating a fl uid imbalance. The client does not need to be on bed rest at this point. The client is not contagious and does not need to be placed in contact isolation. The changes in the color of the skin and urine are related to the jaundice and will not be affected by sunlight.CN: Physiological adaptation;
CL: Synthesize
18.
1. Drug-induced hemolytic anemia is acquired, antibody-mediated, RBC destruction pre- cipitated by medications, such as cephalosporins, sulfa drugs, rifampin, methyldopa, procainamide, quinidine, and thiazides. Purpura is a condi- tion with various manifestations characterized by hemorrhages into the skin, mucous membranes, internal organs, and other tissues. Infectious emboli are clumps of bacteria present in blood or lymph.Ecchymoses are skin discolorations due to extrava- sations of blood into the skin or mucous mem- branes.
CN: Reduction of risk potential;
CL: Analyze
19.
2. Urinary vitamin B12 levels are measured after the ingestion of radioactive vitamin B12. A 24- to 48-hour urine specimen is collected after admin- istration of an oral dose of radioactively tagged vita- min B12 and an injection of nonradioactive vitamin B12. In a healthy state of absorption, excess vitamin B12 is excreted in the urine; in a malabsorptive state stools on a daily basis. Warm salt water is used tosoothe sore mucous membranes. Crohn’s disease and a small-bowel resection may cause several loose stools a day.
CN: Physiological adaptation;
CL: Analyze
12.
3. Coffee and tea increase gastrointestinal motility and inhibit the absorption of nonheme iron.Clients are instructed to add dried fruits to dishes at every meal because dried fruits are a nonheme or nonanimal iron source. Cooking in iron cook- ware, especially acid-based foods such as tomatoes, adds iron to the diet. Clients are instructed to add a rich supply of vitamin C to every meal because the absorption of iron is increased when food with vitamin C or ascorbic acid is consumed.
CN: Reduction of risk potential;
CL: Evaluate
13.
1. It is diffi cult to determine activity intoler- ance without objectively comparing activities from one time frame to another. Because iron defi ciency anemia can occur gradually and individual endur- ance varies, the nurse can best assess the client’s activity tolerance by asking the client to compare activities 6 months ago and at present. Asking a cli- ent how long a problem has existed is a very open- ended question that allows for too much subjectivity for any defi nition of the client’s activity tolerance.Also, the client may not even identify that a “prob- lem” exists. Asking the client whether he is stay- ing abreast of usual activities addresses whether the tasks were completed, not the tolerance of the client while the tasks were being completed or the resulting condition of the client after the tasks were completed. Asking the client if he is more tired now than usual does not address his activity tolerance.
Tiredness is a subjective evaluation and again can be distorted by factors such as the gradual onset of the anemia or the endurance of the individual.
CN: Reduction of risk potential;
CL: Analyze
14.
4, 6. A client with pernicious anemia has lost the ability to absorb vitamin B12 either because of the lack of an acidic gastric environment or the lack of the intrinsic factor. Vitamin B12 must be adminis- tered by a deep intramuscular route. The ventroglu- teal and dorsogluteal locations are the most accept- able sites for a deep intramuscular injection. The other sites are not acceptable.CN: Pharmacological and parenteral therapies; CL: Apply
15.
2. To promote comfort when injecting at the ventrogluteal site, the position of choice is with the client lying on the abdomen with toes pointed inward. This positioning promotes muscleBillings_Part 2_Chap 3_Test 03.indd 382
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23.
2. The normal physiologic response to activ- ity is an increased metabolic rate over the resting basal rate. The decrease in respiratory rate indicates that the client is not strong enough to complete the mechanical cycle of respiration needed for gas exchange. The postactivity pulse is expected to increase immediately after activity but by no more than 50 bpm if it is strenuous activity. The diastolic blood pressure is expected to rise but by no more than 15 mm Hg. The pulse returns to within 6 bpm of the resting pulse after 3 minutes of rest.CN: Physiological adaptation;
CL: Evaluate
24.
3. The nurse should continue to monitor the client because this value refl ects a normal physi- ologic response. The physician does not need to be called, and oxygen does not need to be started based on these laboratory fi ndings. Immediately after surgery, the client’s hematocrit refl ects a falsely high value related to the body’s compensatory response to the stress of sudden loss of fl uids and blood. Activation of the intrinsic pathway and the renin-angiotensin cycle via antidiuretic hormone produces vasoconstriction and retention of fl uid for the fi rst 1 to 2 days postoperatively. By the second to third day, this response decreases and the client’s hematocrit level is more refl ective of the amount of RBCs in the plasma. Fresh bleeding is a less likely occurrence on the third postoperative day but is not impossible; however, the nurse should have expected to see a decrease in the RBC count and hemoglobin value accompanying the hematocrit.CN: Physiological adaptation;
CL: Synthesize
25.
4. The most likely time for a blood transfu- sion reaction to occur is during the fi rst 15 minutes or fi rst 50 mL of the infusion. If a blood transfu- sion reaction does occur, it is imperative to keep an established I.V. line so that medication can be administered to prevent or treat cardiovascular collapse in case of anaphylaxis. PRBCs should be administered through a 19-gauge or larger needle;a peripherally inserted central catheter line is not recommended, in order to avoid a slow fl ow. RBCs will hemolyze in dextrose or lactated Ringer’s solu- tion and should be infused with only normal saline solution.
CN: Pharmacological and parenteral therapies; CL: Synthesize
26.
1, 2, 4. The nurse should teach the client to drink plenty of fl uids when outside in hot weather to avoid becoming dehydrated. The client should avoid high altitudes, such as mountains, where the oxygen levels are low and may precipitate a sickle cell crisis. The nurse should alert young women or when the intrinsic factor is missing, vitamin B12is excreted in the feces. Citrucel is a bulk-forming agent. Laxatives interfere with the absorption of vitamin B12. The client is NPO 8 to 12 hours before the test but is not NPO during the test. A stool col- lection is not a part of the Schilling test. If stool contaminates the urine collection, the results will be altered.
CN: Pharmacological and parenteral therapies; CL: Analyze
20.
3. This client has clinical manifestations of thalassemia major, a disease found in descendants from the Mediterranean Sea area whose mother and father both possess a gene for thalassemia (i.e., the client is homozygous for the gene). The severe hemolytic anemia causes sequestration of red blood cells in the spleen and liver which leads to engorgement of the organs and chronic bone mar- row hyperplasia. Rest will decrease the demands on the heart due to the diminished hemoglobin level, a physiologic concern. The nurse should follow the time schedule of the area in which the client is now living. The nurse can help the client order preferred foods and listen to concerns, but the main priority is to decrease oxygen demands.CN: Physiological adaptation;
CL: Synthesize
21.
2. Most clients with pernicious anemia have defi cient production of intrinsic factor in the stomach. Intrinsic factor attaches to the vitamin in the stomach and forms a complex that allows the vitamin to be absorbed in the small intestine. The stomach is producing enough acid, there is not an excessive excretion of the vitamin, and there is not a rapid production of red blood cells in this condi- tion.CN: Physiological adaptation;
CL: Synthesize
22.
2. This client presented with the typi- cal signs of glucose-6-phosphate dehydrogenase (G6PD)–defi ciency anemia. Ten percent of African Americans inherit an X-linked recessive disorder of the G6PD enzyme in the red blood cell (RBC). When cells with decreased levels of G6PD are exposed to certain drugs, such as sulfonamides, acetylsalicylic acid, thiazide diuretics, and vitamin K, the RBC may hemolyze and anemia and jaundice may occur.The reaction is self-limited as soon as the causative agent is withheld. No further treatment is neces- sary except counseling to prevent acute incidence by avoiding exposure to specifi c drugs. There is no need for increased folic acid, restricted activity in hot weather, or blood transfusions.
CN: Physiological adaptation;
CL: Evaluate
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