Nokea
A client is receiving a colony-stimulating factor and experiences dilutional anemia secondary to fluid retention associated with drug therapy. The nurse would most likely identify which nursing diagnosis?
- A. Fatigue
- B. Constipation
- C. Imbalanced Nutrition: Less Than Body Requirements
- D. Anxiety
Correct Answer: A
Rationale: During administration of the CSF drugs, the patient may experience fluid retention. The increase in fluid volume makes the ratio of cells to fluid in the blood less, which results in a dilutional anemia. The patient may experience fatigue due to this anemia. Constipation is more likely when iron supplements are used. Imbalanced Nutrition: Less Than Body Requirements would be more likely if the client was experiencing anemia. There is no evidence to suggest Anxiety as a nursing diagnosis.
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A nurse is providing care to a client experiencing hematologic failure. The nurse understands that this can include which of the following? Select all that apply.
- A. Anemia
- B. Bleeding
- C. Hypertension
- D. Infection
- E. Hypoglycemia
Correct Answer: A,B,D
Rationale: Hematologic failure results when inadequate numbers of blood cells are produced, leading to decreased oxygen transportation, blood coagulation, or inability for the body to prevent the invasion of microorganisms, which can lead to anemia, bleeding, and infection.
A nurse identifies a nursing diagnosis of Constipation for a client receiving iron supplements. Which of the following would be appropriate to promote resolution of this problem?
- A. Increase the intake of milk and dairy products.
- B. Consume a diet high in fiber.
- C. Take antacids after consuming meals.
- D. Perform vigorous exercises.
Correct Answer: B
Rationale: When caring for a client with constipation, the nurse should instruct the client to consume a high-fiber diet, increase fluid intake to 10 to 12 glasses of water daily, and increase activity. Increased activity can include exercise, however, the client does not need to engage in vigorous exercise. Increasing the intake of milk and dairy products or taking antacids after meals will not help reduce the constipation or the discomfort caused due to it.
A nurse is caring for a client with iron deficiency anemia who is receiving iron supplements. What information should the nurse include in the teaching plan for this client?
- A. Frequency of urination will increase.
- B. Soreness of throat might occur.
- C. Itching of throat might occur.
- D. Color of stools will become darker.
Correct Answer: D
Rationale: The nurse should inform the client receiving oral iron supplements that the color of stools will become darker. Frequency of urination is not known to increase with the oral administration of iron supplements. Similarly, soreness of the throat and itching of the throat are also not known to occur with the oral administration of iron supplements.
A nurse should encourage a client with megaloblastic anemia to eat which of the following foods, as they are rich in folate? Select all that apply.
- A. Collard greens
- B. Grapes
- C. Wheat bread
- D. Salmon
- E. Chicken
Correct Answer: A,C,D,E
Rationale: A deficiency of folic acid (folate) results in megaloblastic anemia, and the nurse should encourage a client to eat foods rich in folic acid including leafy green vegetables (collard greens), fish (salmon), meat, poultry (chicken), and whole grains (wheat bread).
A client is prescribed sargramostim (Leukine). Before administering the drug, the nurse would inform the client that which of the following may occur with this drug? Select all that apply.
- A. Bone pain
- B. Anemia
- C. Infection
- D. Nausea
- E. Rash
Correct Answer: A,D,E
Rationale: Headache, bone pain, nausea, vomiting, diarrhea, alopecia, and rash are adverse reactions the nurse should inform the client about prior to the administration of sargramostim (Leukine).