Nokea
An appropriate nursing intervention for a hospitalized patient with severe hemolytic anemia is to
- A. provide a diet high in vitamin K
- B. alternate periods of rest and activity
- C. teach the patient how to avoid injury
- D. place the patient on protective isolation
Correct Answer: B
Rationale: In severe hemolytic anemia, the priority nursing intervention is to alternate periods of rest and activity. This approach helps to balance activity levels to prevent excessive fatigue while promoting mobility and preventing complications such as muscle weakness or deconditioning. Providing a diet high in vitamin K (choice A) is not directly related to managing hemolytic anemia. Teaching the patient how to avoid injury (choice C) is important but may not be the immediate priority. Placing the patient on protective isolation (choice D) is not indicated for hemolytic anemia, as it is not a contagious condition.
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Which patient statement to the nurse indicates a need for additional instruction about taking oral ferrous sulfate?
- A. I will call my health care provider if my stools turn black.
- B. I will take a stool softener if I feel constipated occasionally.
- C. I should take the iron with orange juice about an hour before eating.
- D. I should increase my fluid and fiber intake while I am taking iron tablets.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A patient with pancytopenia of unknown origin is scheduled for the following diagnostic tests. The nurse will provide a consent form to sign for which test?
- A. Bone marrow biopsy
- B. Abdominal ultrasound
- C. Complete blood count (CBC)
- D. Activated partial thromboplastin time (aPTT)
Correct Answer: A
Rationale: In the case of a patient with pancytopenia of unknown origin, a bone marrow biopsy is usually indicated to determine the cause. A bone marrow biopsy is a minor surgical procedure that requires the patient or guardian to sign a surgical consent form. Abdominal ultrasound (Choice B) is not typically used to diagnose pancytopenia. A Complete Blood Count (CBC) (Choice C) is a routine blood test and does not require a specific consent form. Activated Partial Thromboplastin Time (aPTT) (Choice D) is a coagulation test and not typically performed to diagnose pancytopenia.
Which patient requires the most rapid assessment and care by the emergency department nurse?
- A. The patient with hemochromatosis who reports abdominal pain
- B. The patient with neutropenia who has a temperature of 101.8°F
- C. The patient with thrombocytopenia who has oozing gums after a tooth extraction
- D. The patient with sickle cell anemia who has had nausea and diarrhea for 24 hours
Correct Answer: B
Rationale: The correct answer is B because a neutropenic patient with a fever is at high risk for developing sepsis. Sepsis can progress rapidly and lead to life-threatening complications. Immediate assessment, obtaining cultures, and initiating antibiotic therapy are essential in this situation. Choices A, C, and D do not present with the same level of urgency as a neutropenic patient with a fever. Abdominal pain in a hemochromatosis patient, oozing gums after a tooth extraction in a thrombocytopenic patient, and nausea and diarrhea in a patient with sickle cell anemia, while concerning, do not indicate the same immediate risk of sepsis as a neutropenic patient with a fever.
Which statement by a patient indicates good understanding of the nurse¢â‚¬â„¢s teaching about prevention of sickle cell crisis?
- A. Home oxygen therapy is frequently used to decrease sickling.
- B. There are no effective medications that can help prevent sickling.
- C. Routine continuous dosage narcotics are prescribed to prevent a crisis.
- D. Risk for a crisis is decreased by having an annual influenza vaccination.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Which menu choice indicates that the patient understands the nurse's teaching about recommended dietary choices for iron-deficiency anemia?
- A. Omelet and whole wheat toast
- B. Cantaloupe and cottage cheese
- C. Strawberry and banana fruit plate
- D. Cornmeal muffin and orange juice
Correct Answer: D
Rationale: The correct answer is D: "Cornmeal muffin and orange juice." Cornmeal muffin is a good source of iron, which is beneficial for individuals with iron-deficiency anemia. Orange juice is high in vitamin C, which aids in iron absorption. Choices A, B, and C do not specifically address the need for iron-rich foods, making them less suitable for someone with iron-deficiency anemia. Omelet and whole wheat toast (Choice A) may provide some iron but are not as focused on addressing the specific deficiency. Cantaloupe and cottage cheese (Choice B) and strawberry and banana fruit plate (Choice C) are more general fruit choices and do not emphasize iron-rich options.