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The client with COPD has developed polycythemia vera, and the nurse completes teaching on measures to prevent complications. During a home visit, the nurse evaluates that the client is correctly following the teaching when which actions are noted?
- A. Tells the nurse about discontinuing iron supplements.
- B. States increasing alcohol intake to decrease blood viscosity.
- C. Presents a record that shows a daily fluid intake of 3000 mL.
- D. Discusses yesterday’s phlebotomy treatment to remove blood.
- E. Shows the nurse 3 menu plan for eating three large meals daily.
- F. Wears antiembolic stockings and sits in a recliner with legs uncrossed
Correct Answer: A, C, D, F
Rationale: Iron supplements, including those in multi-vitamins, should be avoided because the iron stimulates RBC production. B. Alcohol increases the risk of bleeding. C. Increasing fluid intake to 3000 mL daily will help decrease blood viscosity. D. Phlebotomy is performed on a routine or intermittent basis to diminish blood viscosity, deplete iron stores, and decrease the client’s ability to manufacture excess erythrocytes. E. Frequent, small meals are better tolerated, especially if the liver is involved. F. Elevating the legs, avoiding constriction or crossing the legs, and wearing antiembolic stockings help prevent DVT.
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The client has a hematocrit of 22.3% and a hemoglobin of 7.7 g/dL. The HCP has ordered two (2) units of packed red blood cells to be transfused. Which interventions should the nurse implement? Select all that apply.
- A. Obtain a signed consent.
- B. Initiate a 22-gauge IV.
- C. Assess the client’s lungs.
- D. Check for allergies.
- E. Hang a keep-open IV of D5W.
Correct Answer: A,C,D
Rationale: Consent (A), lung assessment (C), and allergy checks (D) ensure safe transfusion. A 22-gauge IV (B) is too small (18-gauge preferred), and D5W (E) is incompatible (use NS).
The client is being admitted with folic acid deficiency anemia. Which would be the most appropriate referral?
- A. Alcoholics Anonymous.
- B. Leukemia Society of America.
- C. A hematologist.
- D. A social worker.
Correct Answer: C
Rationale: Folic acid deficiency anemia requires a hematologist (C) for evaluation/treatment. AA (A) is for alcoholism, Leukemia Society (B) is unrelated, and social work (D) is secondary.
Which statement is the scientific rationale for infusing a unit of blood in less than four (4) hours?
- A. The blood will coagulate if left out of the refrigerator for greater than four (4) hours.
- B. The blood has the potential for bacterial growth if allowed to infuse longer.
- C. The blood components begin to break down after four (4) hours.
- D. The blood will not be affected; this is a laboratory procedure.
Correct Answer: B
Rationale: Blood must infuse within 4 hours (B) to minimize bacterial growth risk. Coagulation (A) is not primary, components (C) degrade minimally, and lab procedure (D) is incorrect.
A child with leukemia bruises easily. This is most likely due to which of the following?
- A. Decreased fibrinogen levels
- B. Excessive clotting elsewhere in the body
- C. Decreased platelets
- D. Decreased erythrocytes
Correct Answer: C
Rationale: Leukemia causes bone marrow failure, leading to decreased platelets, which results in easy bruising.
The nurse explains “watchful waiting” (ongoing visits to a physician for observation of signs and symptoms without treatment) to the client with prostate cancer. Which client is a candidate for “watchful waiting”?
- A. 50-year-old with prostate cancer that has metastasized to the bone
- B. 75-year-old expected to live 5 years and has low-grade disease
- C. 45-year-old who has extension of the tumor outside of the prostate
- D. 59-year-old who is asymptomatic with an elevated prostate-specific antigen
Correct Answer: B
Rationale: A. The client with prostate cancer that has metastasized to the bone generally requires aggressive therapy. B. The client is a candidate for “watchful waiting” when older than age 70 with a life expectancy of less than 10 years and with low-grade disease. C. The client with extension of the tumor outside of the prostate generally requires aggressive therapy. D. The client who is asymptomatic with an elevated prostate-specific antigen generally requires aggressive therapy.