Nokea
The nurse assesses that the client with hemolytic anemia has weakness, fatigue, malaise, and skin and mucous membrane pallor. Which finding should the nurse also associate with hemolytic anemia?
- A. Scleral jaundice
- B. A smooth, red tongue
- C. A craving for ice to chew
- D. A poor intake of fresh vegetables
Correct Answer: A
Rationale: A. Jaundice occurs in hemolytic anemia from the shortened life span of the RBC and the breakdown of Hgb. About 80% of heme is converted to bilirubin, conjugated in the liver, and excreted in the bile. The increased bilirubin in the blood causes the jaundice. B. A smooth, red tongue is seen with iron-deficiency anemia. C. A craving for ice is seen with iron-deficiency anemia. D. Folate deficiency occurs in people who rarely eat fresh vegetables.
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The nurse is assisting the HCP with a bone marrow biopsy. Which intervention postprocedure has priority?
- A. Apply pressure to site for five (5) to 10 minutes.
- B. Medicate for pain with morphine slow IVP.
- C. Maintain head of bed in high Fowler’s position.
- D. Apply oxygen via nasal cannula at five (5) L/min.
Correct Answer: A
Rationale: Applying pressure for 5–10 minutes (A) prevents bleeding post-biopsy, a priority. Pain meds (B), HOB (C), and oxygen (D) are secondary or unrelated.
The client’s CBC indicates an RBC 6 (x106/mm3), Hb 14.2 g/dL, Hct 42%, and platelets 69 (x103/mm3). Which intervention should the nurse implement?
- A. Teach the client to use a soft-bristle toothbrush.
- B. Monitor the client for elevated temperature.
- C. Check the client’s blood pressure.
- D. Hold venipuncture sites for one (1) minute.
Correct Answer: A
Rationale: Platelets 69,000 indicate thrombocytopenia; a soft-bristle toothbrush (A) prevents gum bleeding. Fever (B), BP (C), and brief pressure (D) are insufficient for bleeding risk.
Which clinical manifestation of Stage I non-Hodgkin’s lymphoma would the nurse expect to find when assessing the client?
- A. Enlarged lymph tissue anywhere in the body.
- B. Tender left upper quadrant.
- C. No symptom in this stage.
- D. Elevated B-cell lymphocytes on the CBC.
Correct Answer: C
Rationale: Stage I NHL is often asymptomatic (C), with localized node involvement. Enlarged nodes (A) are later, LUQ tenderness (B) suggests spleen, and B-cell elevation (D) is lab-based, not clinical.
A client who receives a diagnosis of pernicious anemia asks why she must receive vitamin shots. What is the best answer for the nurse to give?
- A. Shots work faster than pills.'
- B. Your body cannot absorb vitamin B12 from foods.'
- C. Vitamins are necessary to make the blood cells.'
- D. You can get more vitamins in a shot than a pill.'
Correct Answer: B
Rationale: In pernicious anemia, the lack of intrinsic factor prevents absorption of vitamin B12 from foods, necessitating injections.
The client with O+ blood is in need of an emergency transfusion but the laboratory does not have any O+ blood available. Which potential unit of blood could be given to the client?
- A. The O- unit.
- B. The A+ unit.
- C. The B+ unit.
- D. Any Rh+ unit.
Correct Answer: A
Rationale: O- is the universal donor (A), safe for O+ clients. A+ (B), B+ (C), and other Rh+ (D) risk reactions due to antigens.