Nokea
The nurse caring for a patient in the emergency room with suspected internal injuries will assess for hypovolemic shock, which is evidenced by which symptom?
- A. irritability.
- B. restlessness.
- C. slow bounding pulse.
- D. decreased respirations.
- E. pallor.
- F. hypotension.
Correct Answer: A,B,E,F
Rationale: Indicators of hypovolemia are restlessness, irritability, rapid thready pulse, increasing respirations, pale, cool moist skin, and hypotension. Should the blood loss continue, the patient could go into hypovolemic shock.
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Which is a necessary factor that supports healthy erythropoiesis?
- A. Dietary magnesium
- B. Healthy bone marrow and kidney function
- C. Adequate oxygen source
- D. Vitamin B12
- E. Amino acids
- F. Vitamin B6
Correct Answer: B,D,E,F
Rationale: Erythropoiesis, red blood cell production, is dependent on the availability of healthy bone marrow and kidney function, dietary supply of copper and iron, amino acids, vitamins B12, folic acid, and pyridoxine (B6).
Because older adults suffer from conditions such as colonic diverticula, hiatal hernia, and ulcerations that can cause occult bleeding, the nurse should assess for symptoms of which blood disorder?
- A. leukemia.
- B. iron-deficiency anemia.
- C. sickle cell anemia.
- D. polycythemia.
Correct Answer: B
Rationale: Blood loss is a major cause of iron-deficiency in adults. The major sources of chronic blood loss are from the GI and genitourinary systems.
The nurse assessing a differential sees an increase in immature neutrophils (bands) and is aware that this indicates which concern?
- A. a significant hemorrhage.
- B. aplastic anemia.
- C. an infection or stress.
- D. beginning recovery from an infection.
Correct Answer: C
Rationale: An increase in immature neutrophils (bands) is sometimes referred to as 'a shift to the left', and it indicates an infection or stress.
The nurse explains to a patient with Non-Hodgkin's lymphoma that a positron emission tomography (PET) has been ordered for which reason?
- A. assess bone marrow depression.
- B. measure bone density.
- C. radiate and destroy diseased lymph nodes.
- D. determine the extent of possible metastasis.
Correct Answer: D
Rationale: The PET can aid in the staging of disease by determining the extent of any metastasis in the liver, lungs, or bones.
The presence of excess bands in the peripheral blood that indicate severe infection is indicated in which manner?
- A. shift to the left.
- B. shift to the right.
- C. bone marrow aspiration.
- D. thrombocytosis.
Correct Answer: A
Rationale: The presence of excess bands in the peripheral blood is called a shift to the left (i.e., a shift toward immature cells) and indicates severe infection.