Nokea
The nurse is assigned to care for a client with polycythemia vera. When the nurse encourages the client to drink 3 L of fluid per day, the client states, 'Why do I have to drink so much?' What is the best response by the nurse?
- A. We don't want you to get dehydrated.
- B. It helps adequately hydrate you and ensures a sufficient urine production.
- C. It will help your heart beat regularly and effectively.
- D. It will help restrict blood circulation.
Correct Answer: B
Rationale: The client should be advised to drink 3 quarts (or liters) per day. Adequate hydration promotes venous return and ensures sufficient urine production. Informing the client that the healthcare team does not want them to get dehydrated does not address the rationale that the client requires. Fluid hydration will not help the heart beat regularly or more effectively and it will not help to restrict blood circulation.
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The nurse observes the laboratory studies for a client in the hospital with fatigue, feeling cold all of the time, and hemoglobin of 8.6 g/dL and a hematocrit of 28%. What finding would be an indicator of iron-deficiency anemia?
- A. Erythrocytes that are microcytic and hypochromic
- B. Erythrocytes that are macrocytic and hyperchromic
- C. Clustering of platelets with sickled red blood cells
- D. An increased number of erythrocytes
Correct Answer: A
Rationale: A blood smear reveals erythrocytes that are microcytic (smaller than normal) and hypochromic (lighter in color than normal). It does not reveal macrocytic (larger than normal) or hyperchromic erythrocytes. Clustering of platelets with sickled red blood cells would indicate sickle cell anemia. An increase in the number of erythrocytes would indicate polycythemia vera.
A client is seen in the emergency department with severe pain related to a sickle cell crisis. What does the nurse understand is occurring with this client?
- A. The client has a decreased tolerance of pain related to the chronic nature of the illness.
- B. Bone marrow decreases the erythrocyte production causing decrease in hypoxia.
- C. Overhydration enlarges the red blood cells.
- D. Vascular occlusion in small vessels decreasing blood and oxygen to the tissues.
Correct Answer: D
Rationale: The person with sickle cell disease repeatedly suffers from two major problems: (1) episodes of sickle cell crisis from vascular occlusion, which develops rapidly under hypoxic conditions, and (2) chronic hemolytic anemia. During a sickle cell crisis, the sickle-shaped cells lodge in small blood vessels, where they block the flow of blood and oxygen to the affected tissue. The vascular occlusion induces severe pain in the ischemic tissue. The client may have increased tolerance for pain due to the chronic nature of the illness. Bone marrow increases the erythrocyte production. Underhydration increases the client's risk of developing a vaso-occlusive crisis.
The nurse is caring for an older adult client who has been admitted to the unit with anemia. What would the nurse expect the client to possibly exhibit?
- A. Excessive consumption of coffee or tea
- B. Elimination of iron by the body
- C. Decrease in the total body iron stores with age
- D. Blood loss from the gastrointestinal or genitourinary tract
Correct Answer: D
Rationale: If an older adult is anemic, blood loss from the gastrointestinal or genitourinary tract is suspected. This is because iron-deficiency anemia is unusual in older adults as the body does not eliminate excessive iron, causing total body iron stores to increase with age. Excessive consumption of coffee or tea is not a causative factor for anemia in older adults.
A client who is diagnosed multiple myeloma experiences decreased production of red blood cells (RBCs). Which prescribed medication should the nurse prepare to administer to increase the production of erythrocytes?
- A. Filgrastim
- B. Pegfilgrastim
- C. Erythropoietin
- D. Dexamethasone
Correct Answer: C
Rationale: The medication erythropoietin can be used to stimulate the production of red blood cells; therefore, this is the prescribed medication that the nurse prepares to administer to the client. Filgrastim and pegfilgrastim promote proliferation of neutrophils, not erythrocytes. Dexamethasone is a corticosteroid that is prescribed for clients who are diagnosed with multiple myeloma to inhibit the inflammatory immune response.
The nurse is instructing the client with polycythemia vera how to perform isometric exercises such as contracting and relaxing the quadriceps and gluteal muscle during periods of inactivity. What does the nurse understand is the rationale for this type of exercise?
- A. Isometric exercise programs are inclusive of all muscle groups and have an aerobic effect to increase the heart rate.
- B. Isometric exercise decreases the workload of the heart and restores oxygenated blood flow.
- C. This type of exercise increases arterial circulation as it returns to the heart.
- D. Contraction of skeletal muscle compresses the walls of veins and increases the circulation of venous blood as it returns to the heart.
Correct Answer: D
Rationale: Isometric exercise induce contraction of skeletal muscle so that it compresses the walls of veins and increases the circulation of venous blood as it returns to the heart. Isometric exercises do not have an aerobic effect and should not increase the heart rate; although, it may increase blood pressure. Isometric exercise does not decrease the workload of the heart. Arterial flow moves blood flow away from the heart after being oxygenated.