Nokea
The nurse is caring for a 32-year old client admitted with pernicious anemia. Which set of findings should the nurse expect when assessing the client?
- A. Pallor, bradycardia, and reduced pule
- B. Sore tongue, dyspnea, and weight gain
- C. Angina, double vision, and anorexia
- D. Pallor, tachycardia, and a sore tongue
Correct Answer: D
Rationale: Pernicious anemia is a type of megaloblastic anemia caused by the body's inability to absorb vitamin B12, essential for the production of red blood cells. The characteristic findings associated with pernicious anemia include pallor due to decreased red blood cells, tachycardia as the heart compensates for decreased oxygen-carrying capacity, and a sore tongue (glossitis) due to vitamin B12 deficiency affecting the oral mucosa. Therefore, the nurse should expect to find pallor, tachycardia, and a sore tongue when assessing a client with pernicious anemia.
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A client diagnosed with DIC is ordered heparin. What is the reason for this medication?
- A. Prevent clot formation
- B. Increase clot formation
- C. Increased blood flow to target organs
- D. Decrease blood flow to target organs
Correct Answer: A
Rationale: Heparin is a medication commonly used to prevent clot formation in various clinical conditions, including Disseminated Intravascular Coagulation (DIC). DIC is a serious condition characterized by abnormal blood clotting and bleeding throughout the body. Heparin works by inhibiting the formation of new clots and preventing the existing clots from further growing, thus helping to manage and prevent complications associated with DIC. By using heparin, the aim is to help stabilize the patient's clotting process and reduce the risk of severe complications such as organ damage or failure.
Which of the following nursing interventions will help prevent a further increase in ICP?
- A. Encourage fluids
- B. Provide physical therapy
- C. Elevate the head of the bed
- D. Reposition the patient frequently
Correct Answer: C
Rationale: Elevating the head of the bed helps to promote venous drainage from the brain, which can help reduce intracranial pressure (ICP). By positioning the patient with the head of the bed at a 30-45 degree angle, it can facilitate the circulation of cerebrospinal fluid and blood, thus preventing a further increase in ICP. This intervention is a crucial aspect of managing patients with increased ICP and can help improve their overall neurological status.
The nurse is caring for a school-age child who has had a cardiac catheterization. The child tells the nurse that the bandage is "too wet." The nurse finds the bandage and bed soaked with blood. What is the priority nursing action?
- A. Notify physician
- B. Apply new bandage with more pressure
- C. Place the child in Trendelenburg position
- D. Apply direct pressure above catheterization site
Correct Answer: D
Rationale: The priority nursing action in this situation is to apply direct pressure above the catheterization site to control the bleeding. This is important to prevent excessive blood loss and ensure the child's safety. The nurse should quickly address the issue of the soaked bandage and bed by applying direct pressure to the catheterization site to stop the bleeding. Once bleeding is controlled, the nurse should then notify the physician for further evaluation and treatment. Placing the child in Trendelenburg position is not necessary in this scenario, as the immediate focus should be on controlling the bleeding.
A client is admitted to the hospital with a bleeding ulcer and is to receive 4 units of packed cells. Which nursing intervention is of primary importance in the administration of blood?
- A. Checking the flow rate
- B. Monitoring the vital signs
- C. Identifying the client
- D. Maintaining blood temperature
Correct Answer: C
Rationale: The primary nursing intervention in the administration of blood is to correctly identify the client. This is crucial to ensure that the right blood is being administered to the right patient to prevent transfusion reactions and ensure patient safety. Before any blood transfusion, the nurse must verify the patient's identity using at least two unique identifiers, such as name, date of birth, and hospital or medical record number. Patient safety hinges on this critical step, making it the priority when administering blood products. While monitoring vital signs, checking the flow rate, and maintaining blood temperature are all important aspects of blood transfusion management, identifying the client is fundamental and must come first to prevent errors.
The nurse is explaining the action of insulin to a newly diagnosed diabetic client. During the teaching, the nurse reviews the process of insulin secretion in the body. The nurse is correct when stating that insulin is secreted from the:
- A. adenohypohysis.
- B. alpha cells of the pancreas.
- C. beta cells of the pancreas.
- D. parafollicular cells of the thyroid.
Correct Answer: C
Rationale: Insulin is secreted from the beta cells of the pancreas. These specialized cells are located in the islets of Langerhans within the pancreas. When blood glucose levels rise after eating, beta cells release insulin into the bloodstream to help regulate glucose levels by allowing cells to take in glucose for energy or storage. Insulin also helps lower blood sugar by promoting the conversion of glucose to glycogen in the liver and muscles. Therefore, the nurse is correct in stating that insulin is secreted from the beta cells of the pancreas.