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The nurse is discussing dietary sources of iron with a client who has iron deficiency anemia. Which menu, if selected by the client, indicates the best understanding of the diet?
- A. Milkshake, hot dog, and beets
- B. Beef steak, spinach, and grape juice
- C. Chicken salad, green peas, and coffee
- D. Macaroni and cheese, coleslaw, and lemonade
Correct Answer: B
Rationale: Beef, spinach, and grape juice contain iron. Milk contains no iron, and the other options have lower iron content.
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The nurse is administering vesicant chemotherapy medications such as doxorubicin hydrochloride to clients. Which nursing actions should the nurse implement to prevent extravasation?
- A. Give through an IV catheter in a large peripheral vein if infusing in less than 60 minutes.
- B. Check patency every 5 to 10 minutes during infusion and ask about IV site discomfort.
- C. Check the IV pump and alarm for indications of an infiltration of the medication.
- D. Check for blood return in a central venous catheter prior to administration of the vesicant.
- E. Use small-gauged syringes with small barrels when flushing any access devices with saline.
Correct Answer: A, B, D
Rationale: A peripheral IV catheter may be used for a vesicant if administration time is less than 60 minutes, a large vein is used, and there is careful monitoring of the IV site. B. Checking for patency and asking about discomfort at the IV site will help prevent an infiltration. C. IV pumps and alarms cannot be relied upon to detect extravasation because infiltration usually does not cause sufficient pressure to trigger an alarm. D. Checking for blood return in the central venous catheter prior to administration will help ensure that the medication is being administered into a vessel and not into tissues. E. Small-gauge syringes with small barrels produce high pressures and may cause injury to the blood vessel or may damage a central line catheter and should not be used.
The nurse is admitting a 24-year-old African American female client with a diagnosis of rule-out anemia. The client has a history of gastric bypass surgery for obesity four (4) years ago. Current assessment findings include height 5’5”; weight 75 kg; P 110, R 27, and BP 104/66; pale mucous membranes and dyspnea on exertion. Which type of anemia would the nurse suspect the client has developed?
- A. Vitamin B12 deficiency.
- B. Folic acid deficiency.
- C. Iron deficiency.
- D. Sickle cell anemia.
Correct Answer: A
Rationale: Gastric bypass impairs B12 absorption, causing B12 deficiency anemia (A) with pale membranes, tachycardia, and dyspnea. Folic acid (B) is less likely, iron (C) is possible but secondary, and sickle cell (D) is genetic.
The nurse is caring for clients on an oncology unit. Which neutropenia precautions should be implemented?
- A. Hold all venipuncture sites for at least five (5) minutes.
- B. Limit fresh fruits and flowers.
- C. Place all clients in reverse isolation.
- D. Have the clients use a soft-bristle toothbrush.
Correct Answer: B
Rationale: Neutropenia increases infection risk; limiting fresh fruits/flowers (B) reduces microbial exposure. Holding venipuncture (A) prevents bleeding, reverse isolation (C) is excessive, and soft toothbrushes (D) prevent gum trauma but are secondary.
The client diagnosed with von Willebrand’s disease calls a clinic after experiencing hemarthrosis. The client states that factor concentrate is infusing. Which intervention should the nurse recommend now?
- A. “Take two 325-mg aspirin tablets every 4 hours for pain.”
- B. “Apply a cold pack to the area for 30 minutes every 1 to 2 hours.”
- C. “Come to the clinic; you need an infusion of fresh frozen plasma.”
- D. “If wearing a splint, remove it to avoid compartment syndrome.”
Correct Answer: B
Rationale: A. Aspirin (Ecotrin) and NSAIDs are contraindicated because they interfere with platelet aggregation. B. Hemarthrosis is bleeding into the joint. The pressure of the ice pack and cold will reduce the bleeding and swelling. The ice pack should be covered with a cloth. C. The client and family are usually taught how to administer factor concentrates at home at the first sign of bleeding. D. The splint should be left on initially to control bleeding. The client should be instructed on how to assess for adequate tissue perfusion.
Which statement made by the parent of a child newly diagnosed with sickle cell anemia indicates a need for more teaching?
- A. We are going to the mountains for our vacation this year.'
- B. It's a good thing she likes to drink juices.'
- C. If she needs something for pain, I will give her baby acetaminophen.'
- D. I will make sure that she doesn't get chilled when it is cold outside.'
Correct Answer: A
Rationale: High altitudes, like mountains, have lower oxygen levels, which can precipitate a sickle cell crisis, indicating a need for more teaching. Drinking juices, using acetaminophen, and avoiding chills are appropriate.