Nokea
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.
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The nurse is admitting a client with Cooley's anemia to the hospital with a hemoglobin of 6.2 g/dL and hematocrit of 26%. What does the nurse document about the client's skin?
- A. Bronzing of the skin
- B. Jaundice of the skin and mucous membranes
- C. Ruddy complexion
- D. Pale skin and mucous membranes
Correct Answer: A
Rationale: Clients with Cooley's anemia, a severe form of beta-thalassemia, exhibit symptoms of severe anemia and a bronzing of the skin caused by hemolysis of erythrocytes. The client is not jaundiced, ruddy, or pale with this disorder.
The nurse is caring for a client with hypovolemic anemia who is now in hypovolemic shock. What indication does the nurse have that the client is having inadequate renal perfusion?
- A. Hematuria
- B. Blood pressure of 90/60 mm Hg
- C. Jaundice of the sclera
- D. Urine output of 15 mL/hour
Correct Answer: D
Rationale: Urine output of less than 30 to 50 mL/hour reflects inadequate renal perfusion. The kidneys must excrete 30 to 50 mL/hour or 500 mL/24 hours to eliminate wastes sufficiently. Hematuria is an indicator of other problems such as hemorrhagic cystitis, trauma to the bladder, etc. It is not an indicator of renal perfusion. A blood pressure of 90/60 mm Hg does not indicate that the client is having a decrease in renal perfusion nor does jaundice. Jaundice is present when the liver starts to fail.
A client is being treated in the hospital for hypovolemia related to a bleeding peptic ulcer. The nurse obtains a blood pressure reading of 88/62 mm Hg, heart rate of 112 beats/minute, and a respiratory rate of 24 breaths/minute. What is the first action by the nurse?
- A. Administer blood.
- B. Notify the physician.
- C. Insert two large-bore intravenous catheters.
- D. Administer a colloid solution.
Correct Answer: B
Rationale: A systolic blood pressure below 90 mm Hg and heart rate above 100 beats/minute should be reported immediately. Administering blood, inserting two large-bore IV catheters, and administration of a colloid solution should be performed only with a physician's prescription and may not be required at this time.
The LPN is following a plan of care for a client who is being treated for hypovolemic anemia and is at risk for hypovolemic shock. The nurse assesses vital signs and O2 saturation and observes the saturation at 89% for 3 minutes. What should the first action by the nurse be?
- A. Notify the charge nurse.
- B. Prepare to assist with intubation.
- C. Give oxygen per nasal cannula
- D. Place the client in the supine position.
Correct Answer: C
Rationale: An expected outcome for the client with hypovolemic anemia is to monitor to detect hypoxemia and manage and minimize inadequate oxygenation. The oxygen saturation should be monitored to measure the percentage of oxygen bound to hemoglobin. The nurse should report a sustained oxygen saturation value below 90%. Give oxygen per nasal cannula or simple mask to maintain oxygen saturation at or above 90%. It is important to administer the oxygen first and then contact the charge nurse to alert them. It is not necessary at this time if the client is not in respiratory distress to intubate the client. Placing the client in the supine position would decrease the oxygen saturation level further.
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.