Nokea
The nurse is performing an assessment on a client with possible pernicious anemia. Which data would support this diagnosis?
- A. A weight loss of 10 pounds in 2 weeks
- B. Complaints of numbness and tingling in the extremities
- C. A red, beefy tongue
- D. A hemoglobin level of 12.0 gm/dL
Correct Answer: C
Rationale: A red, beefy tongue is a classic sign of pernicious anemia due to vitamin B12 deficiency affecting mucosal tissues.
You may also like to solve these questions
A client scheduled for a carotid endarterectomy requires insertion of an intra-arterial blood pressure-monitoring device. The nurse plans to perform the Allen test. Which observation indicates patency of the ulnar artery?
- A. Blanching of the hand on compression and release of the ulnar artery
- B. Muscular twitching of the bicep muscle with use of a tourniquet at the wrist
- C. Hand turning pink after the nurse releases the pressure on the ulnar artery
- D. Flexion of the wrist when tapping the ulnar artery with a reflex hammer
Correct Answer: C
Rationale: The Allen test assesses collateral circulation. The hand turning pink after releasing ulnar artery pressure indicates patency, ensuring adequate blood flow if the radial artery is cannulated.
The nurse is caring for a 27-year-old client in active labor. After reviewing the fetal heart tone strip shown, the nurse should take which action first?
- A. reposition the client
- B. draw a potassium level
- C. notify the health care provider
- D. prepare the client for a cesarean section
Correct Answer: A
Rationale: Repositioning the client is the first step to improve fetal oxygenation if the fetal heart tone strip shows distress, as it is non-invasive and may resolve the issue.
A client has been receiving cyanocobalamine (B12) injections for the past six weeks. Which laboratory finding indicates that the medication is having the desired effect?
- A. Neutrophil count of 60%
- B. Basophil count of 0.5%
- C. Monocyte count of 2%
- D. Reticulocyte count of 1%
Correct Answer: D
Rationale: Increased reticulocyte count indicates effective B12 therapy for anemia.
A client with a missed abortion at 29 weeks gestation is admitted to the hospital. The client will most likely be treated with:
- A. Magnesium sulfate
- B. Calcium gluconate
- C. Dinoprostone (Prostin E.)
- D. Bromocrystine (Parlodel)
Correct Answer: C
Rationale: Dinoprostone is used to induce uterine contractions and facilitate expulsion in a missed abortion.
The nurse is caring for a 9-year-old child admitted with asthma. Upon the morning rounds, the nurse finds an O2 sat of 78%. Which of the following actions should the nurse take first?
- A. Notify the physician
- B. Do nothing; this is a normal O2 sat for a 9-year-old
- C. Apply oxygen
- D. Assess the child's pulse
Correct Answer: C
Rationale: An O2 sat of 78% indicates severe hypoxemia, so applying oxygen is the first action to stabilize the child.