Which collaborative treatment would the nurse anticipate for the client diagnosed with DIC?
- A. Administer oral anticoagulants.
- B. Prepare for plasmapheresis.
- C. Administer frozen plasma.
- D. Calculate the intake and output.
Correct Answer: C
Rationale: Frozen plasma (C) replaces clotting factors in DIC. Oral anticoagulants (A) worsen bleeding, plasmapheresis (B) is rare, and I&O (D) is routine.
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Which of the following would be the most appropriate snack for a client who has iron deficiency anemia?
- A. Half of a grapefruit
- B. A carrot raisin salad
- C. A cup of yogurt
- D. Apple slices and cheese
Correct Answer: B
Rationale: Carrot raisin salad contains raisins, which are a good source of iron, making it appropriate for iron deficiency anemia.
The nurse is teaching self-care measures to the client hospitalized with HP. Which measures should the nurse plan to include?
- A. “Use dental floss daily after brushing your teeth.”
- B. “Use only an electric razor when you need to shave.”
- C. “Remove throw rugs in your home and avoid clutter.”
- D. “Increase fiber in your diet and drink plenty of liquids.”
- E. “Keep appointments for monthly platelet transfusions.”
Correct Answer: B, C, D
Rationale: Dental floss can traumatize the gums and increase the risk for bleeding. B. Because the client is at risk for bleeding due to low platelet counts, measures to decrease the risk of bleeding should be implemented, such as using an electric razor. C. Throw rugs and clutter increase the risk for falls with subsequent bleeding. D. Fiber and fluids help prevent constipation. Constipation can lead to hemorrhoids and increase the risk for bleeding. E. Platelet transfusions are usually avoided because the person’s antiplatelet antibodies bind with the transfused platelets, causing them to be destroyed.
The client diagnosed with end-stage renal disease (ESRD) has developed anemia. Which would the nurse anticipate the HCP prescribing for this client?
- A. Place the client in reverse isolation.
- B. Discontinue treatments until blood count improves.
- C. Monitor CBC daily to assess for bleeding.
- D. Give client erythropoietin, a biologic response modifier.
Correct Answer: D
Rationale: ESRD causes erythropoietin deficiency; prescribing erythropoietin (D) treats anemia. Isolation (A), stopping treatment (B), and daily CBC (C) are inappropriate.
The 24-year-old female client is diagnosed with idiopathic thrombocytopenic purpura (ITP). Which question would be important for the nurse to ask during the admission interview?
- A. Do you become short of breath during activity?'
- B. How heavy are your menstrual periods?'
- C. Do you have a history of deep vein thrombosis?'
- D. How often do you have migraine headaches?'
Correct Answer: B
Rationale: ITP causes bleeding; heavy menstrual periods (B) assess bleeding severity. Dyspnea (A), DVT (C), and migraines (D) are unrelated.
The client diagnosed with leukemia has received a bone marrow transplant. The nurse monitors the client’s absolute neutrophil count (ANC). What is the client’s neutrophil count if the WBCs are 2.2 (x103/mm3), neutrophils are 25%, and bands are 5%?
Correct Answer: 660
Rationale: ANC = WBC × (neutrophils% + bands%). WBC = 2,200/mm3, neutrophils = 25%, bands = 5%. ANC = 2,200 × (0.25 + 0.05) = 2,200 × 0.3 = 660/mm3.
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