Nokea
Which would a nurse reinforce in a teaching plan for a home health patient with a hemoglobin of 8.4 mg?
- A. Exercising for periods of 30 minutes daily
- B. Limiting fluid intake
- C. Alternating activity with rest periods
- D. Avoiding the use of oxygen
Correct Answer: C
Rationale: Persons with severe anemia need to conserve their energy. Observing a rest period after a period of activity will reduce hypoxia. Oxygen may be used as necessary.
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The nurse caring for a patient in the emergency room with suspected internal injuries will assess for hypovolemic shock, which is evidenced by which symptom?
- A. irritability.
- B. restlessness.
- C. slow bounding pulse.
- D. decreased respirations.
- E. pallor.
- F. hypotension.
Correct Answer: A,B,E,F
Rationale: Indicators of hypovolemia are restlessness, irritability, rapid thready pulse, increasing respirations, pale, cool moist skin, and hypotension. Should the blood loss continue, the patient could go into hypovolemic shock.
The presence of excess bands in the peripheral blood that indicate severe infection is indicated in which manner?
- A. shift to the left.
- B. shift to the right.
- C. bone marrow aspiration.
- D. thrombocytosis.
Correct Answer: A
Rationale: The presence of excess bands in the peripheral blood is called a shift to the left (i.e., a shift toward immature cells) and indicates severe infection.
A patient has been diagnosed with pernicious anemia. When reinforcing instructions, the nurse explains this disorder results from which process?
- A. Poor nutritional intake of iron
- B. Lack of the intrinsic factor
- C. Blood loss due to hemorrhage
- D. Excess production of red blood cells
Correct Answer: B
Rationale: With pernicious anemia, the body lacks the intrinsic factor. Iron deficiency anemia is caused by poor nutritional iron intake. Blood loss associated anemia is due to hemorrhage. Pernicious anemia is not associated with excess production of red blood cells.
Which food would the nurse recommend to a person with iron-deficiency anemia as an excellent meat source for erythropoiesis?
- A. Dark meat of chicken
- B. Cured ham
- C. Pork chops
- D. Processed meat
Correct Answer: A
Rationale: The dark meat of poultry is a good meat source for erythropoiesis.
The nurse expects the plan of care for a patient with leukemia to focus on which aspect of care?
- A. Prevention of abnormal clotting
- B. Promotion of mobility activities
- C. Frequent transfusions of plasma
- D. Prevention of infectious diseases
Correct Answer: D
Rationale: The white blood cells are abnormal and not functioning well with leukemia, therefore, prevention of infection is a priority of care. A lack of platelets is seen with leukemia, causing excessive bleeding, not abnormal clotting. Promoting mobility is not a priority of care with leukemia. Plasma transfusions are not associated with care of a patient with leukemia.