Cardiovascular System | Hematologic Disorders NCLEX Quiz 9

1. A client with pernicious anemia asks why she must take vitamin B12 injections for the rest of her life. What is the nurse's best response?

“The reason for your vitamin deficiency is an excessive excretion of the vitamin because of kidney dysfunction.”

“The reason for your vitamin deficiency is an increased requirement for the vitamin because of rapid red blood cell production.”

Most clients with pernicious anemia have deficient production of intrinsic factor in the stomach. Intrinsic factor attaches to the vitamin in the stomach and forms a complex that allows the vitamin to be absorbed in the small intestine.Options A. C. and D: The stomach is producing enough acid. there is not an excessive excretion of the vitamin. and there is not a rapid production of RBCs in this condition.

Explanation

Most clients with pernicious anemia have deficient production of intrinsic factor in the stomach. Intrinsic factor attaches to the vitamin in the stomach and forms a complex that allows the vitamin to be absorbed in the small intestine.Options A. C. and D: The stomach is producing enough acid. there is not an excessive excretion of the vitamin. and there is not a rapid production of RBCs in this condition.

2. A client with macrocytic anemia has a burn on her foot and states that she had been watching television while lying on a heating pad. What is the nurse's first response?

Assess for potential abuse

Check for diminished sensations

Document the findings

Clean and dress the area

Macrocytic anemias can result from deficiencies in vitamin B12 or ascorbic acid. Only vitamin B12 deficiency causes diminished sensations of peripheral nerve endings. The nurse should assess for peripheral neuropathy and instruct the client in self-care activities for her diminished sensation to heat and pain.Option A: The burn could be related to abuse. but this conclusion would require more supporting data.Option C: The findings should be documented. but the nurse would want to address the client’s sensations first.Option D: The decision of how to treat the burn should be determined by the physician.

Explanation

Macrocytic anemias can result from deficiencies in vitamin B12 or ascorbic acid. Only vitamin B12 deficiency causes diminished sensations of peripheral nerve endings. The nurse should assess for peripheral neuropathy and instruct the client in self-care activities for her diminished sensation to heat and pain.Option A: The burn could be related to abuse. but this conclusion would require more supporting data.Option C: The findings should be documented. but the nurse would want to address the client’s sensations first.Option D: The decision of how to treat the burn should be determined by the physician.

3. A client states that she is afraid of receiving vitamin B12 injections because of the potential toxic reactions. What is the nurse's best response to relieve these fears?

“Vitamin B12 will cause ringing in the eats before a toxic level is reached.”

“Vitamin B12 may cause a very mild skin rash initially.”

“Vitamin B12 may cause mild nausea but nothing toxic.”

“Vitamin B12 is generally free of toxicity because it is water soluble.”

Vitamin B12 is a water-soluble vitamin. When water-soluble vitamins are taken in excess of the body’s needs. they are filtered through the kidneys and excreted. Vitamin B12 is considered to be nontoxic. Adverse reactions that have occurred are believed to be related to impurities or to the preservative in B12 preparations.Options A. B. and C: Ringing in the ears. skin rash. and nausea are not considered to be related to vitamin B12 administration.

Explanation

Vitamin B12 is a water-soluble vitamin. When water-soluble vitamins are taken in excess of the body’s needs. they are filtered through the kidneys and excreted. Vitamin B12 is considered to be nontoxic. Adverse reactions that have occurred are believed to be related to impurities or to the preservative in B12 preparations.Options A. B. and C: Ringing in the ears. skin rash. and nausea are not considered to be related to vitamin B12 administration.

4. When a client is diagnosed with aplastic anemia. the nurse monitors for changes in which of the following physiological functions?

Bleeding tendencies

Intake and output

Peripheral sensation

Bowel function

Aplastic anemia decreases the bone marrow production of RBCs. WBCs. and platelets. The client is at risk for bruising and bleeding tendencies.Option B: A change in the intake and output is important. but assessment for the potential for bleeding takes priority.Option C: Change in the peripheral nervous system is a priority problem specific to clients with vitamin B12 deficiency.Option D: Change in bowel function is not associated with aplastic anemia.

Explanation

Aplastic anemia decreases the bone marrow production of RBCs. WBCs. and platelets. The client is at risk for bruising and bleeding tendencies.Option B: A change in the intake and output is important. but assessment for the potential for bleeding takes priority.Option C: Change in the peripheral nervous system is a priority problem specific to clients with vitamin B12 deficiency.Option D: Change in bowel function is not associated with aplastic anemia.

5. The nurse is assessing a client's activity intolerance by having the client walk on a treadmill for 5 minutes. Which of the following indicates an abnormal response?

Pulse rate increased by 20 bpm immediately after the activity

Respiratory rate decreased by 5 breaths/minute

Diastolic blood pressure increased by 7 mm Hg

Pulse rate within 6 bpm of resting phase after 3 minutes of rest.

The normal physiologic response to activity is an increased metabolic rate over the resting basal rate. The decrease in respiratory rate indicates that the client is not strong enough to complete the mechanical cycle of respiration needed for gas exchange.Option A: The post activity pulse is expected to increase immediately after activity but by no more than 50 bpm if it is strenuous activity.Option C: The diastolic blood pressure is expected to rise but by no more than 15 mm Hg.Option D: The pulse returns to within 6 bpm of the resting pulse after 3 minutes of rest.

Explanation

The normal physiologic response to activity is an increased metabolic rate over the resting basal rate. The decrease in respiratory rate indicates that the client is not strong enough to complete the mechanical cycle of respiration needed for gas exchange.Option A: The post activity pulse is expected to increase immediately after activity but by no more than 50 bpm if it is strenuous activity.Option C: The diastolic blood pressure is expected to rise but by no more than 15 mm Hg.Option D: The pulse returns to within 6 bpm of the resting pulse after 3 minutes of rest.

6. When comparing the hematocrit levels of a post-op client. the nurse notes that the hematocrit decreased from 36% to 34% on the third day even though the RBC and hemoglobin values remained stable at 4.5 million and 11.9 g/dL. respectively. Which nursing intervention is most appropriate?

Check the dressing and drains for frank bleeding

Call the physician

Continue to monitor vital signs

Start oxygen at 2L/min per NC

The nurse should continue to monitor the client. because this value reflects a normal physiologic response. Immediately after surgery. the client’s hematocrit reflects a falsely high value related to the body’s compensatory response to the stress of sudden loss of fluids and blood. Activation of the intrinsic pathway and the renin-angiotensin cycle via antidiuretic hormone produces vasoconstriction and retention of fluid for the first 1 to 2 day post-op. By the second to third day. this response decreases and the client’s hematocrit level is more reflective of the amount of RBCs in the plasma.Option A: Fresh bleeding is a less likely occurrence on the third post-op day but is not impossible; however. the nurse would have expected to see a decrease in the RBC and hemoglobin values accompanying the hematocrit.Options B and D: The physician does not need to be called. and oxygen does not need to be started based on these laboratory findings.

Explanation

The nurse should continue to monitor the client. because this value reflects a normal physiologic response. Immediately after surgery. the client’s hematocrit reflects a falsely high value related to the body’s compensatory response to the stress of sudden loss of fluids and blood. Activation of the intrinsic pathway and the renin-angiotensin cycle via antidiuretic hormone produces vasoconstriction and retention of fluid for the first 1 to 2 day post-op. By the second to third day. this response decreases and the client’s hematocrit level is more reflective of the amount of RBCs in the plasma.Option A: Fresh bleeding is a less likely occurrence on the third post-op day but is not impossible; however. the nurse would have expected to see a decrease in the RBC and hemoglobin values accompanying the hematocrit.Options B and D: The physician does not need to be called. and oxygen does not need to be started based on these laboratory findings.

7. Which of the following nursing assessments is a late symptom of polycythemia vera?

Headache

Dizziness

Pruritus

Shortness of breath

Pruritus is a late symptom that results from abnormal histamine metabolism.Options A and B: Headache and dizziness are early symptoms from engorged veins.Option D: Shortness of breath is an early symptom from congested mucous membrane and ineffective gas exchange.

Explanation

Pruritus is a late symptom that results from abnormal histamine metabolism.Options A and B: Headache and dizziness are early symptoms from engorged veins.Option D: Shortness of breath is an early symptom from congested mucous membrane and ineffective gas exchange.

8. A client is to receive epoetin (Epogen) injections. What laboratory value should the nurse assess before giving the injection?

Hematocrit

Partial thromboplastin time

Hemoglobin concentration

Prothrombin time

Epogen is a recombinant DNA form of erythropoietin. which stimulates the production of RBCs and therefore causes the hematocrit to rise. The elevation in hematocrit causes an elevation in blood pressure; therefore. the blood pressure is a vital sign that should be checked.Options B. C. and D: The PTT. hemoglobin level. and PT are not monitored for this drug.

Explanation

Epogen is a recombinant DNA form of erythropoietin. which stimulates the production of RBCs and therefore causes the hematocrit to rise. The elevation in hematocrit causes an elevation in blood pressure; therefore. the blood pressure is a vital sign that should be checked.Options B. C. and D: The PTT. hemoglobin level. and PT are not monitored for this drug.

9. A client with microcytic anemia is having trouble selecting food items from the hospital menu. Which food is best for the nurse to suggest for satisfying the client's nutritional needs and personal preferences?

Egg yolks

Brown rice

Vegetables

Tea

Brown rice is a source of iron from plant sources (nonheme iron). Other sources of non heme iron are whole-grain cereals and breads. dark green vegetables. legumes. nuts. dried fruits (apricots. raisins. dates). oatmeal. and sweet potatoes.Option A: Egg yolks have iron but it is not as well absorbed as iron from other sources.Option C: Vegetables are a good source of vitamins that may facilitate iron absorption.Option D: Tea contains tannin. which combines with nonheme iron. preventing its absorption.

Explanation

Brown rice is a source of iron from plant sources (nonheme iron). Other sources of non heme iron are whole-grain cereals and breads. dark green vegetables. legumes. nuts. dried fruits (apricots. raisins. dates). oatmeal. and sweet potatoes.Option A: Egg yolks have iron but it is not as well absorbed as iron from other sources.Option C: Vegetables are a good source of vitamins that may facilitate iron absorption.Option D: Tea contains tannin. which combines with nonheme iron. preventing its absorption.

10. The nurse is teaching a client with polycythemia vera about potential complications from this disease. Which manifestations would the nurse include in the client's teaching plan? Select all that apply.

Hearing loss

Visual disturbance

Headache

Orthopnea

Gout

Weight loss

Polycythemia vera. a condition in which too many RBCs are produced in the blood serum. can lead to an increase in the hematocrit and hypervolemia. hyperviscosity. and hypertension. Subsequently. the client can experience dizziness. tinnitus. visual disturbances. headaches. or a feeling of fullness in the head. The client may also experience cardiovascular symptoms such as heart failure (shortness of breath and orthopnea) and increased clotting time or symptoms of an increased uric acid level such as painful swollen joints (usually the big toe).Options A and F: Hearing loss and weight loss are not manifestations associated with polycythemia vera.

Explanation

Polycythemia vera. a condition in which too many RBCs are produced in the blood serum. can lead to an increase in the hematocrit and hypervolemia. hyperviscosity. and hypertension. Subsequently. the client can experience dizziness. tinnitus. visual disturbances. headaches. or a feeling of fullness in the head. The client may also experience cardiovascular symptoms such as heart failure (shortness of breath and orthopnea) and increased clotting time or symptoms of an increased uric acid level such as painful swollen joints (usually the big toe).Options A and F: Hearing loss and weight loss are not manifestations associated with polycythemia vera.

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