1.
You admit a 23 yr old african american female patient w/ a diagnosis of rule-out anemia. She has a hx of gastric bypass surgery for obesity 4 yrs ago. Current assessment findings are P 110, R 27, BP 104/66, pale mucous membranes and dyspnea upon exertion. Which type of anemia would you expect the patient has developed?
Correct Answer
A. Vit B12 deficiency
Explanation
The rugae in the stomach produces IF to allow the body to use B12. Gastric bypass reduces the amount of rugae drastically.
2.
The patient dx with menorrhagia complains to the nurse of feeling listless and tired all the time. Which scientific rationale would explain why these symptoms are happening?
Correct Answer
D. The menorrhea has caused the patient to have decreased hemoglobin
Explanation
Menorrhagia is excessive blood loss during the menses. If blood loss is severe, then the patient will not have the blood's oxygen carrying capacity needed for daily activities. The most frequent symptom and complication of anemia is fatigue.
3.
SATA. You write a dx of altered tissue perfusion for your patient dx with anemia. Which interventions should you include
Correct Answer(s)
A. Monitor hb and hct
B. Move the patient closer to the nurse's station.
D. Assess for numbness and tingling
E. Allow for periods of rest during the day
Explanation
Nurse should monitor hb and act in all patients dx with anemia. Decreased O2 levels can cause confusion and safety issues so the patient should be near the nurses station. Numbness and tingling is a near symptom of anemia. Fatigue is the most common symptom of anemia.
4.
A patient that has dx of iron deficiency anemia is prescribed ferrous gluconate orally. Which should the nurse educate on.
Correct Answer
C. Stool may be very dark and can mask appearance of blood
Explanation
Stool will be a dark-green black, which can mask appearance of blood in stool
5.
The nurse and a UAP are taking care of patients. What task can the nurse delegate?
Correct Answer
B. Take vitals of a patient who received blood a day prior
Explanation
The UAP can take vitals of a stable patient.
6.
A patient is being admitted with a dx of folic acid deficiency anemia. Which is the most appropriate referral?
Correct Answer
A. Alcoholic anonymous
Explanation
Most patients dx with folic acid deficiency anemia have developed anemia from chronic ETOH abuse.
7.
The charge nurse is making assignments on a medical floor. Which patient should be assigned to the most experienced nurse?
Correct Answer
C. A patient dx with aplastic anemia who has developed pancytopenia.
Explanation
Pancytopenia develops when the bone marrow is not able to produce cells of any kind. The patient has anemia, thrombocytopenia, and leukopenia. This pt could develop an infection or hemorrhage, have CHF, or other complications.
8.
A patient dx with anemia begins to c/o dyspnea when ambulating. Which intervention should you implement first?
Correct Answer
B. Get a wheelchair.
Explanation
The patient has dyspnea upon exertion which is common for patients with anemia.
9.
You are discharging a patient dx with anemia. What should you educate on?
Correct Answer
C. Have a CBC checked at the HCP office.
Explanation
The patient should have a CBC regularly to determine status of anemia.
10.
You write a client problem of activity intolerance for a patient dx with anemia. Which intervention should you implement?
Correct Answer
A. Pace activities according to tolerance.
Explanation
The patient's problem is activity intolerance and pacing of activities directly affects the diagnosis.
11.
Mild anemia has which as a symptom
Correct Answer
A. Asymptomatic
Explanation
Mild anemia is characterized by a low red blood cell count or hemoglobin level, but it does not typically cause noticeable symptoms. Asymptomatic means that there are no apparent signs or symptoms of the condition. Therefore, it is the correct answer for mild anemia as it aligns with the fact that it does not cause any noticeable symptoms in most cases.
12.
Moderate anemia has which as a symptom
Correct Answer
B. Cardiopulmonary symptoms at rest
Explanation
Moderate anemia is characterized by a decrease in the number of red blood cells or a decrease in hemoglobin levels. Cardiopulmonary symptoms at rest are commonly observed in individuals with moderate anemia. These symptoms may include shortness of breath, rapid heartbeat, chest pain, and fatigue. The reduced oxygen-carrying capacity of the blood in moderate anemia can lead to inadequate oxygen supply to the tissues, causing these cardiopulmonary symptoms to occur even during rest.
13.
Severe anemia has which symptoms
Correct Answer
C. Multi-organ problems
Explanation
Severe anemia can lead to multi-organ problems because it results in a decreased amount of oxygen being carried to various organs and tissues in the body. This lack of oxygen can cause dysfunction and damage in multiple organs, leading to symptoms such as fatigue, weakness, shortness of breath, dizziness, pale skin, and rapid heartbeat. The organs most commonly affected by severe anemia include the heart, lungs, brain, and kidneys. Additionally, severe anemia can also lead to complications such as heart failure, stroke, and kidney failure.
14.
Which type of anemia is this? Inadequate dietary intake, malabsorption
Correct Answer
A. Iron-deficiency anemia
Explanation
Iron-deficiency anemia is the correct answer because inadequate dietary intake and malabsorption are both common causes of iron deficiency. Iron is an essential component of hemoglobin, the protein in red blood cells that carries oxygen to the body's tissues. When there is insufficient iron in the body, it leads to a decrease in the production of healthy red blood cells, resulting in iron-deficiency anemia. Acute and chronic blood loss can also cause anemia, but the given information does not mention any bleeding. Vitamin B12 deficiency is not related to inadequate dietary intake or malabsorption, so it is not the correct answer.
15.
Which is a symptom of iron-deficiency anemia?
Correct Answer(s)
A. Pallor
B. Glossitis
C. Cheilitis
D. Pica
Explanation
Internal pain is a sx of acute blood loss and impaired though processes is a sx of folic acid deficiency anemia
16.
Which labs are most important in iron-deficiency anemia?
Correct Answer(s)
A. Hb
B. HCT
C. Platelets
Explanation
The labs that are most important in iron-deficiency anemia are Hb (hemoglobin), HCT (hematocrit), and platelets. Hemoglobin and hematocrit levels are used to assess the severity of anemia and determine the need for treatment. Low platelet levels may indicate bleeding or other complications associated with iron-deficiency anemia. Folate levels and serum B12 are not specific to iron-deficiency anemia and may be useful in diagnosing other types of anemia.
17.
Can you use a stool guaiac test to diagnose iron-deficiency anemia?
Correct Answer
A. Yes
Explanation
Yes, a stool guaiac test can be used to diagnose iron-deficiency anemia. This test detects the presence of blood in the stool, which can indicate bleeding in the gastrointestinal tract. Iron-deficiency anemia can be caused by chronic blood loss, and the stool guaiac test helps identify this underlying cause. Therefore, using a stool guaiac test is a valid method for diagnosing iron-deficiency anemia.
18.
Which -scopy can diagnose iron-deficiency anemia?
Correct Answer(s)
A. Endoscopy
B. Colonoscopy
Explanation
Both endoscopy and colonoscopy can be used to diagnose iron-deficiency anemia. Endoscopy is a procedure that allows a doctor to examine the upper digestive system, including the esophagus, stomach, and small intestine. Colonoscopy, on the other hand, is a procedure that examines the large intestine and rectum. Iron-deficiency anemia can be caused by bleeding in the gastrointestinal tract, which can be detected and diagnosed through both endoscopy and colonoscopy.
19.
Which type of anemia is this? Result of sudden hemorrhage such as trauma or recent surgery
Correct Answer
B. Acute blood loss
Explanation
This type of anemia is known as acute blood loss. Acute blood loss anemia occurs as a result of sudden hemorrhage, such as from trauma or recent surgery. This type of anemia is characterized by a rapid decrease in the number of red blood cells, leading to a decrease in the oxygen-carrying capacity of the blood. Treatment for acute blood loss anemia typically involves addressing the underlying cause of the hemorrhage and providing blood transfusions if necessary.
20.
What are s/sx of acute blood loss?
Correct Answer(s)
A. Increased HR
B. Increased RR
C. Internal pain
D. Numbness
Explanation
The symptoms and signs of acute blood loss include increased heart rate (HR) and increased respiratory rate (RR) as the body tries to compensate for the loss of blood volume. Internal pain may be experienced due to organ ischemia or damage caused by inadequate blood supply. Numbness may occur as a result of reduced blood flow to certain areas of the body. Glossitis, which is inflammation of the tongue, and cheilitis, which is inflammation of the lips, are not typically associated with acute blood loss.
21.
You would do a CBC for acute blood loss. True or false?
Correct Answer
A. True
Explanation
A CBC (Complete Blood Count) is a common blood test that provides information about the different components of blood, such as red blood cells, white blood cells, and platelets. Acute blood loss can lead to a decrease in red blood cells, causing anemia. By performing a CBC, healthcare professionals can assess the levels of red blood cells and other blood components to diagnose and monitor acute blood loss. Therefore, it is true that a CBC would be done for acute blood loss.
22.
Which is a treatment for acute blood loss?
Correct Answer
A. Surgery
Explanation
Surgery is the correct answer because it is a common treatment for acute blood loss. When a person experiences significant blood loss, surgery may be necessary to stop the bleeding and repair any damaged blood vessels or organs. This can involve procedures such as blood vessel ligation, blood transfusions, or even organ removal if necessary. Surgery allows for direct intervention and control of the bleeding source, making it an effective treatment option for acute blood loss.
23.
Which type of anemia is this? Ulcer caused by bacteria or alcoholism. Slow bleed from injury. Menses
Correct Answer
C. Chronic blood loss
Explanation
The given answer, chronic blood loss, is the most appropriate explanation for the symptoms described. Chronic blood loss can occur due to conditions such as ulcers caused by bacteria or alcoholism, slow bleed from injury, or heavy menstrual bleeding. This type of anemia is characterized by a gradual decrease in red blood cell count over time, leading to a deficiency in iron stores and subsequent iron-deficiency anemia. Therefore, chronic blood loss is the most likely cause of the anemia in this case.
24.
What type of anemia is missing intrinsic factor?
Correct Answer
Pernicious anemia, pernicious,
Explanation
Pernicious anemia is a type of anemia that is characterized by the lack of intrinsic factor, a protein produced by the stomach that is necessary for the absorption of vitamin B12. Without intrinsic factor, the body is unable to properly absorb vitamin B12 from the diet, leading to a deficiency of this essential vitamin. This deficiency can result in a decrease in the production of healthy red blood cells, causing symptoms such as fatigue, weakness, and shortness of breath. Therefore, pernicious anemia is the correct answer for the type of anemia that is missing intrinsic factor.
25.
If you do not treat a Vit B12 deficiency, does it cause irreversible neurological damage?
Correct Answer
A. Yes
Explanation
If a Vitamin B12 deficiency is not treated, it can cause irreversible neurological damage. This is because Vitamin B12 is essential for the proper functioning of the nervous system. Without enough Vitamin B12, the nerves can become damaged, leading to symptoms such as tingling, numbness, and difficulty walking. If left untreated for a prolonged period, these neurological symptoms can become permanent. Therefore, it is important to address a Vitamin B12 deficiency to prevent irreversible damage to the nervous system.
26.
What is needed to absorb B12?
Correct Answer
Intrinsic factor, intrisic factor, IF, if
Explanation
In order to absorb B12, the body requires a substance called intrinsic factor. This factor is essential for the absorption of B12 in the small intestine. Without intrinsic factor, the body would not be able to effectively absorb B12 from the diet, leading to a deficiency in this important vitamin.
27.
Erythropoietin is a ________ produced by the kidneys
Correct Answer
Hormone, hormone
Explanation
Erythropoietin is a hormone produced by the kidneys.
28.
What plays a key role in the production of RBCs
Correct Answer
Erythropoietin, erythropoietin
Explanation
Erythropoietin is a hormone that plays a crucial role in the production of red blood cells (RBCs). It is produced primarily by the kidneys and stimulates the bone marrow to produce more RBCs. When the body detects low oxygen levels, such as during high altitude or in cases of anemia, it releases erythropoietin to increase RBC production. This hormone helps maintain the balance of oxygen-carrying RBCs in the bloodstream, ensuring adequate oxygen supply to tissues and organs.
29.
The client diagnosed with RA is being seen in the outpatient clinic. Which preventive care should the nurse include in the regularly scheduled clinic visits?
Correct Answer
C. Recommend the flu and pneumonia vaccines.
Explanation
RA is a disease with many immunological abnormalities. The clients have increased susceptibility to infectious disease, such as the flu or pneumonia, and, therefore, vaccines, which are preventive, should be recommended.
30.
The client with RA has nontender, movable nodules in the subcutaneous tissue over the elbows and shoulders. Which statement is the scientific rationale for the nodules?
Correct Answer
A. The nodules indicate a rapidly progressive destruction of the affected tissue.
Explanation
The nodules may appear over bony prominences and resolve simultaneously. They appear in clients with the rheumatoid factor and are associated with rapidly progressive and destructive disease.
31.
The nurse is assessing a client diagnosed with RA. Which assessment findings warrant immediate intervention?
Correct Answer
D. The client is crying, has a flat facial affect, and refuses to speak to the nurse.
Explanation
The client has the signs and symptoms of depression. The nurse should attempt to intervene with therapeutic conversation and discuss these findings with the HCP.
32.
The client diagnosed with RA who has been prescribed etanercept, a tumor necrosis factor alpha inhibitor, shows marked improvement. Which instruction regarding the use of this medication should the nurse teach?
Correct Answer
B. Continue to have checkups and laboratory work while taking the medication.
Explanation
The drug requires close monitoring to prevent organ damage.
33.
The client diagnosed with RA has developed swan-neck fingers. Which referral is most appropriate for the client?
Correct Answer
B. Occupational therapy
Explanation
The occupational therapist assists the client in the use of the upper half of the body, fine motor skills, and activities of daily living. This is needed for the client with abnormal fingers.
34.
The nurse is planning the care for a client diagnosed with RA. Which intervention should be implemented?
Correct Answer
D. Obtain an order for a sedative.
Explanation
Sleep deprivation resulting from pain is common in clients diagnosed with RA. A mild sedative can increase the client’s ability to sleep, promote rest, and increase the client’s tolerance of pain.
35.
The 20-year-old female client diagnosed with advanced unremitting RA is being admitted to receive a regimen of immunosuppressive medications. Which question should the nurse ask during the admission process regarding the medications?
Correct Answer
A. “Are you sexually active, and, if so, are you using birth control?”
Explanation
Immunosuppressive medications are considered class C drugs and should not be taken while pregnant. These drugs are teratogenic and carcinogenic, and the client is only 20 years old.
36.
Which client problem is priority for a client diagnosed with RA?
Correct Answer
C. Alteration in comfort
Explanation
The client diagnosed with RA has chronic pain; therefore, alteration in comfort is a priority problem.
37.
The nurse is caring for clients on a medical floor. Which client should the nurse assess first?
Correct Answer
C. The client diagnosed with advanced RA who is receiving antineoplastic drugs IV.
Explanation
Antineoplastic drugs can be caustic to tissues; therefore, the client’s IV site should be assessed. The client should be assessed for any untoward reactions to the medications first.
38.
The nurse and a licensed practical nurse are caring for clients in a rheumatologist’s office. Which task can the nurse assign to the licensed practical nurse?
Correct Answer
C. Demonstrate how to use clothing equipped with Velcro fasteners.
Explanation
The nurse cannot assign assessment, evaluation, or teaching or any medication requiring specialized knowledge or skills to administer safely.
39.
The client with early-stage RA is being discharged from the outpatient clinic. Which discharge instruction should the nurse teach regarding the use of nonsteroidal anti-inflammatory drugs (NSAIDs)?
Correct Answer
D. Avoid taking the NSAID on an empty stomach.
Explanation
NSAID medications decrease prostaglandin production in the stomach, resulting in less mucus production, which creates a risk for the development of ulcers. The client should take the NSAID with food.
40.
The nurse is preparing to administer morning medications. Which medication should the nurse administer first?
Correct Answer
A. The pain medication to a client diagnosed with RA.
Explanation
Pain medication is important and should be given before the client’s pain becomes worse.
41.
The school nurse is preparing to teach a health class to ninth graders regarding sexually transmitted diseases. Which information regarding acquired immunodeficiency syndrome (AIDS) should be included?
Correct Answer
D. Abstinence is the only guarantee of not becoming infected with sexually transmitted HIV.
Explanation
Abstinence is the only guarantee the client will not contract a sexually transmitted disease, including AIDS. An individual who is HIV negative in a monogamous relationship with another individual who is HIV negative and committed to a monogamous relationship is the safest sexual relationship.
42.
The nurse is admitting a client diagnosed with protein-calorie malnutrition secondary to AIDS. Which intervention should be the nurse’s first intervention?
Correct Answer
A. Assess the client’s body weight and ask what the client has been able to eat.
Explanation
Assessment is the first step in the nursing process. The nursing process is a good place to start when setting priorities for the nurse’s actions.
43.
The client diagnosed with AIDS is complaining of a sore mouth and tongue. When the nurse assesses the buccal mucosa, the nurse notes white, patchy lesions covering the hard and soft palates and the right inner cheek. Which interventions should the nurse implement?
Correct Answer
B. Notify the HCP for an order for an antifungal swish-and-swallow medication.
Explanation
This most likely is a fungal infection known as oral candidiasis, commonly called thrush. An antifungal medication is needed to treat this condition.
44.
Which type of isolation technique is designed to decrease the risk of transmission of recognized and unrecognized sources of infections?
Correct Answer
D. Standard Precautions.
Explanation
Standard Precautions are used for all contact with blood and body secretions.
45.
The nurse is describing the HIV virus infection to a client who has been told he is HIV positive. Which information regarding the virus is important to teach?
Correct Answer
A. The HIV virus is a retrovirus, which means it never dies as long as it has a host to live in.
Explanation
Standard Precautions are used for all contact with blood and body secretions.
46.
The client who has engaged in needle-sharing activities has developed a flu-like infection. An HIV antibody test is negative. Which statement best describes the scientific rationale for this finding?
Correct Answer
C. The client may be in the primary infection pHase of an HIV infection.
Explanation
The primary phase of infection ranges from being asymptomatic to severe flu-like symptoms, but during this time, the test may be negative although the individual is infected with HIV.
47.
The nurse caring for a client who is HIV positive is stuck with the stylet used to start an IV. Which intervention should the nurse implement first?
Correct Answer
A. Flush the skin with water and try to get the area to bleed.
Explanation
The nurse should attempt to flush the skin and get the area to bleed. It is hoped this will remove contaminated blood from the body prior to infecting the nurse.
48.
The client on a medical floor is diagnosed with HIV encephalopathy. Which client problem is priority?
Correct Answer
D. Risk for injury.
Explanation
Safety is always an issue with a client with diminished mental capacity.
49.
The client diagnosed with Pneumocystis pneumonia (PCP) is being admitted to the intensive care unit. Which HCP’s order should the nurse implement first?
Correct Answer
B. Administer oxygen to the client via nasal cannula.
Explanation
Oxygen is a priority, especially with a client diagnosed with a respiratory illness.
50.
Which intervention is an important psychosocial consideration for the client diagnosed with AIDS?
Correct Answer
C. Complete an advance directive.
Explanation
Clients diagnosed with AIDS should be encouraged to discuss their end-of-life issue with the significant others and to put those wishes in writing. This is important for all clients, not just those diagnosed with AIDS.