A nurse in a clinic is caring for a client who has suspected anemia. Which of the following laboratory test results should the nurse expect?
Iron 90 mcg/dL
RBC 6.5 million/uL
WBC 4,800 mm3
Hgb 10 g/dL
A nurse is caring for a client who is receiving warfarin for anticoagulation therapy. Which of the following laboratory test results indicates to the nurse that the client needs an increase in the dosage?
aPTT 38 seconds
INR 1.1
PT 22 seconds
D‑dimer negative
A nurse is providing teaching for a client who is scheduled for a bone marrow biopsy of the iliac crest. Which of the following statements made by the client indicates an understanding of the teaching?
“This test will be performed while I am lying flat on my back.”
“I will need to stay in bed for about an hour after the test.”
“This test will determine which antibiotic I should take for treatment.”
“I will receive general anesthesia for the test.”
A nurse is preparing to administer packed RBCs to a client who has a Hgb of 8 g/dL. Which of the following actions should the nurse plan to take during the first 15 min of the transfusion?
Obtain consent from the client for the transfusion.
Assess for an acute hemolytic reaction.
Explain the transfusion procedure to the client.
Obtain blood culture specimens to send to the lab.
A nurse is caring for a client who is receiving a blood transfusion. Which of the following actions should the nurse expect if an allergic transfusion reaction is suspected? (Select all that apply.)
Stop the transfusion.
Monitor for hypertension.
Maintain an IV infusion with 0.9% sodium chloride.
Position the client in an upright position with the feet lower than the heart.
Administer diphenhydramine.
A nurse is monitoring a client who began receiving a unit of packed RBCs 10 min ago. Which of the following findings should the nurse identify as an indication of a febrile transfusion reaction? (Select all that apply.)
Temperature change from 37° C (98.6° F) pretransfusion to 37.2° C (99.0° F)
Current blood pressure 178/90 mm Hg
Heart rate change from 88/min pretransfusion to 120/min
Client report of itching
Client appears flushed
A nurse is providing preoperative teaching for a client who requests autologous donation in preparation for a scheduled orthopedic surgical procedure. Which of the following statements should the nurse include in the teaching?
“you should make an appointment to donate blood 8 weeks prior to the surgery.”
“If you need an autologous transfusion, the blood your brother donates can be used.”
“you can donate blood each week if your hemoglobin is stable.”
“Any unused blood that is donated can be used for other clients.”
A nurse preceptor is observing a newly licensed nurse on the unit who is preparing to administer a blood transfusion to an older adult client. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure?
Inserts an 18‑gauge IV catheter in the client
Verifies blood compatibility and expiration date of the blood with an assistive personnel (AP)
Administers dextrose 5% in 0.9% sodium chloride IV with the transfusion
Obtains vital signs every 15 min throughout the procedure
A nurse is planning care for a client who has Hgb 7.5 g/dL and Hct 21.5%. Which of the following actions should the nurse include in the plan of care? (Select all that apply.)
Provide assistance with ambulation.
Monitor oxygen saturation.
Weigh the client weekly.
Obtain stool specimen for occult blood.
Schedule daily rest periods.
A nurse is teaching a client who has a new prescription for ferrous sulfate. Which of the following information should the nurse include in the teaching?
Stools will be dark red.
Take with a glass of milk if gastrointestinal distress occurs.
Foods high in vitamin C will promote absorption.
Take for 14 days.
A nurse is providing discharge teaching to a client who had a gastrectomy for stomach cancer. Which of the following information should the nurse include in the teaching? (Select all that apply.)
“you will need a monthly injection of vitamin B12 for the rest of your life.”
“Using the nasal spray form of vitamin B12 on a daily basis can be an option.”
“An oral supplement of vitamin B12 taken on a daily basis can be an option.”
“you should increase your intake of animal proteins, legumes, and dairy products to increase vitamin B12 in your diet.”
“Add soy milk fortified with vitamin B12 to your diet to decrease the risk of pernicious anemia.”
A nurse is completing an integumentary assessment of a client who has anemia. Which of the following findings should the nurse expect?
Absent turgor
Spoon‑shaped nails
Shiny, hairless legs
Yellow mucous membranes
A nurse in a clinic receives a phone call from a client seeking information about a new prescription for erythropoietin. Which of the following information should the nurse review with the client?
The client needs an erythrocyte sedimentation rate (ESR) test weekly.
The client should have his hemoglobin checked twice a week.
Oxygen saturation levels should be monitored.
Folic acid production will increase.
A nurse is caring for a client who has disseminated intravascular coagulation (DIC). Which of the following laboratory values indicates the client’s clotting factors are depleted? (Select all that apply.)
Platelets 100,000/mm3
Fibrinogen levels 57 mg/dL
Fibrin degradation products 4.3 mcg/mL
D‑dimer 0.03 mcg/mL
Sedimentation rate 38 mm/hr
A nurse is assessing a client and suspects the client is experiencing DIC. Which of the following physical findings should the nurse anticipate?
Bradycardia
Hypertension
Epistaxis
Xerostomia
A nurse is caring for a client who has idiopathic thrombocytopenic purpura (ITP). The nurse should notify the provider and report possible small‑vessel clotting when which of the following is assessed?
Petechiae on the upper chest
Hypotension
Cyanotic nail beds
Severe headache
A nurse is caring for a client who has DIC. Which of the following medications should the nurse anticipate administering?
Heparin
Vitamin K
Mefoxin
Simvastatin
A nurse is teaching a newly licensed nurse about heparin‑induced thrombocytopenia. Which of the following risk factors for this disorder should the nurse include in the teaching?
Warfarin therapy for atrial fibrillation
Placental abruption
Systemic lupus erythematosus
Heparin therapy for deep‑vein thrombosis
A nurse is admitting a client who reports nausea, vomiting, and weakness. The client has dry oral mucous membranes, temperature 38.5° C (101.3° F), pulse 92/min, respirations 24/min, skin cool with tenting present, and blood pressure 102/64 mm Hg. Urine is concentrated with a high specific gravity. Which of the following are manifestations of fluid volume deficit for which the nurse should monitor? (Select all that apply.)
Decreased skin turgor
Concentrated urine
Low‑grade fever
Tachypnea
A nurse is admitting an older adult client who is experiencing dyspnea, weakness, weight gain of 2 lb, and 1+ bilateral edema of the lower extremities. The client has temperature 37.2° C (99° F), pulse 96/min, respirations 26/min, oxygen saturation 94% on 3 L oxygen via nasal cannula, and blood pressure 152/96 mm Hg. Which of the following manifestations of fluid volume excess should the nurse expect? (Select all that apply.)
Dyspnea
Edema
Weakness
A nurse is assessing a client who is dehydrated for fluid volume deficit. Which of the following findings should the nurse expect in the client?
Moist skin
Distended neck veins
Increased urinary output
Tachycardia
A nurse is caring for an older adult client in a long‑term care facility. The client has become weak and confused. He ate 40% of his breakfast and lunch. The client’s temperature is 38.3° C (100.9° F), pulse 92/min, respirations 20/min, and blood pressure 108/60 mm Hg. He has lost ¾ lb and reports dizziness when assisted to the bathroom. He also has a nonproductive cough with diminished breath sounds in the right lower lobe. Which of the following actions should the nurse take?
Initiate fluid restrictions to limit intake.
Observe for signs of peripheral edema.
Encourage the client to ambulate to promote oxygenation.
Monitor for orthostatic hypotension
A nurse is caring for a client who has a serum sodium level 133 mEq/L and serum potassium level 3.4 mEq/L. The nurse should recognize that which of the following treatments can result in these laboratory findings?
Three tap water enemas
0.9% sodium chloride solution IV at 50 mL/hr
5% dextrose in water solution with 20 mEq of K+ IV at 80 mL/hr
Antibiotic therapy
A nurse is caring for a client who has a serum potassium 5.4 mEq/L. The nurse should assess for which of the following manifestations?
ECG changes
Constipation
Polyuria
A nurse is caring for a client who has a nasogastric tube attached to low intermittent suctioning. The nurse should monitor for which of the following electrolyte imbalances?
Hypercalcemia
Hyponatremia
Hyperphosphatemia
Hypomagnesemia
A nurse is assessing a client who has hyperkalemia. The nurse should identify which of the following conditions as being associated with this electrolyte imbalance?
Diabetic ketoacidosis
Heart failure
Cushing’s syndrome
Thyroidectomy
A nurse is assessing a client for Chvostek’s sign. Which of the following techniques should the nurse use to perform this test?
Apply a blood pressure cuff to the client’s arm.
Place the stethoscope bell over the client’s carotid artery.
Tap lightly on the client’s cheek.
Ask the client to lower her chin to her chest.
A nurse is caring for a client admitted with confusion and lethargy. The client was found at home unresponsive with an empty bottle of aspirin lying next to her bed. Vital signs reveal blood pressure 104/72 mm Hg, heart rate 116/min with regular rhythm, and respiratory rate 42/min and deep. Which of the following arterial blood gas findings should the nurse expect?
pH 7.68 PaO2 96 mm Hg PaCO2 38 mm Hg HCO3− 28 mEq/L
pH 7.48 PaO2 100 mm Hg PaCO2 28 mm Hg HCO3− 23 mEq/L
pH 6.98 PaO2 100 mm Hg PaCO2 30 mm Hg HCO3− 18 mEq/L
pH 7.58 PaO2 96 mm Hg PaCO2 38 mm Hg HCO3− 29 mEq/L
A nurse is caring for a client who was in a motor‑vehicle accident. The client reports chest pain and difficulty breathing. A chest x‑ray reveals the client has a pneumothorax. Which of the following arterial blood gas findings should the nurse expect?
pH 7.06 PaO2 86 mm Hg PaCO2 52 mm Hg HCO3− 24 mEq/L
pH 7.42 PaO2 100 mm Hg PaCO2 38 mm Hg HCO3− 23 mEq/L
A nurse is obtaining arterial blood gases for a client who has vomited for 24 hr. The nurse should expect which of the following acid‑base imbalances to result from vomiting for 24 hr?
Respiratory acidosis
Respiratory alkalosis
Metabolic acidosis
Metabolic alkalosis
A charge nurse is teaching a group of nurses about conditions related to metabolic acidosis. Which of the following statements by a unit nurse indicates the teaching has been effective?
“Metabolic acidosis can occur due to diabetic ketoacidosis.”
“Metabolic acidosis can occur in a client who has myasthenia gravis.”
“Metabolic acidosis can occur in a client who has asthma.”
“Metabolic acidosis can occur due to cancer.”
A nurse is assessing a client who has pancreatitis. The client’s arterial blood gases reveal metabolic acidosis. Which of the following are expected findings? (Select all that apply.)
Bounding pulses
Hyperreflexia
Dysrhythmia
