ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 31 : Caring for Clients With Disorders of the Hematopoietic System Questions
Question 1 of 5
A client with multiple myeloma is complaining of severe pain when the nurse comes in to give a bath and change position. What is the priority intervention by the nurse?
Correct Answer: C
Rationale: When pain is severe, the nurse delays position changes and bathing until an administered analgesic has reached its peak concentration level and the client is experiencing maximum pain relief. Pain medication should never be delayed to assist in the control of the level of pain. Pain will not be relieved by a bath and clean sheets, only analgesics at this point in the client's illness.
Question 2 of 5
A teenaged client with hemophilia sustains a leg laceration after falling off a skateboard and is brought to the emergency department. The laceration is bleeding profusely even with direct pressure to the site. What does the nurse anticipate will be prescribed for administration to control bleeding?
Correct Answer: A
Rationale: Treatment includes transfusion of fresh blood, frozen plasma, factor VIII concentrate, and anti-inhibitor coagulant complex for hemophilia A, factor IX concentrate for hemophilia B, factor XI for hemophilia C, and the application of thrombin or fibrin to the bleeding area. Other measures used to help control bleeding are the administration of fresh frozen plasma, aminocaproic acid that helps to hold a clot in place once it has formed, direct pressure over the bleeding site, and cold compresses or ice packs. Hetastarch, lactated Ringer's, or albumin will not control the bleeding related to hemophilia.
Question 3 of 5
The nurse caring for an older adult with a diagnosis of leukemia would encourage the client to use an electric razor. What is the rationale for this statement by the nurse?
Correct Answer: A
Rationale: In a client with leukemia who is at risk for hemorrhage, the nurse handles the client gently when assisting and encourages the client to use electric razors. Trauma and microabrasions from razors may contribute to anemia from bleeding. Fragile tissues and altered clotting mechanisms may result in hemorrhage even after minor trauma.
Therefore, the nurse inspects the skin for signs of bruising and petechiae and reports melena, hematuria, or epistaxis (nosebleeds). The risks for spontaneous and uncontrolled bleeding or infection from microorganisms are not addressed by the use of electric razors.
Question 4 of 5
A client is found to have a low hemoglobin and hematocrit when laboratory work was performed. What does the nurse understand the anemia may have resulted from? Select all that apply.
Correct Answer: B,C,D
Rationale: Most anemias result from (1) blood loss, (2) inadequate or abnormal erythrocyte production, or (3) destruction of normally formed red blood cells. The most common types include hypovolemic anemia, iron-deficiency anemia, pernicious anemia, folic acid deficiency anemia, sickle cell anemia, and hemolytic anemias. Although each form of anemia has unique manifestations, all share a common core of symptoms. Anemia does not result from infection or inadequate formed white blood cells.
Question 5 of 5
The registered nurse (RN) and licensed practical nurse (LPN) are preparing an educational program for clients who may be at risk for the development of iron-deficiency anemia. Which client(s) would receive the greatest benefit from this program? Select all that apply.
Correct Answer: A,B,C
Rationale: Those who consume a healthy diet absorb less than 10% of the iron in food. Clients whose nutrition is compromised by unhealthy dieting or who cannot afford to eat a healthy diet, lack knowledge about nutrition, or have malabsorption disorders are at great risk for iron-deficiency anemia. An adolescent client with bulimia nervosa has an unhealthy diet. An older adult client on a fixed income may not have the funds to eat a healthy diet. A client with Crohn's disease has a malabsorption syndrome. A client who resides in a nursing home has prepared meals as well as available supplements if required. A client who is a vegetarian is still able to receive ample iron supplementation in the vegetables being eaten.