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
The nurse is caring for a client with hypovolemic anemia who is now in hypovolemic shock. What indication does the nurse have that the client is having inadequate renal perfusion?
Correct Answer: D
Rationale: Urine output of less than 30 to 50 mL/hour reflects inadequate renal perfusion. The kidneys must excrete 30 to 50 mL/hour or 500 mL/24 hours to eliminate wastes sufficiently. Hematuria is an indicator of other problems such as hemorrhagic cystitis, trauma to the bladder, etc. It is not an indicator of renal perfusion. A blood pressure of 90/60 mm Hg does not indicate that the client is having a decrease in renal perfusion nor does jaundice. Jaundice is present when the liver starts to fail.
Question 2 of 5
The LPN is following a plan of care for a client who is being treated for hypovolemic anemia and is at risk for hypovolemic shock. The nurse assesses vital signs and O2 saturation and observes the saturation at 89% for 3 minutes. What should the first action by the nurse be?
Correct Answer: C
Rationale: An expected outcome for the client with hypovolemic anemia is to monitor to detect hypoxemia and manage and minimize inadequate oxygenation. The oxygen saturation should be monitored to measure the percentage of oxygen bound to hemoglobin. The nurse should report a sustained oxygen saturation value below 90%. Give oxygen per nasal cannula or simple mask to maintain oxygen saturation at or above 90%. It is important to administer the oxygen first and then contact the charge nurse to alert them. It is not necessary at this time if the client is not in respiratory distress to intubate the client. Placing the client in the supine position would decrease the oxygen saturation level further.
Question 3 of 5
The nurse provides care for an older adult client, diagnosed with anemia, who has a hemoglobin of 9.6 g/dL and a hematocrit of 34%. To determine the cause of the client's blood loss, which is the priority nursing action?
Correct Answer: B
Rationale: If an older adult is anemic, blood loss from the gastrointestinal (GI) or genitourinary (GU) tracts is suspected. Observing the stool for blood will determine if the source of the client's bleeding is in the GI tract. Iron-deficiency anemia is unusual in older adults because the body does not eliminate excessive iron, thus increasing total body iron stores and necessitating maintenance of hydration. If evaluation of the GI and GU tracts does not reveal a source of bleeding, evaluating the client's diet may be appropriate; however, this is not the priority nursing action. Monitoring the client's body temperature and BP will assist the nurse in determining the source of the client's blood loss, but these are not priority nursing actions.
Question 4 of 5
The nurse is collecting data for a client who has been diagnosed with iron-deficiency anemia. What subjective findings does the nurse recognize as symptoms related to this type of anemia?
Correct Answer: D
Rationale: Most clients with iron-deficiency anemia have reduced energy, feel cold all the time, and experience fatigue and dyspnea with minor physical exertion. The heart rate usually is rapid even at rest. The CBC and hemoglobin, hematocrit, and serum iron levels are decreased. The client would feel cold and not hot. The client is fatigued and able to sleep often with a decrease in appetite, not an increase.
Question 5 of 5
The nurse observes the laboratory studies for a client in the hospital with fatigue, feeling cold all of the time, and hemoglobin of 8.6 g/dL and a hematocrit of 28%. What finding would be an indicator of iron-deficiency anemia?
Correct Answer: A
Rationale: A blood smear reveals erythrocytes that are microcytic (smaller than normal) and hypochromic (lighter in color than normal). It does not reveal macrocytic (larger than normal) or hyperchromic erythrocytes. Clustering of platelets with sickled red blood cells would indicate sickle cell anemia. An increase in the number of erythrocytes would indicate polycythemia vera.