A nurse is caring for a client who has renal failure and is receiving epoetin. The nurse should monitor the client for which of the following adverse effects?

Correct Answer: A

Rationale: The correct answer is A: Hypertension. Epoetin is a medication used to stimulate red blood cell production in patients with renal failure. One of the potential adverse effects of epoetin therapy is an increase in blood pressure due to the rapid rise in red blood cell count. This can lead to hypertension. Monitoring for hypertension is crucial to prevent any complications. The other choices, muscle pain, edema, and dry mouth, are not directly associated with epoetin therapy in renal failure patients. Muscle pain could be a general issue but not specific to this medication. Edema is more commonly associated with fluid retention in renal failure, and dry mouth is not a typical adverse effect of epoetin therapy.

Correct Answer: B

Rationale: The correct answer is B: A low mean corpuscular volume. In iron deficiency anemia, there is a decreased amount of iron available for hemoglobin synthesis, leading to smaller and paler red blood cells. This results in a low mean corpuscular volume (MCV). Atrophic gastritis (choice A) is associated with vitamin B12 deficiency anemia, not iron deficiency anemia. Choice C (reduced total iron binding capacity) is incorrect because in iron deficiency anemia, there is an increased total iron binding capacity due to the body's attempt to capture more iron. Megaloblastic changes in the bone marrow (choice D) are seen in megaloblastic anemia, not iron deficiency anemia.

Correct Answer: C

Rationale: The correct answer is C: Posterior iliac crest. A bone marrow biopsy is commonly performed at the posterior iliac crest because it provides easy access to the bone marrow. This site has a high concentration of red bone marrow, making it an ideal location for obtaining a bone marrow specimen. The iliac crest is also a flat and easily accessible surface, which allows for safe and efficient insertion of the biopsy needle. Ribs (A) are not typically used due to the risk of puncturing the lungs. The humerus (B) is not a common site for bone marrow biopsy. Long bones in the legs (D) are not typically used due to the difficulty in accessing the bone marrow at those sites.

Correct Answer: B

Rationale: The correct answer is B: Removal of old red blood cells from circulation. The spleen is responsible for filtering and removing old or damaged red blood cells from the bloodstream. When the spleen is removed, this function is compromised, leading to a decreased ability to clear out old red blood cells. This can result in an increased risk of anemia and other complications related to the breakdown of red blood cells. Choices A, C, and D are incorrect: A: Filtration of waste products - The spleen primarily filters blood cells, not waste products. C: Clearance of mucous in the tracheobronchial tree - This function is mainly carried out by the respiratory system, not the spleen. D: Facilitation of glucose to be used by the cell for energy - This is a function of the pancreas and insulin, not the spleen.

Correct Answer: A

Rationale: The correct answer is A: Vital signs. During a blood transfusion, the nurse should monitor the patient's vital signs regularly to detect any signs of a transfusion reaction, such as fever, chills, rash, or hypotension. Vital signs provide crucial information about the patient's overall condition and can help the nurse identify and respond promptly to any adverse reactions. Skin turgor (B), bowel sounds (C), and pupil reactivity (D) are not directly related to monitoring for transfusion reactions and are not sensitive indicators of an adverse reaction during a blood transfusion. Monitoring vital signs is essential for patient safety and early detection of any complications during the transfusion process.