A nurse is monitoring a client who is undergoing anticoagulant therapy with heparin. Which of the following findings should the nurse identify as a possible indication of hemorrhage?

Correct Answer: A

Rationale: The correct answer is A: Rapid pulse. When a client is undergoing anticoagulant therapy with heparin, the nurse should monitor for signs of hemorrhage. A rapid pulse can indicate internal bleeding, a common complication of anticoagulant therapy. Other choices such as B: Yellowing of the sclera, C: Elevated blood pressure, and D: Pale-colored stools are not typically associated with hemorrhage. Yellowing of the sclera may indicate jaundice, elevated blood pressure may be related to other conditions, and pale-colored stools may indicate liver or gallbladder issues. Rapid pulse is the most pertinent finding related to hemorrhage in this context.

Correct Answer: A

Rationale: Rationale: 1. Aplastic anemia is characterized by bone marrow failure, leading to decreased production of all blood cell types. 2. Pancytopenia refers to low levels of red blood cells, white blood cells, and platelets, consistent with aplastic anemia. 3. Erythrocytosis is an increase in red blood cell count, contradictory to the reduced production in aplastic anemia. 4. Bone marrow hypercellularity indicates increased cellularity, opposite to the hypocellularity seen in aplastic anemia. 5. Reticulocytosis is an elevated number of immature red blood cells, which is not typically seen in the context of bone marrow failure in aplastic anemia. Summary: A is correct as it aligns with the characteristic pancytopenia in aplastic anemia. B, C, and D are incorrect due to their inconsistency with the pathophysiology of the condition.

Correct Answer: A

Rationale: The correct term to describe hemoglobin that has given up its oxygen to the body's cells is "Reduced." When hemoglobin releases oxygen to the body's cells, it becomes deoxygenated or reduced hemoglobin. This term accurately reflects the chemical state of the hemoglobin molecule after oxygen release. Summary of other choices: - B: "Detached" does not accurately describe the process of oxygen release by hemoglobin. - C: "Oxyhemoglobin" refers to hemoglobin bound to oxygen, not after it has given up oxygen. - D: "Hypoxyhemoglobin" refers to hemoglobin with low oxygen levels, not after it has given up oxygen.

Correct Answer: C

Rationale: The correct answer is C: Clubbed fingertips. Clubbing of the fingertips is a sign of long-term hypoxia due to chronic lung disease, causing changes in the nail bed angle and soft tissue around the nails. Pallor (A) is a paleness of the skin and not specific to hypoxia. Dyspnea (B) is difficulty breathing, which can occur in acute or chronic conditions. Pulmonary crackles (D) are abnormal lung sounds indicating fluid in the lungs, commonly seen in conditions like pneumonia. Clubbed fingertips specifically point towards long-term hypoxia in chronic lung disease.

Correct Answer: C

Rationale: The correct first step is to discontinue the blood transfusion (Choice C) because the patient is experiencing symptoms of a transfusion reaction, such as chest pain and warmth. Stopping the transfusion is crucial to prevent further harm. Calling the physician (Choice A) can be done after discontinuing the transfusion. Administering diuretics (Choice B) is not appropriate for this situation. Assessing vital signs and cardiovascular status (Choice D) should be done after stopping the transfusion to monitor the patient's condition.