The nurse caring for a client with anemia recognizes which clinical manifestation as the one that is specific for a hemolytic type of anemia?
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Solution
Answer A is correct. In hemolytic anemia, destruction of red blood cells causes the release of bilirubin, leading to the yellow hue of the skin. Answers C and D occur with several anemias, but they are not specific to hemolytic. Answer B does not relate to anemia.
Which action by the nurse would be most effective in relieving phantom limb pain on a client with an above-the-knee amputation?
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Solution
Answer C is correct. The TENS unit is applied for pain relief. A TENS unit is a batteryoperated unit applied to the skin that stimulates non–pain receptors in the same areas that transmit the pain. This is the only answer that actually does anything about the pain the client is experiencing. Answer A is a psychosocial acknowledgment. Answers B and D might help the pain, but answer C would help more.
The nurse is observing a student perform the skill of intramuscular injection by the Z track method. Which technique would the student utilize to prevent tracking of the medication?
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Solution
Answer D is correct. The 0.2mL of air that would be administered after the medication with an intramuscular injection would allow the medication to be dispersed into the muscle. In answer A, the muscle is too small. Answer C is an incorrect procedure, and answer B doesn’t help prevent tracking.
An elderly female is admitted with a fractured right femoral neck. Which clinical manifestation would the nurse expect to find?
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Solution
Answer D is correct. Symptoms of a fractured right femoral neck include shortened, adducted, and external rotation. Answer A is incorrect because the patient usually is unable to move the leg because of pain. Answers B and C are incorrect because the fracture will cause adduction instead of abduction, and external rotation rather than internal rotation.
The nurse is reinforcing teaching to a client with iron-deficiency anemia about a high-iron diet. The nurse recognizes that teaching has been effective when the client selects which meal plan?
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Solution
Answer B is correct. This selection is the one with the highest iron content. Other foods high in iron include cream of wheat, oatmeal, liver, collard greens and mustard greens, clams, chili with beans, brown rice, and dried apricots. Answers A, C, and D are not high in iron.
The orthopedic nurse should be particularly alert for a fat embolus in which of the following clients having the greatest risk for this complication after a fracture?
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Solution
Answer C is correct. Fat emboli occur more frequently with long bone or pelvic fractures and usually in young adults ages 20 to 30. The answers in A, B, and D are not high-risk groups for this complication.
Which of these tasks would it be most appropriate to assign to a nursing assistant?
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Solution
Answer D is correct. It is appropriate for the nursing assistant to perform activity orders for stable clients. It is beyond the role of the nurse’s assistant to perform blood sugars and obtain vital signs on unstable clients, as in answers A and B. A client with a stroke might have dysphasia, which makes answer C inappropriate for the assistant, especially because the client is new and has not been evaluated.
The nurse has given dietary instructions about food to be included in a low-purine diet. Which selection by the client with gout would indicate that teaching has been ineffective?
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Solution
Answer D is correct. Answers A, B, and C are all foods included on a low-purine diet. Spinach should be avoided on a low-purine diet. Other foods to avoid include poultry, liver, lobster, oysters, peas, fish, and oatmeal.
A client is admitted with a diagnosis of pernicious anemia. Which of the following signs or symptoms would indicate that the client has been noncompliant with ordered B12 injections?
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Solution
Answer C is correct. Vitamin B12 is an essential component for proper functioning of the peripheral nervous system. Clients without an adequate vitamin B12 level will have symptoms such as paresthesia due to the deficiency. Answers A and D don’t occur with pernicious anemia. The client would have weight loss rather than weight gain, as in answer B.
A client with sickle cell disease is admitted with pneumonia. Which nursing intervention would be most helpful to prevent a sickling crisis?
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Solution
Answer D is correct. Hydration is needed to prevent slowing of blood flow and occlusion. It is important to perform assessments in answers A, B, and C, but answer D is the best intervention for preventing the crisis.