Question 6111)
A client had a resection of the terminal ileum 3 years ago. While obtaining a health history and physical assessment, the nurse finds that the client has weakness, shortness of breath and a sore tongue. Which additional information from the client indicates a need for client teaching?
A. I have been drinking plenty of fluids.
B. I have been gargling with warm salt water for my sore tongue.
C. I have regular bowel movements on most days.
D. I take a vitamin B12 tablet every day.
Answer: D
Explanation: Vitamin B12 combines with intrinsic factor in the stomach and is then carried to the ileum, where it is absorbed into the bloodstream.
Question 6112)
A client who follows a vegetarian diet was referred to a dietician for nutritional counselling for anemia. Which client outcome indicates that the client does not understand nutritional counselling? The client:
A. adds dried fruit to cereal and baked goods.
B. cooks tomato-based foods in iron pots.
C. drinks coffee or tea with meals.
D. adds vitamin C to all meals.
Answer: C
Explanation: Coffee and tea increase gastrointestinal motility and inhibit the absorption of nonheme iron.
Question 6113)
A client was admitted to the hospital with iron deficiency anemia and blood streaked emesis. Which question is most appropriate for the nurse to ask in determining the extent of the client's activity intolerance?
A. What daily activities were you able to do 6 months ago compared with the present?
B. How long have you had this problem?
C. Have you been able to keep up with all your usual activities?
D. Are you more tired now than you used to be?
Answer: A
Explanation: It is difficult to determine activity intolerance without objectively comparing activities from one-time frame to another.
Question 6114)
Which position would most help to decrease a client's discomfort when the client's spouse injects vitamin B12 using the ventrogluteal site?
A. Lying on the side with legs extended
B. Lying on the abdomen with toes pointed inward
C. Learning over the edge of a low table with hips flexed
D. standing upright with the feet one shoulder-width apart
Answer: B
Explanation: To promote comfort when injecting at the ventrogluteal site, the position of choice is with the client lying on the abdomen with toes pointed inward.
Question 6115)
A client has fatigue, temperature of 99.5 degree F, dark bronze skin, and dark urine. Hemoglobin is 9 g/dL, hematocrit is 49 and red blood cells are 2.75 million/uL. What should the nurse do first?
A. Initiate an intake and output record.
B. Place the client on bed rest.
C. Place the client on contact isolation.
D. Keep the client out of sunlight.
Answer: A
Explanation: The nurse should prepare to start an intake and output record because the client is exhibiting clinical manifestations of anemia with jaundice and is demonstrating a fluid imbalance.
Question 6116)
When a client is receiving a cephalosporin, the nurse must monitor the client for which finding?
A. Drug-induced haemolytic anemia
B. Purpura
C. Infectious emboli
D. Ecchymosis
Answer: A
Explanation: Drug-induced hemolytic anemia is acquired,antibody-mediated, RBC destruction precipitated by medications, such as cephalosporins, sulfa drugs, rifampin, methyldopa, procainamide, quinidine, and thiazides.
Question 6117)
A client is to have a Schilling's test. The nurse should:
A. administer methylcellulose.
B. start a 24 to 48 hour urine specimen collection.
C. maintain nothing by mouth status.
D. start a 72 hour stool specimen collection.
Answer: B
Explanation: Urinary vitamin B12 levels are measured after the ingestion of radioactive vitamin B12.
Question 6118)
A client with pernicious anemia is receiving vitamin B12. The nurse should evaluate the client for which expected outcomes of vitamin B12?
A. increased energy
B. healed tongue and lips
C. absence of paresthesias
D. improved clotting time
Answer: C
Explanation: Pernicious anemia is caused by a lack of vitamin B12, primary symptoms including neuropathy with paresthesias of hands and feet.
Question 6119)
The nurse is assessing a client's activity tolerance. Which report from a treadmill test indicates an abnormal response?
A. pulse rate increased by 20 bpm immediately after the activity
B. respiratory rate decreased by 5 breaths/min
C. diastolic blood pressure increased by 7 mm Hg.
D. pulse rate within 6 bpm of resting pulse after 3 minutes of rest
Answer: B
Explanation: The normal physiologic response to activity is an increased metabolic rate over the resting basal rate.
Question 6120)
In a postoperative client, the hematocrit decreased from 36% to 34% on the 3rd day even though the red blood cell (RBC) count and hemoglobin, value remained stable at 4.5 million/uL and 11.9 g/dL, respectively. The nurse should next:
A. check the dressing and drains for frank bleeding.
B. call the healthcare provider.
C. continue to monitor vital signs.
D. start oxygen at 2 L/min per nasal cannula.
Answer: C
Explanation: The nurse should continue to monitor the client because this value reflects a normal physiologic response.
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