NR-324 Adult Health I - Set 4 - Part 2

Correct Answer: Risk for injury from impaired sensation

Diminished sensitivity to heat and pain plus lost position sense means this client can fall or burn without noticing. Protecting from falls, burns and trauma outranks the fatigue every anemic client has. Option b is incorrect because fatigue and reduced tolerance for activity are real in this anemia but they do not threaten the client immediately. Neurological loss that allows an unnoticed burn or fall does. Option c is incorrect because a sore, beefy red tongue does interfere with eating and deserves mouth care, yet it causes discomfort rather than harm. Nothing about it can injure the client suddenly. Option d is incorrect because the pale yellow skin tone comes from bilirubin released as fragile megaloblasts break down, and it resolves with treatment. Appearance never outranks a hazard that can cause physical harm.

Correct Answer: Shave the client with an electric razor only

An electric razor removes the commonest way a client with a very low platelet count nicks the skin. Blade shaving, firm brushing, alcohol rinses and rectal insertions all breach fragile tissue. Option a is incorrect because stiff bristles injure the gums and start the very bleeding the instruction claims to control. A soft bristle toothbrush is the standard precaution for a low platelet count. Option c is incorrect because alcohol dries the oral mucosa and makes the gums more likely to bleed. Rinses containing alcohol are specifically excluded from the teaching list for these clients. Option d is incorrect because suppositories, enemas and rectal thermometers can tear the rectal mucosa and cause bleeding that is hard to see and hard to stop. Constipation is prevented with fluids instead.

Correct Answer: Hold the transfusion and notify the prescriber

Signed informed consent obtained by the prescriber is a prerequisite for transfusion, alongside the order and the crossmatch. The nurse holds the product and notifies the prescriber, who discusses risks, benefits and alternatives and obtains the signature. Option a is incorrect because the nurse may witness a signature but cannot supply the discussion of risks, benefits and alternatives that makes the consent informed. That conversation belongs to the prescriber ordering the product. Option b is incorrect because a witnessed verbal agreement does not replace the signed document required before blood is given. A charge nurse has no authority to substitute for the prescriber in this process. Option c is incorrect because an order authorizes the therapy but says nothing about whether the client agreed to it. Starting without documented agreement exposes the client to a risk they never accepted.

Correct Answer: The client whose stoma is dusky

A dusky or pale stoma signals inadequate perfusion of bowel living on a tenuous blood supply. Ischemia progresses to necrosis and reoperation, so this client outranks pain, a leaking appliance and teaching needs. Option b is incorrect because moderate incision pain after surgery is expected and can be treated once the unstable finding is handled. Analgesia matters, but it does not compete with threatened bowel viability. Option c is incorrect because a leaking pouch threatens peristomal skin and dignity and needs prompt refitting, yet skin breakdown develops over hours. Perfusion loss in the stoma develops much faster and comes first. Option d is incorrect because discharge teaching is important but never urgent. Education can be delivered at any point in the shift, whereas a stoma losing its blood supply has a narrow window before necrosis.

Correct Answer: Stop the infusion at the four hour limit

A unit must be completed within four hours because bacteria multiply in blood held at room temperature. The nurse stops the infusion at the limit and notifies the provider and blood bank, who can split a future unit. Option a is incorrect because the four hour ceiling is absolute and is not extended by slowing the drip. Running longer increases the time bacteria have to multiply in a warm unit at the bedside. Option b is incorrect because a unit that has hung at room temperature cannot be returned to storage and reissued. Once spiked, the product is used within the time limit or discarded according to policy. Option d is incorrect because rushing a large volume into an older adult invites circulatory overload, with crackles, dyspnea and jugular venous distension. Speed cannot be traded against the hazard of finishing the unit late.

Correct Answer: A tender palpable abdominal mass

Acute diverticulitis inflames sigmoid pouches, producing left lower quadrant pain with fever, leukocytosis with a left shift, a raised C reactive protein and often a palpable tender mass in that quadrant. Option a is incorrect because tenesmus with small bloody stools reflects rectal inflammation and points to ulcerative colitis. Diverticulitis produces localized pain and infection signs rather than an urgent painful need to defecate. Option c is incorrect because migration toward the right lower quadrant belongs to appendicitis, where visceral periumbilical pain becomes somatic over the appendix. Diverticular pain stays on the left, where the sigmoid pouches sit. Option d is incorrect because forceful vomiting without nausea suggests a central nervous system lesion raising intracranial pressure. Vomiting in diverticulitis, when present, follows the abdominal inflammation and is preceded by nausea.

Correct Answer: The client whose type is AB positive

A person of group AB positive carries the A antigen, the B antigen and the D antigen, and therefore carries no antibodies against A, B or D. That makes AB positive the universal red cell recipient. Option b is incorrect because a client of group B produces antibodies directed at the A antigen from early childhood. Those antibodies would attack the donor cells immediately and trigger an acute hemolytic reaction. Option c is incorrect because group O plasma holds antibodies against both A and B, and an Rh negative client must not be given Rh positive cells. The unit fails on two separate counts. Option d is incorrect because this client lacks the D antigen and would be sensitized by Rh positive blood, and group B plasma also attacks A antigen. Sensitization threatens later transfusions and future pregnancies.

Correct Answer: The result may be falsely negative

Proton pump inhibitors, bismuth and antibiotics suppress the organism without eradicating it, so urea breath, stool antigen and biopsy urease tests can read negative while infection persists. These agents are withheld before testing. Option a is incorrect because acid suppression reduces rather than inflates the measurable organism burden. Nothing in this drug history would exaggerate the labeled carbon dioxide returned in the breath after the urea dose. Option c is incorrect because bismuth darkens the stool and the tongue rather than anything in exhaled air. The breath study measures an isotope in expired gas, which no pigment can affect. Option d is incorrect because it describes serology. Antibody testing shows exposure only and cannot confirm cure, whereas the breath test is one of the studies that identifies active infection when drugs are not suppressing the organism.

Correct Answer: The client with tingling likely lacks B12

Both deficiencies enlarge the red cell identically, so the MCV cannot separate them. Only vitamin B12 damages myelin, so paresthesia, lost position sense and an unsteady gait point to the B12 deficient client. Option a is incorrect because folate deficiency produces the same large cells and sore tongue but never the neurological findings. Assigning both clients to folate leaves the tingling and gait change unexplained. Option b is incorrect because a shortage of iron makes the cell small, giving a volume under eighty femtoliters. A value above one hundred rules that mechanism out for both of these clients. Option d is incorrect because it reverses the discriminator. Absent neurological signs point toward folate, while the nerve findings belong to the client whose myelin is failing for want of cobalamin.

Correct Answer: Serum iron low, ferritin low, total iron binding capacity high

Iron and ferritin fall because circulating iron and stores are depleted, while the liver makes extra transferrin to hunt for scarce iron. More carrier protein means the total iron binding capacity rises. Option a is incorrect because it reverses the binding capacity. Capacity measures how much transferrin is available rather than how much iron is present, and empty stores drive that carrier protein upward, not downward. Option b is incorrect because a high ferritin with a low binding capacity describes anemia of chronic inflammation, where iron is trapped in storage cells. This client is losing iron monthly instead. Option c is incorrect because a high serum iron alongside high ferritin fits iron overload such as hemochromatosis or repeated transfusion. A client bleeding heavily every month cannot be carrying excess iron.

Correct Answer: Duodenal ulcer, where food buffers acid

Duodenal ulcer pain arrives two to five hours after a meal, is relieved by food or antacids, and characteristically wakes the client at night when the stomach is empty and acid is unbuffered. Option b is incorrect because gastric ulcer pain appears sooner, roughly one to two hours after eating, and food does not reliably relieve it and may aggravate it. Clients often lose weight because eating hurts. Option c is incorrect because stress related mucosal damage follows major trauma, burns, sepsis or mechanical ventilation and frequently presents as painless bleeding. It does not produce a rhythmic pattern tied to meals. Option d is incorrect because gastric outlet obstruction presents with copious vomiting of undigested food eaten hours earlier, epigastric fullness and weight loss. Relief after a snack is the opposite of that picture.

Correct Answer: Packed red blood cells to treat the anemia

Packed red blood cells are the product for symptomatic anemia and blood loss, and they are the most commonly transfused component. Each unit raises the hemoglobin roughly one gram per deciliter and the hematocrit about three percent. Option a is incorrect because fresh frozen plasma carries clotting factors and no red cells, so it cannot improve oxygen delivery. It is reserved for bleeding caused by multiple factor deficiencies such as liver failure. Option b is incorrect because cryoprecipitate supplies fibrinogen for a client whose fibrinogen level is low and who is bleeding. This client has lost red cell mass, not fibrinogen, so cryoprecipitate would do nothing useful. Option d is incorrect because platelets are given for thrombocytopenia or platelet dysfunction with bleeding. Nothing in this situation suggests a low platelet count, and adding platelets leaves the oxygen carrying deficit completely uncorrected.

Correct Answer: Label the bag with the date and time hung

Formula at room temperature grows bacteria, so open system bags carry limited hang times. Labelling with the date and time hung is what allows the bag to be discarded at the correct point. Option a is incorrect because heating formula in a water bath encourages bacterial growth and can scald the gut. Formula is allowed to reach room temperature on its own before it is hung. Option c is incorrect because pouring fresh formula into a partly used bag restarts nothing; the old contents remain, and the container has been open and warm for hours. Bags are emptied and replaced. Option d is incorrect because a hang time limit is set by contamination risk, not by how much fluid is left. Any formula remaining when that limit expires is discarded rather than infused.

Correct Answer: The total iron binding capacity in each

Serum iron falls in both conditions, so it cannot separate them. Binding capacity rises in iron deficiency because transferrin increases, and it stays low or normal when inflammation traps iron inside storage cells. Option a is incorrect because both pictures can show a cell size at or just below the lower cut off. Chronic inflammation is often normocytic and sometimes mildly microcytic, so size alone settles nothing. Option b is incorrect because circulating iron is reduced in iron deficiency and also in anemia of chronic inflammation, where iron is sequestered away from the marrow. An identical result in both tells the nurse nothing. Option c is incorrect because the reticulocyte count shows only whether the marrow is responding, and it is low in both of these production problems. It separates production failure from hemolysis instead.

Correct Answer: Crohn disease with transmural skip lesions

Skip lesions, cobblestoning, perianal fistula and abscess, malabsorptive weight loss and right lower quadrant pain all follow from transmural inflammation that can appear anywhere from mouth to anus. Terminal ileal disease is most common. Option b is incorrect because ulcerative colitis is continuous from the rectum proximally and stops at the submucosa, so it produces bloody diarrhea and tenesmus without skip lesions, fistulas or perianal abscesses. Option c is incorrect because diverticulitis causes acute left lower quadrant pain with fever and leukocytosis over days, not months of diarrhea and wasting. Cobblestoning and intervening healthy segments are not part of it. Option d is incorrect because celiac disease is an immune reaction to gluten that flattens small intestinal villi, giving steatorrhea and deficiency states. It does not create fistulas, abscesses or endoscopic cobblestoning.

Correct Answer: Apply supplemental oxygen to correct the hypoxemia

Oxygenated hemoglobin S does not polymerize, so correcting a saturation of eighty eight percent attacks the sickling process itself. Oxygen comes first, followed closely by analgesia, then hydration, then transfusion if needed. Option a is incorrect because hydration dilutes intracellular hemoglobin and improves flow, but it does nothing about the low saturation that is driving cells to sickle right now. Fluids follow oxygen and analgesia. Option b is incorrect because the opioid must certainly be given and severe pain is treated aggressively in this disease. Relieving pain does not reverse the hypoxemia that is generating new sickled cells. Option d is incorrect because transfusion is reserved for severe anemia, acute chest syndrome, stroke or surgery, and it takes considerable time to arrange. The immediate threat here is a saturation below ninety.

Correct Answer: Hold the dose and notify the provider

Lip smacking and involuntary tongue movement are tardive dyskinesia, a potentially irreversible movement disorder that carries a boxed warning for this drug. The dose is held and the provider notified before further doses are given. Option a is incorrect because altering the timing does not reverse a dopamine blocking effect on movement. This drug is normally given half an hour before meals and at bedtime, but continuing it now is unsafe. Option c is incorrect because these movements are not sedation and are not expected. Treatment with this agent is capped at twelve weeks precisely because the risk of a permanent movement disorder rises with duration. Option d is incorrect because comfort measures do nothing for a neurologic adverse effect, and waiting another day allows more drug exposure. Every further dose increases the chance the movements become permanent.

Correct Answer: The stomach or duodenum, an upper source

Melena is black, tarry and foul smelling because hemoglobin has been digested by acid, enzymes and bacteria during transit. That takes time and volume, so the source lies in the upper tract. Option a is incorrect because bleeding from the sigmoid colon reaches the rectum quickly and appears as red or maroon blood. There is neither the acid exposure nor the transit time needed to blacken it. Option b is incorrect because hemorrhoidal bleeding is bright red, often seen on the tissue or coating formed stool, and is painless. It never produces the sticky tar like consistency described here. Option c is incorrect because the descending colon sits too far distally for digestion of blood to occur. Left sided colonic bleeding presents as hematochezia, and the classic cause there is diverticular bleeding.

Correct Answer: Erythropoietin that stimulates the bone marrow

Erythropoietin is a glycoprotein growth factor released mainly by the kidney when oxygen delivery falls, and it stimulates the marrow to increase red cell production. Damaged kidneys make less, so red cell production drops. Option a is incorrect because intrinsic factor comes from gastric parietal cells, not from the kidney, and its loss produces a macrocytic vitamin B12 deficiency rather than the normocytic anemia that renal failure causes. Option b is incorrect because ferritin is the storage protein that holds iron inside tissue cells. It measures how full the iron stores are and has no signaling role in driving marrow production. Option d is incorrect because transferrin is the plasma carrier protein that transports iron to the marrow. The liver makes it, and a shortage of it does not explain anemia arising from kidney damage.

Correct Answer: Serve only thoroughly cooked food and wash hands first

Protective isolation guards a pancytopenic client from the environment. All food is thoroughly cooked, fresh produce is avoided, and meticulous hand hygiene before every contact is the single most effective measure. Option a is incorrect because uncooked fruit and vegetables carry organisms that a client with almost no neutrophils cannot fight. The diet for protective isolation deliberately excludes fresh produce. Option c is incorrect because negative pressure pulls room air inward and is used to keep organisms from escaping, as with tuberculosis. This client needs positive pressure so that outside air never flows in. Option d is incorrect because anything inserted rectally can tear fragile mucosa in a client whose platelet count is very low. Rectal thermometers, suppositories and enemas are all avoided during bleeding precautions.