A nurse is assigned to care for a female patient diagnosed with aplastic anemia. What are the expected outcomes of the nurse's interventions? Note: Credit will be given only if all correct choices and no incorrect choices are selected
Select all that apply. 1. The patient will list three sources of iron that should be included in the daily diet.
2. The patient will identify activities that increase her risk for falls.
3. The patient will demonstrate no complications from blood transfusions.
4. The patient will maintain a hematocrit level of 32%.
5. The patient will have regrowth of hair.
2,3
Rationale 1: The patient with aplastic anemia has increased iron stores and may need iron chelation therapy. Increased dietary iron is not indicated.
Rationale 2: The patient with aplastic anemia is at risk for falls because of the reduced oxygen-carrying capacity of the blood. The patient should be able to identify activities that increase the risk for falls and describe a plan to reduce that risk.
Rationale 3: Blood transfusions may be necessary to replace red blood cells and platelets. The nurse should follow transfusion protocols to help prevent transfusion reactions.
Rationale 4: A hematocrit of 32% is a low value for a female. The goal is a normal hematocrit of 36.1 to 44.3%.
Rationale 5: The patient with aplastic anemia is not expected to lose her hair.
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Which are appropriate responses by the nurse when providing care for a client who is experiencing a situational crisis? Select all that apply
A) "I know just how you feel." B) "I am sorry this happened to you." C) "It's best to stay busy." D) "Things will get better and you will feel better." E) "It could have been worse."
You are working in a long-term care facility with a group of older adults with cardiac disorders. Why would it be important for you to closely monitor an older adult receiving digitalis preparations for cardiac disorders?
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In teaching the pregnant adolescent about nutrition, the nurse should
a. Emphasize the need to eliminate common teen snack foods, because they are too high in fat and sodium. b. Determine the weight gain needed to meet adolescent growth and add 35 lb. c. Suggest that she not eat at fast-food restaurants, to avoid foods of poor nutritional value. d. Realize that most adolescents are unwilling to make dietary changes during pregnancy.
A patient is admitted with an ulcer on the right great toe
The nurse determines that the blood pressure in the patient's right arm is 138 systolic, the left arm is 136 systolic, the right ankle is 65 systolic, and the left ankle is 66 systolic. How does the nurse evaluate these readings? 1. The wound will require debridement. 2. The patient is getting adequate circulation to the feet. 3. This ulcer is not likely to heal. 4. The patient needs intravenous fluids to support intravascular volume.