1. A nurse is caring for a client with an elevated red blood cell count.
The nurse should assess for which of the following complications?
A. Stroke
B. Heart failure
C. Thrombosis
D. Renal failure
Answer: C. Thrombosis
Rationale: An elevated red blood cell count can cause blood to thicken,
increasing the risk for thrombosis (blood clots), which can lead to
complications such as stroke or deep vein thrombosis.
2. A nurse is caring for a client who has polycythemia vera. The nurse
should monitor for which of the following complications?
A. Stroke
B. Hypertension
C. Hyperglycemia
D. Anemia
Answer: A. Stroke
Rationale: Polycythemia vera increases the red blood cell mass, which
increases blood viscosity and the risk for stroke.
,3. A nurse is assessing a client who has been diagnosed with anemia.
Which of the following findings is most consistent with anemia?
A. Increased appetite
B. Hypotension
C. Pale skin
D. Rapid weight gain
Answer: C. Pale skin
Rationale: Anemia reduces the oxygen-carrying capacity of the blood,
which leads to pallor, especially in the skin and mucous membranes.
4. A nurse is caring for a client who is receiving chemotherapy and has
a platelet count of 25,000/mm³. Which of the following is the priority
intervention?
A. Encourage the client to ambulate to increase circulation.
B. Administer a stool softener as prescribed.
C. Monitor for signs of bleeding.
D. Increase the client’s protein intake.
Answer: C. Monitor for signs of bleeding.
Rationale: A platelet count of 25,000/mm³ places the client at
significant risk for bleeding, so the priority is to monitor for signs of
bleeding, such as bruising or petechiae.
, 5. A nurse is caring for a client who is undergoing chemotherapy and is
experiencing neutropenia. Which of the following should the nurse
implement to reduce the client’s risk for infection?
A. Place the client in a room with another patient to decrease isolation.
B. Ensure that all staff and visitors wear masks and gloves.
C. Restrict all visitors from coming into the room.
D. Offer the client fresh fruits and vegetables to promote nutrition.
Answer: B. Ensure that all staff and visitors wear masks and gloves.
Rationale: Neutropenic clients are at high risk for infection, so
precautions such as wearing personal protective equipment (PPE) by
staff and visitors can help reduce exposure to pathogens.
6. A nurse is caring for a client who has a history of frequent blood
transfusions. The nurse should monitor for which of the following
complications?
A. Iron overload
B. Hypokalemia
C. Hypoglycemia
D. Hypernatremia
Answer: A. Iron overload
Rationale: Repeated blood transfusions can lead to iron overload, as the
body has no way to eliminate the excess iron, which can damage
organs.
The nurse should assess for which of the following complications?
A. Stroke
B. Heart failure
C. Thrombosis
D. Renal failure
Answer: C. Thrombosis
Rationale: An elevated red blood cell count can cause blood to thicken,
increasing the risk for thrombosis (blood clots), which can lead to
complications such as stroke or deep vein thrombosis.
2. A nurse is caring for a client who has polycythemia vera. The nurse
should monitor for which of the following complications?
A. Stroke
B. Hypertension
C. Hyperglycemia
D. Anemia
Answer: A. Stroke
Rationale: Polycythemia vera increases the red blood cell mass, which
increases blood viscosity and the risk for stroke.
,3. A nurse is assessing a client who has been diagnosed with anemia.
Which of the following findings is most consistent with anemia?
A. Increased appetite
B. Hypotension
C. Pale skin
D. Rapid weight gain
Answer: C. Pale skin
Rationale: Anemia reduces the oxygen-carrying capacity of the blood,
which leads to pallor, especially in the skin and mucous membranes.
4. A nurse is caring for a client who is receiving chemotherapy and has
a platelet count of 25,000/mm³. Which of the following is the priority
intervention?
A. Encourage the client to ambulate to increase circulation.
B. Administer a stool softener as prescribed.
C. Monitor for signs of bleeding.
D. Increase the client’s protein intake.
Answer: C. Monitor for signs of bleeding.
Rationale: A platelet count of 25,000/mm³ places the client at
significant risk for bleeding, so the priority is to monitor for signs of
bleeding, such as bruising or petechiae.
, 5. A nurse is caring for a client who is undergoing chemotherapy and is
experiencing neutropenia. Which of the following should the nurse
implement to reduce the client’s risk for infection?
A. Place the client in a room with another patient to decrease isolation.
B. Ensure that all staff and visitors wear masks and gloves.
C. Restrict all visitors from coming into the room.
D. Offer the client fresh fruits and vegetables to promote nutrition.
Answer: B. Ensure that all staff and visitors wear masks and gloves.
Rationale: Neutropenic clients are at high risk for infection, so
precautions such as wearing personal protective equipment (PPE) by
staff and visitors can help reduce exposure to pathogens.
6. A nurse is caring for a client who has a history of frequent blood
transfusions. The nurse should monitor for which of the following
complications?
A. Iron overload
B. Hypokalemia
C. Hypoglycemia
D. Hypernatremia
Answer: A. Iron overload
Rationale: Repeated blood transfusions can lead to iron overload, as the
body has no way to eliminate the excess iron, which can damage
organs.
