The nurse is reviewing a patients assessment data

13.
The nurse is reviewing a patient’s assessment data upon admission to the acute care facility.
Which finding best indicates iron deficiency anemia?
a. Pulse of 90 beats/min
b. Yellow sclera
c. Tea-colored urine
d. Pale conjunctivae
ANS: D
Pale conjunctivae are an indication of anemia. A pulse rate of 90 beats/min is within the
higher limits of normal. Yellow sclera is indicative of jaundice. Tea-colored urine may
indicate the presence of bilirubin or blood in the urine.
PTS: 1 DIF: Cognitive Level: Application REF: 332
OBJ: 7 (theory) TOP: Signs of Anemia
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
14.
The nurse is caring for a patient with pernicious anemia immediately following a bone
marrow biopsy of the left posterior iliac crest. Which action should the nurse perform first?
PTS: 1 DIF: Cognitive Level: Analysis REF: 335, Table 15-1
OBJ: 7 (clinical) TOP: Post-marrow Aspiration Care
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential
15.
The nurse is caring for a patient who is taking radiation treatments. The patient has a platelet
count of 100,000/mm 3 . Which action is most important for the nurse to add to the patient’s
care plan?

This patient is thrombocytopenic (low platelet count) and is at an increased risk for bleeding.
A cluttered room increases the risk for falls, and a fall could be particularly dangerous for this
patient. Changing positions slowly is indicated in the patient with orthostatic hypotension.
Removing the fresh orange from the patient’s tray and limiting visitors are infection control
measures for the patient on neutropenic precautions.
PTS: 1 DIF: Cognitive Level: Analysis REF: 331
OBJ: 2 (theory) TOP: Thrombocytopenia
KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential