Exam 5
Text Chapters: 13, 40, 66, 67, 68
ATI Chapters: 39-42, 56-61
What type of tubing do you use for blood transfusions and which intravenous fluids?
The nurse chooses a Y-type blood administration set to initiate a blood transfusion. Why does the
nurse use this type of tubing?
a. It contains an in-line filter
b. It is micro drip tubing
c. It applies negative pressure
d. It keeps the blood product at the appropriate temperature
Y-tubing facilitates maintenance of IV access in case a patient will need more than 1 unit of blood and
it contains an in-line filter to remove debris and/or microemboli.
The nurse is administering a blood transfusion. Which action requires correction?
a. Monitors the patient's vital signs at 5 minutes, 15 minutes, and every 30 minutes until 1 hour after
transfusion.
b. Leaves Y-tubing set to be used for possible second transfusion the next day.
c. Administers the patient's PO pain medication as requested.
d. Opens the common tubing clamp and initiates the transfusion at a rate of 2 mL/minute.
The nurse is preparing equipment to administer a unit of blood to a patient. Which type of fluid would
the nurse piggyback with the blood transfusion?
A. 0.45% normal saline
B. 0.9% normal saline
C. Dextrose 5% and 0.45% normal saline
D. Dextrose 5% and 0.9% normal saline
Which food should you recommend to patients with iron deficiency anemia and which one(s)
have the greatest amount of iron? What causes Fe deficiency anemia?
A group of nursing students is discussing the diagnosis of iron deficiency anemia, and one of the
students asks what foods would be good for this child to eat. Which foods are high in iron? Select all
that apply.
a) Milk
b) Raisins
c) Peanut butter
d) Oatmeal
e) Egg yolks
f) Cheese
Egg yolks, raisins, peanut butter and oatmeal are food sources high in iron. Milk and cheese are not
food sources that are high in iron.
,A nurse is teaching a client who is at risk for iron-deficiency anemia about optimizing her dietary
intake of iron. The nurse should explain that which of the following sources of iron is easiest for the
body to absorb?
A. Spinach
B. Cantaloupe
C. Chicken
D. Lentils
Food sources of iron fall into two categories – heme iron (from lean red meat, poultry, and fish) and
nonheme iron (from fruit, vegetables, grains, and dried peas and beans). The body more easily
absorbs heme iron
A nurse is teaching a client who has a history of ulcerative colitis and a new diagnosis of anemia.
Which of the following manifestations of colitis should the nurse identify as a contributing factor to the
development of the anemia?
A. Dietary iron restrictions
B. Intestinal malabsorption syndrome
C. Chronic blood loss
D. Intestinal parasites
A client with long-standing ulcerative colitis is most likely anemic due to chronic blood loss in small
amounts that occurs over time, although the colitis may result in erosion of the intestine and
hemorrhage. These clients often report bloody stools and are therefore at increased risk for
developing anemia.
A nurse is teaching a client who is postpartum and has been diagnosed with iron deficiency anemia.
Which of the following dietary recommendations should the nurse include in the teaching plan?
A. Yogurt and mozzarella
B. Spinach and beef
C. Milk and turkey slices
D. Fish and cottage cheese
Spinach and beef are high in iron and would be recommended for this client.
Locations that can be used for a bone marrow aspiration
The client diagnosed with chronic lymphocytic leukemia (CLL) is scheduled for a bone marrow
aspiration and biopsy. The client says, "I am frightened. I have never had this test before, and I don't
know what to expect." Which statements will the nurse include when responding to the client's
concerns? (Select all that apply.)
A. "We will move you to the operating room where the test is always performed."
B. "The bone in the front of your chest will be used for the biopsy specimen."
C. "A tight pressure dressing will be placed over the test site after the procedure."
, D. "You will not feel any discomfort as the local anesthetic is injected."
E. "There is a risk of bleeding, so we will monitor the test site frequent
Hemophilia A manifestations
Know your lab values (CBC, CMP, serum osmolality) – you’ll need to know what is abnormal
Red blood cells RBC: circulating cells that transport oxygen.
Expected range: Females 4.2- 5.4million/uL and Males 4.7- 6.1
Lower levels: anemia, hemorrhage, kidney disease
Higher levels: causes include polycythemia, severe dehydration
Creatinine: waste product from the normal breakdown of muscles in the body.
Expected range: 0.6- 1.2 mg/dL
Increased levels: indicates the presence of kidney dysfunction
Creatine is a more accurate assessment of kidney function than BUN.
Blood Urea Nitrogen (BUN): Nitrogen in the blood from the waste product urea, produced when
protein is broken down in the body.
Expected range: 10-20 mg/dL
BUN>20 mg/dL: cause include kidney disease, dehydration, or conditions that decrease blood
flow to the kidneys (CHF, MI, Shock).
Glomerular Filtration Rate (GFR) used to assess kidney function. Measures how much blood
passes through the glomeruli each min
1. Expected range: > 90 ml/min
2. CKD STAGES
o Stage 1: GFR > 90 ml/min, minimal kidney damage
o Stage 2: GFR 60-89 ml/min, mild kidney damage
o Stage 3: GFR 30-59 ml/min, moderate kidney damage
o Stage 4: 15-29 ml/min, severe kidney damage
o Stage 5: GFR < 15 ml/min, kidney failure
Urine Output:
Expected ranges: urine output per hour:> 30 ml
Urine output less than 30 can indicate shock, trauma, infection, notify provider
Urine specific gravity: compares density to urine to the density of water
Text Chapters: 13, 40, 66, 67, 68
ATI Chapters: 39-42, 56-61
What type of tubing do you use for blood transfusions and which intravenous fluids?
The nurse chooses a Y-type blood administration set to initiate a blood transfusion. Why does the
nurse use this type of tubing?
a. It contains an in-line filter
b. It is micro drip tubing
c. It applies negative pressure
d. It keeps the blood product at the appropriate temperature
Y-tubing facilitates maintenance of IV access in case a patient will need more than 1 unit of blood and
it contains an in-line filter to remove debris and/or microemboli.
The nurse is administering a blood transfusion. Which action requires correction?
a. Monitors the patient's vital signs at 5 minutes, 15 minutes, and every 30 minutes until 1 hour after
transfusion.
b. Leaves Y-tubing set to be used for possible second transfusion the next day.
c. Administers the patient's PO pain medication as requested.
d. Opens the common tubing clamp and initiates the transfusion at a rate of 2 mL/minute.
The nurse is preparing equipment to administer a unit of blood to a patient. Which type of fluid would
the nurse piggyback with the blood transfusion?
A. 0.45% normal saline
B. 0.9% normal saline
C. Dextrose 5% and 0.45% normal saline
D. Dextrose 5% and 0.9% normal saline
Which food should you recommend to patients with iron deficiency anemia and which one(s)
have the greatest amount of iron? What causes Fe deficiency anemia?
A group of nursing students is discussing the diagnosis of iron deficiency anemia, and one of the
students asks what foods would be good for this child to eat. Which foods are high in iron? Select all
that apply.
a) Milk
b) Raisins
c) Peanut butter
d) Oatmeal
e) Egg yolks
f) Cheese
Egg yolks, raisins, peanut butter and oatmeal are food sources high in iron. Milk and cheese are not
food sources that are high in iron.
,A nurse is teaching a client who is at risk for iron-deficiency anemia about optimizing her dietary
intake of iron. The nurse should explain that which of the following sources of iron is easiest for the
body to absorb?
A. Spinach
B. Cantaloupe
C. Chicken
D. Lentils
Food sources of iron fall into two categories – heme iron (from lean red meat, poultry, and fish) and
nonheme iron (from fruit, vegetables, grains, and dried peas and beans). The body more easily
absorbs heme iron
A nurse is teaching a client who has a history of ulcerative colitis and a new diagnosis of anemia.
Which of the following manifestations of colitis should the nurse identify as a contributing factor to the
development of the anemia?
A. Dietary iron restrictions
B. Intestinal malabsorption syndrome
C. Chronic blood loss
D. Intestinal parasites
A client with long-standing ulcerative colitis is most likely anemic due to chronic blood loss in small
amounts that occurs over time, although the colitis may result in erosion of the intestine and
hemorrhage. These clients often report bloody stools and are therefore at increased risk for
developing anemia.
A nurse is teaching a client who is postpartum and has been diagnosed with iron deficiency anemia.
Which of the following dietary recommendations should the nurse include in the teaching plan?
A. Yogurt and mozzarella
B. Spinach and beef
C. Milk and turkey slices
D. Fish and cottage cheese
Spinach and beef are high in iron and would be recommended for this client.
Locations that can be used for a bone marrow aspiration
The client diagnosed with chronic lymphocytic leukemia (CLL) is scheduled for a bone marrow
aspiration and biopsy. The client says, "I am frightened. I have never had this test before, and I don't
know what to expect." Which statements will the nurse include when responding to the client's
concerns? (Select all that apply.)
A. "We will move you to the operating room where the test is always performed."
B. "The bone in the front of your chest will be used for the biopsy specimen."
C. "A tight pressure dressing will be placed over the test site after the procedure."
, D. "You will not feel any discomfort as the local anesthetic is injected."
E. "There is a risk of bleeding, so we will monitor the test site frequent
Hemophilia A manifestations
Know your lab values (CBC, CMP, serum osmolality) – you’ll need to know what is abnormal
Red blood cells RBC: circulating cells that transport oxygen.
Expected range: Females 4.2- 5.4million/uL and Males 4.7- 6.1
Lower levels: anemia, hemorrhage, kidney disease
Higher levels: causes include polycythemia, severe dehydration
Creatinine: waste product from the normal breakdown of muscles in the body.
Expected range: 0.6- 1.2 mg/dL
Increased levels: indicates the presence of kidney dysfunction
Creatine is a more accurate assessment of kidney function than BUN.
Blood Urea Nitrogen (BUN): Nitrogen in the blood from the waste product urea, produced when
protein is broken down in the body.
Expected range: 10-20 mg/dL
BUN>20 mg/dL: cause include kidney disease, dehydration, or conditions that decrease blood
flow to the kidneys (CHF, MI, Shock).
Glomerular Filtration Rate (GFR) used to assess kidney function. Measures how much blood
passes through the glomeruli each min
1. Expected range: > 90 ml/min
2. CKD STAGES
o Stage 1: GFR > 90 ml/min, minimal kidney damage
o Stage 2: GFR 60-89 ml/min, mild kidney damage
o Stage 3: GFR 30-59 ml/min, moderate kidney damage
o Stage 4: 15-29 ml/min, severe kidney damage
o Stage 5: GFR < 15 ml/min, kidney failure
Urine Output:
Expected ranges: urine output per hour:> 30 ml
Urine output less than 30 can indicate shock, trauma, infection, notify provider
Urine specific gravity: compares density to urine to the density of water
