How it Works
Try Naxlex NCLEX-RN (Free-Trial)

The nurse is assisting in the development of a care plan for a patient with pernicious anemia. Which of the following would be the most common nursing diagnosis with this medical condition?

A.

Activity intolerance related to tissue hypoxia

B.

Ineffective airway clearance related to dyspnea.

C.

Risk for infection related to reduction in white blood cells (WBCs)

D.

Chronic pain related to bone marrow dysfunction

Answer and Explanation

The Correct Answer is A

A. Activity intolerance related to tissue hypoxia: Pernicious anemia leads to a decrease in the body’s ability to carry oxygen due to a lack of intrinsic factor and subsequent vitamin B12 deficiency, resulting in tissue hypoxia. This can cause fatigue and activity intolerance as the body struggles to meet its oxygen demands.

B. Ineffective airway clearance related to dyspnea: Dyspnea may occur, but ineffective airway clearance is not directly related to pernicious anemia, as this condition primarily affects oxygen transport, not the airway.

C. Risk for infection related to reduction in white blood cells (WBCs): Pernicious anemia primarily affects red blood cells due to vitamin B12 deficiency; it does not typically lead to a reduction in white blood cells.

D. Chronic pain related to bone marrow dysfunction: While bone marrow may be affected in some anemias, chronic pain is not a typical symptom of pernicious anemia, and bone marrow dysfunction is not usually present.


Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Free Nursing Study Resources

Related Questions

Correct Answer is ["1610"]

Explanation

Solution:

  1. Convert ounces to milliliters (1 oz = 30 mL):
    • Coffee: 8 oz × 30 mL = 240 mL
    • Juice: 3 oz × 30 mL = 90 mL
    • Soda: 12 oz × 30 mL = 360 mL
  2. Calculate water intake:
    • Initial pitcher: 800 mL
    • Remaining: 200 mL
    • Water intake = 800 mL - 200 mL = 600 mL
  3. Calculate IV fluids intake:
    • IV rate: 40 mL/hr
    • Time: 8 hours
    • IV fluids = 40 mL/hr × 8 hrs = 320 mL
  4. Total intake:
    • 240 mL (coffee) + 90 mL (juice) + 360 mL (soda) + 600 mL (water) + 320 mL (IV) = 1610 mL

Answer: 1610 mL

Correct Answer is D

Explanation

A. 2 hr: While some patients may tolerate faster infusion rates, the maximum safe time is 4 hours, and there is no requirement to complete it in 2 hours.

B. 8 hr: Blood cannot be left out for 8 hours due to the increased risk of bacterial growth and contamination.

C. 6 hr: Infusing blood over 6 hours exceeds the safe time limit and poses a risk of bacterial contamination.

D. 4 hr: To reduce the risk of bacterial contamination, a unit of packed RBCs must be transfused within 4 hours of starting the infusion. This time frame ensures that the blood remains safe for the patient while minimizing exposure to room temperature.

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Register