Which of the following nursing diagnoses would typically NOT be associated with anemia?

Ineffective tissue perfusion.

Activity intolerance.

Fluid volume deficit.

Risk for decreased cardiac output.

Answer and Explanation

The Correct Answer is C

This nursing diagnosis is typically not associated with anemia because anemia does not cause dehydration or loss of body fluids. Anemia is a condition in which the hemoglobin concentration or the number of red blood cells is lower than normal, resulting in decreased oxygen delivery to the tissues.

Choice A. Ineffective tissue perfusion is wrong because anemia can impair tissue perfusion by reducing the oxygen-carrying capacity of the blood.

Choice B. Activity intolerance is wrong because anemia can cause fatigue, weakness, and dyspnea on exertion due to inadequate oxygen supply to the muscles.

Choice D. Risk for decreased cardiac output is wrong because anemia can increase the risk of cardiac complications such as tachycardia, palpitations, angina, and heart failure due to increased cardiac workload and demand for oxygen.

Normal ranges for hemoglobin are 13.5 to 17.5 g/dL for men and 12 to 15.5 g/dL for women; normal ranges for hematocrit are 38.8 to 50% for men and 34.9 to 44.5% for women; normal ranges for red blood cell count are 4.7 to 6.1 million/mm3 for men and 4.2 to 5.4 million/mm3 for women; normal ranges for reticulocyte count are 0.5 to 1.5% of red blood cells.

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Correct Answer is D

Explanation

Localized warmth at the site of injury is a sign of localized inflammation of the tissues, which is a response to tissue damage caused by an ankle injury. Localized inflammation involves changes in blood flow, vessel permeability, and leukocyte migration to the site of injury. Heat is one of the five classic signs of acute local inflammation, along with redness, swelling, pain, and loss of function.

Choice A is wrong because 3+ palpable pedal pulses below the affected injury site indicate normal blood flow to the foot and do not reflect inflammation.

Choice B is wrong because full range of motion at the site of injury is unlikely in the presence of inflammation, which usually causes pain and loss of function.

Choice C is wrong because sanguineous drainage at the site of injury is a sign of bleeding, not inflammation.

Inflammation may cause fluid leakage from blood vessels, but this fluid is usually clear or yellowish, not bloody.

A. Hourly vital signs. B. Implementing all fall risk precautions. C. Utilizing bariatric bed and trapeze bar. D. Supine positioning.

Correct Answer is C

Explanation

A patient with a BMI of 38 is considered to have obesity, which means they have excess body fat that may impair their mobility and increase their risk of complications such as pressure ulcers, infections, and respiratory problems. A bariatric bed is designed to accommodate the weight and size of obese patients, and a trapeze bar can help them change positions and transfer to a chair or wheelchair.

These interventions can promote comfort, safety, and independence for the patient.

Choice A is wrong because hourly vital signs are not necessary for a patient with obesity unless they have other conditions that warrant frequent monitoring.

Choice B is wrong because implementing all fall risk precautions may be excessive and restrictive for a patient with obesity who is otherwise stable and alert.

Choice D is wrong because supine positioning can compromise the patient’s breathing and circulation, and increase the risk of pressure ulcers and aspiration.

The patient should be encouraged to change positions frequently and elevate the head of the bed when lying down.

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Which of the following nursing diagnoses would typically NOT be associated with anemia?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who was brought to the emergency department with an ankle injury. Which of the following manifestations should the nurse identify as localized inflammation of the tissues?

Correct Answer is D

Explanation

A nurse is caring for a patient with a BMI of. Appropriate nursing interventions include:

Correct Answer is C

Explanation

A nurse is caring for a client with chronic fatigue syndrome. Which of the following criteria were used to assist in making this diagnosis? Select all that apply.

A client’s bloodwork indicates that he has severe hypokalemia. What is a priority nursing intervention?

The nurse includes which of the following as an appropriately constructed goal statement for the client with COPD?

The nurse does not turn a client every two hours as ordered, and the client develops a pressure injury. What legal concept applies?

The nurse utilizes the SBAR format to give report to the next nurse. Which one of the following statements is correct about the SBAR?

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