A client with anemia presents with pallor of the skin and mucous membranes. The nurse should assess for which other related clinical manifestation?
Petechiae
Jaundice
Cyanosis
Diaphoresis
The Correct Answer is B
A) This choice is incorrect because petechiae, which are tiny red or purple spots on the skin, are associated with platelet disorders and not directly related to anemia.
B) This choice is correct. Pallor (pale skin) and jaundice (yellowing of the skin and mucous membranes) are related clinical manifestations of anemia. Jaundice can occur in hemolytic anemias when the breakdown of red blood cells leads to an accumulation of bilirubin.
C) This choice is incorrect because cyanosis, a bluish discoloration of the skin, is not directly related to anemia.
D) This choice is incorrect because diaphoresis, or excessive sweating, is not a typical clinical manifestation of anemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) This choice is incorrect because hemoglobin electrophoresis is used to identify abnormal hemoglobin types, not to assess the size and shape of red blood cells.
B) This choice is incorrect because a reticulocyte count measures the number of immature red blood cells in the blood and helps determine if the bone marrow is responding appropriately to anemia, but it does not assess the size and shape of red blood cells.
C) This choice is correct. A peripheral blood smear is used to examine the morphology of red blood cells, including their size, shape, and appearance. It can help identify different types of anemia and determine the cause of anemia.
D) This choice is incorrect because serum iron levels provide information about iron status but do not directly assess the size and shape of red blood cells.
Correct Answer is D
Explanation
A) This choice is incorrect because monitoring the client's temperature is important, but it is not the priority during the PRBC transfusion process.
B) This choice is incorrect because administering pain medication may be necessary if the client is experiencing discomfort during or after the transfusion, but it is not the priority action.
C) This choice is incorrect because obtaining informed consent is an essential step before any medical intervention, including transfusions, but it is not the priority during the transfusion process.
D) This choice is correct. Checking the client's blood type is a priority before administering a PRBC transfusion to ensure compatibility and prevent adverse reactions. Transfusion reactions can be life-threatening, so verifying the blood type is crucial for client safety.
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