The client with pernicious anemia asks why vitamin B12 injections are necessary. What is the best response by the nurse?
Vitamin B12 contributes to the increased production of RBCs after significant blood loss.
Vitamin B12 is needed to prevent excessive production of red blood cells.
Vitamin B12 is needed to prevent RBCs from sticking together.
Your stomach does not provide a substance necessary for the absorption of vitamin B12.
The Correct Answer is D
Choice A reason: Vitamin B12 does not contribute to the increased production of RBCs after significant blood loss. Vitamin B12 is a type of vitamin that is essential for the normal formation and maturation of red blood cells (RBCs), which carry oxygen throughout the body. ¹ However, vitamin B12 does not increase the production of RBCs in response to blood loss. That is the role of erythropoietin, a hormone that stimulates the bone marrow to produce more RBCs. ²
Choice B reason: Vitamin B12 is not needed to prevent excessive production of red blood cells. Vitamin B12 is needed for the normal production of red blood cells, not for the prevention of overproduction. Excessive production of red blood cells, also known as polycythemia, can cause the blood to become thick and viscous, increasing the risk of clotting and stroke. ³ Polycythemia can be caused by various factors, such as smoking, dehydration, or genetic mutations, but not by a lack of vitamin B12.
Choice C reason: Vitamin B12 is not needed to prevent RBCs from sticking together. Vitamin B12 is needed for the normal formation and maturation of RBCs, not for the prevention of aggregation. RBCs can stick together and form clumps, also known as rouleaux, which can impair blood flow and oxygen delivery. Rouleaux can be caused by various factors, such as inflammation, infection, or cancer, but not by a lack of vitamin B12.
Choice D reason: Vitamin B12 is needed for the normal formation and maturation of RBCs, but it cannot be absorbed by the body without a substance called intrinsic factor. Intrinsic factor is a protein that is produced by the stomach and binds to vitamin B12, allowing it to be absorbed by the small intestine. ¹ Pernicious anemia is a type of anemia that occurs when the stomach does not produce enough intrinsic factor, leading to vitamin B12 deficiency. The only way to treat pernicious anemia is by giving vitamin B12 injections, which bypass the need for intrinsic factor.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: This is not the best answer. Respiratory rate and depth can indicate the client's oxygenation and ventilation, but not necessarily their fluid status. The client may have normal or increased respiratory rate and depth due to dehydration, acidosis, or anxiety, but this does not reflect their fluid volume or distribution. The nurse should monitor the client's respiratory rate and depth, but also assess other parameters of fluid status.
Choice B reason: This is not the best answer. Rectal temperature can indicate the client's core body temperature, but not necessarily their fluid status. The client may have normal or elevated rectal temperature due to infection, inflammation, or dehydration, but this does not reflect their fluid volume or distribution. The nurse should monitor the client's rectal temperature, but also assess other parameters of fluid status.
Choice C reason: This is the best answer. Blood pressure lying, sitting and standing can indicate the client's fluid status and vascular tone. The client may have low blood pressure due to fluid loss, hypovolemia, or vasodilation, and this can cause orthostatic hypotension, which is a drop in blood pressure when changing positions. The nurse should measure the client's blood pressure in different positions and observe for signs of orthostatic hypotension, such as dizziness, fainting, or blurred vision.
Choice D reason: This is not the best answer. Pulse oximetry reading at rest can indicate the client's oxygen saturation, but not necessarily their fluid status. The client may have normal or decreased pulse oximetry reading due to hypoxia, anemia, or poor peripheral perfusion, but this does not reflect their fluid volume or distribution. The nurse should monitor the client's pulse oximetry reading, but also assess other parameters of fluid status.
Correct Answer is D
Explanation
Choice A reason: Avoiding strenuous activity and standing up slowly is not a relevant response to the client's complaint of headache. These actions may help prevent or reduce orthostatic hypotension, which is another possible side effect of nitroglycerin, but not headache.
Choice B reason: Headache is expected and should subside with continued use is a correct and appropriate response to the client's complaint of headache. The nurse should explain that headache is a common and transient side effect of nitroglycerin, which is caused by the vasodilation effect of the drug. The nurse should also advise the client to take over-the-counter analgesics, such as acetaminophen, to relieve the headache.
Choice C reason: Reducing the dosage to help relieve this side effect is not a correct or appropriate response to the client's complaint of headache. The nurse should not suggest any changes in the prescribed dosage of nitroglycerin, as this may compromise the effectiveness of the drug and increase the risk of angina or myocardial infarction. The nurse should also remind the client to follow the instructions for applying and removing the Nitropatch.
Choice D reason: You will have this side effect as long as you are taking nitroglycerin is not a correct or appropriate response to the client's complaint of headache. The nurse should not discourage or alarm the client by implying that the headache is inevitable and permanent. The nurse should reassure the client that the headache will likely diminish over time as the body adapts to the drug.
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