NR-324 Adult Health I - Set 4 - Part 3

Correct Answer: Attach fresh tubing and infuse normal saline

The vein must stay open for fluids and emergency drugs, but the existing set is primed with the offending blood. The nurse disconnects that set at the catheter hub and attaches a fresh line primed with normal saline. Option b is incorrect because opening the saline arm pushes the blood sitting in the shared tubing straight into the client. That residual volume is not trivial and would deepen a reaction already underway. Option c is incorrect because losing venous access during a reaction is dangerous. This client may need rapid fluids, vasopressors and emergency medication within minutes, so the catheter is left in place and used. Option d is incorrect because a flush through contaminated tubing delivers the same residual blood the nurse is trying to withhold. Saline is given, but only after a clean set replaces the blood administration set.

Correct Answer: The client who is difficult to rouse

A change in level of consciousness in a severely thrombocytopenic client means intracranial hemorrhage until proven otherwise, and cerebral bleeding is the complication that kills. The clue is neurological, not hematologic. Option a is incorrect because pinpoint non blanching spots over dependent areas are the expected skin finding at this platelet count. They are documented and monitored, but they do not represent a new emergency. Option b is incorrect because gum bleeding is typical mucosal bleeding from failed primary hemostasis and calls for a soft toothbrush and no alcohol based rinse. It is troubling yet not immediately life threatening. Option c is incorrect because hematuria belongs on the list of findings to monitor in thrombocytopenia and warrants reporting and serial counts. Bleeding into the skull still takes precedence over bleeding into the bladder.

Correct Answer: Continue the iron because dark stools are expected

Unabsorbed iron characteristically darkens the stool to dark green or black, and this is an expected effect rather than a complication. The client has no findings suggesting gastrointestinal bleeding. Option a is incorrect because stopping a needed supplement over an expected color change interrupts therapy that must continue for months. Nothing in this call points to a problem requiring the drug to be held. Option b is incorrect because the finding that signals bleeding is melena, which is black, tarry, sticky and foul smelling and comes with a falling hemoglobin, tachycardia and low blood pressure. Option d is incorrect because enteric coated preparations dissolve past the duodenum, where iron is normally absorbed, so they deliver less iron rather than more. Plain ferrous sulfate remains the best absorbed form.

Correct Answer: Take it with orange juice before meals

Iron is absorbed best in an acid environment on an empty stomach, about one hour before a meal. Ascorbic acid in orange juice keeps iron in the absorbable ferrous form. Option a is incorrect because the calcium in milk competes directly with iron for the same absorption sites in the duodenum. Pairing the dose with dairy lowers the amount of iron the client actually receives. Option c is incorrect because antacids raise gastric pH, and iron needs acid to stay in the form the small bowel can take up. Proton pump inhibitors blunt absorption for the same reason. Option d is incorrect because supplemental calcium is one of the substances that must be separated from an iron dose. Giving them together at night wastes much of the prescribed iron.

Correct Answer: A central venous catheter with tip verification

Solutions above roughly nine hundred milliosmoles per liter destroy peripheral veins. Central placement delivers the admixture into high flow blood in the superior vena cava, where it is diluted immediately on arrival. Option b is incorrect because catheter size does not change the tonicity reaching the vessel wall. A hypertonic admixture in any forearm vein causes chemical phlebitis and thrombosis within a very short time. Option c is incorrect because a midline ends in a peripheral vein of the arm rather than in a central vessel. It carries the same concentration limit and cannot be used for this admixture. Option d is incorrect because rotating a peripheral site frequently manages irritation from dilute infusions, not injury from concentrated dextrose. Moving the damage to a new vein every other day is not a solution.

Correct Answer: Hold the feeding and notify the provider promptly

A change in external length means the tube has migrated, and the tip may now sit in the esophagus. Feeding is withheld and the provider is notified so that position can be reconfirmed. Option a is incorrect because blindly pushing a displaced tube back in risks driving the tip into the airway or coiling it in the pharynx. Repositioning is done only on an order with imaging. Option b is incorrect because a slow rate offers no protection when the tip has moved above the lower esophageal sphincter. Formula delivered there refluxes into the pharynx and is aspirated before coughing warns anyone. Option c is incorrect because securing a tube at the wrong depth fixes the error in place. Documentation alone leaves an unsafe tube in use, and the migration itself demands assessment rather than a note.

Correct Answer: High reticulocytes, high bilirubin, low haptoglobin

Rapid destruction drives the marrow to release immature cells, so reticulocytes rise. Released heme becomes unconjugated bilirubin faster than the liver can clear it, and haptoglobin is consumed binding free hemoglobin. Option b is incorrect because a low reticulocyte count would mean the marrow is not compensating, which describes a production failure such as aplastic anemia. Haptoglobin also falls rather than rises during hemolysis. Option c is incorrect because bilirubin must rise when heme pigment is released from ruptured cells, and that rise is what yellows the sclerae. The jaundice described already contradicts a low value. Option d is incorrect because it gets only the haptoglobin right. An actively hemolyzing marrow pushes reticulocytes up, and the pigment load from broken cells pushes bilirubin up as well.

Correct Answer: The inflammation is suppressing albumin production

Albumin is a negative acute phase reactant, so inflammatory mediators lower it regardless of intake. A rising C reactive protein alongside a falling albumin points to the infection rather than to poor eating. Option a is incorrect because the client is described as eating most of each meal. Blaming intake ignores the stated history and would send the nurse chasing an appetite problem that does not exist. Option b is incorrect because a single low albumin never justifies tube feeding on its own. Access decisions rest on whether the client can swallow and meet requirements orally, which this one appears able to do. Option c is incorrect because albumin turns over across about three weeks, so it cannot move meaningfully in a few days. Prealbumin is the marker chosen when a short term response must be followed.

Correct Answer: I will eat a steady amount of green vegetables.

Consistency is what matters with warfarin. A steady intake of vitamin K keeps the international normalized ratio stable, whereas sudden increases lower it and sudden decreases raise it beyond the intended range. Option a is incorrect because eliminating vitamin K foods swings the ratio upward and raises bleeding risk. Clients are told to keep the amount even, not to give these vegetables up altogether. Option c is incorrect because nonsteroidal drugs add antiplatelet effect and gastric ulceration on top of anticoagulation, which is a recipe for gastrointestinal bleeding. Pain relief must be discussed with the prescriber first. Option d is incorrect because the dietary concern with warfarin is vitamin K, not potassium. Bananas and juice are restricted for other reasons entirely, and confusing the two leads clients to change the wrong foods.

Correct Answer: Review the medications and send a stool specimen

Diarrhea in a tube fed client is usually caused by medications, antibiotic associated infection or rate, not by the formula. Reviewing the drug list and testing the stool identifies the real cause. Option a is incorrect because abandoning a working gut for intravenous feeding trades a manageable problem for central line infection and higher cost. Enteral nutrition is preserved whenever the intestine still functions. Option b is incorrect because weakening the formula reduces calories and protein at the moment the client needs them, and the evidence points at the new medications rather than at the feed itself. Option d is incorrect because adding fiber before the cause is known may thicken formula, clog the tube and worsen cramping. It also does nothing about a possible Clostridioides difficile infection.