EAQ #7 PDF

EAQ#7 1) Which route of administration is associated with the Z-track method? Oral Intravenous Intramuscular Subcutaneous. Rationale: The Z-track method is used for the administration of injectable drugs through the intramuscular route. Oral iro...

EAQ#7 1) Which route of administration is associated with the Z-track method? Oral Intravenous Intramuscular Subcutaneous. Rationale: The Z-track method is used for the administration of injectable drugs through the intramuscular route. Oral iron supplements can be ingested directly by the oral route. The Z-track method cannot be used for intravenous or subcutaneous administration. (р. 856) 2) Which part of the body is associated with the formation of new blood cells? Liver Heart Kidney Bone marrow Rationale: Bone marrow is involved in the formation of new blood cells. The bone marrow produces erythrocytes, leukocytes, and thrombocytes. The liver is involved in the storage of iron and the destruction of red blood cells (RBCs) in the body. The heart is involved in the circulation of blood. Kidneys secrete the hormone erythropoietin, which is involved in the maturation of RBCs. (р. 848) 3) The formation of erythrocytes and maturation of red blood cells (RBCs) is driven by which hormone? Testosterone Progesterone Erythropoietin Free thyroxine Rationale: Erythropoiesis is the process of erythrocyte formation, and this involves the maturation of a nucleated RBC precursor into a hemoglobin-filled, nucleus-free erythrocyte. This process is driven by the hormone erythropoietin, which is produced by the kidneys. Erythropoietin is also produced commercially and is used to treat anemia in certain specific circumstances. Testosterone, progesterone, and free thyroxine do not drive the formation of erythrocytes and maturation of RBCs. 4) Which symptom is a side effect associated with oral iron therapy? Fatigue Tarry stools Yellow urine Hypertension Rationale: Tarry stools, vomiting, and epigastric pain are the side effects associated with oral iron supplements. The nurse instructs the patient to expect these adverse effects so that the patient does not panic. Fatigue is a symptom of anemia. It is relieved upon administration of oral iron supplements. Yellow urine is an adverse effect associated with folic acid therapy. Hypertension is a side effect associated with the administration of epoetin alfa. 5) Which type of anemia is caused by a genetic defect? Sickle cell anemia Pernicious anemia Megaloblastic anemia Iron-deficiency anemia Rationale: A genetic defect can cause abnormalities in the structure of red blood cells.  Sickle cell anemia is the only type of anemia that is caused by a genetic defect. Pernicious anemia is caused by a deficiency of cyanocobalamin (vitamin B12). Megaloblastic anemia is caused by a deficiency of folic acid. Iron-deficiency anemia is caused by a deficiency of dietary iron. (р. 850) 6) How much elemental iron would a patient receive if administered two tablets (each containing 325 mg) of ferrous fumarate iron salts? Record your answer using a whole number. 214 mg Rationale: Ferrous fumarate iron salts are available as 325-mg tablets. They are 33% elemental iron. Therefore one tablet provides 107 mg of elemental iron. Thus, two tablets will provide 107 x 2 =214 mg. (р. 851) 7) A patient with anemia is prescribed an oral formulation of ferrous fumarate 150 mg twice a day. What concentration of elemental iron is absorbed by the patient daily? Record your answer using a whole number. 99 mg Rationale: Ferrous fumarate tablets are 33% elemental iron. Therefore a 150-mg tablet would provide 49.5 mg of elemental iron. The patient is prescribed the drug twice a day, so the total elemental iron in a day would be 99 mg. (pg. 851) 8) Where does the process of erythropoiesis take place in the human body? Liver Heart Blood Kidneys Rationale: Erythropoiesis involves the maturation of precursors of nucleated red blood cells (RBCs) into hemoglobin-filled, nucleus-free erythrocytes. It takes place in the circulation, where nucleated RBCs undergo a 24- to 36-hour maturation process to become mature, fully functional RBCs. The breakdown of RBCs takes place in the liver. The heart pumps the blood to all of the organs; it has no role in erythropoiesis. The primary function of the kidneys is filtration. The kidneys are involved in the production of the hormone erythropoietin, which helps in the maturation of RBCs; however, they are not the site of erythropoiesis. (р. 848) 9) Which injectable iron requires a test dose before an actual dose of the drug? Iron sucrose Iron dextran Ferric gluconate Ferrous fumarate Rationale: Iron dextran is administered only after a test dose. Iron sucrose is an injectable iron used for iron- deficiency anemia. The chance of precipitating anaphylaxis is much lower with this type of iron injection, and it can be used without a test dose. Ferric gluconate is an injectable iron product that is indicated for repletion of total body iron content in patients with iron-deficiency anemia who are undergoing hemodialysis. The risk of anaphylaxis is much less than with iron dextran, and a test dose is not required. Ferrous fumarate is available only for oral use. (р. 853) 10) Iron dextran is prescribed for a patient with severe iron-deficiency anemia. How will the nurse administer the drug? Administer a test dose by the intravenous route.  Administer a test dose by the subcutaneous route. Administer the full dose by the intravenous route. Administer the full dose by the subcutaneous route. Rationale: Iron dextran is a colloidal solution of iron and dextran that can be administered by the intravenous or intramuscular route. It has the potential to cause anaphylactic reactions in some patients. Because of this, a test dose of the drug is initially administered by the intravenous route before administering the full dose. It is not administered by the subcutaneous route because of limited effectiveness. Administration of the full dose may lead to an anaphylactic reaction in the patient. (р. 853) 11) For which reason is an iron supplement prescribed with erythropoiesis-stimulating agents? To improve the efficacy of erythropoiesis-stimulating agents To decrease the absorption of erythropoiesis-stimulating agents To increase the elimination of erythropoiesis-stimulating agents To reduce the adverse effects of erythropoiesis-stimulating agents Rationale: Iron supplements increase the efficacy of erythropoiesis-stimulating agents by promoting the maturation of erythrocytes. Iron supplements enhance the absorption of erythropoiesis-stimulating agents. Erythropoiesis-stimulating agents work effectively when iron stores in the body are adequate. Iron does not affect the elimination of erythropoiesis-stimulating agents from the body but helps in their absorption. Adverse effects of erythropoiesis-stimulating agents include hypertension, fever, and headache, which are not prevented by iron supplements. (Pg. 851) 12) The nurse would plan to inject iron dextran by which technique? Intramuscular injection using the Z-track method Subcutaneous injection with a ½/inch, 25-gauge needle Intramuscular injection with a ½-inch, 18-gauge needle Intradermal injection with a sunburst technique of administration Rationale: Iron dextran should be administered deep in a large muscle mass using the Z-track method and a 23-gauge, 1½-inch needle to prevent skin irritation and potential necrosis. Iron dextran should not be administered via the subcutaneous or intradermal routes. Iron dextran should not be administered via the intramuscular route with a ½-inch needle because of the risk of skin irritation and potential necrosis. (р. 856) 13) Epoetin alfa would be prescribed for which reason? To replace blood loss from surgery To replace blood loss from a trauma For treatment of pregnancy-associated anemia For treatment of a patient with anemia with renal failure Rationale: Epoetin alfa is the synthetic form of erythropoietin and is a hormone produced by the kidneys. The patient in renal failure does not have typical kidney function and therefore may have this medication prescribed to treat anemia associated with the lack of natural production of the hormone. It is also indicated for chemotherapy induced anemia. It is not indicated for replacement of blood loss from surgery or trauma or to treat anemia associated with pregnancy. 14) Which condition is a common expected adverse effect of iron supplementation? Flatus Fatigue Heartburn Constipation  Rationale: Constipation and a change in the color of stool to darker or green are the most common complaints with iron supplementation and are expected. Flatus, fatigue, and heartburn are not common and expected adverse effects of iron supplementation (р. 852) 15) When administering ferrous sulfate (iron) to a patient, the nurse would plan to administer which fluid to increase absorption of the iron? Hot tea Orange juice 4 oz. Milk 8 oz. Water Rationale: The absorption of iron can be enhanced when it is given with ascorbic acid (vitamin C), which is present in orange juice. Hot tea, milk, and water do not increase the absorption of iron. (Pg. 852) 16) An elderly and malnourished patient is prescribed iron sucrose for anemia. Which will the nurse monitor in the patient to ensure safe administration of the drug? Fluid intake Temperature Blood pressure Respiratory rate Rationale: Iron sucrose tends to cause hypotension in patients who are elderly and underweight. Therefore the nurse would monitor the patient's blood pressure when administering the drug. Fluid intake does not have any effect on iron sucrose administration; therefore it is not a primary intervention. Temperature and respiratory rate are unlikely to be affected by iron sucrose. (р. 853) 17) The nurse would question the prescription for epoetin in a patient with which condition? Anemia HIVAIDS Chronic renal failure Uncontrolled hypertension Rationale: Hypertension is a side effect of epoetin; hence, the drug should not be given to patients with uncontrolled hypertension. Anemia, antiretroviral treatment for human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), and chronic renal failure are indications for the therapeutic use of epoetin. (р. 851) 18) A patient with cardiac diease is transferred to the intensive care unit (ICU) because of decreased cardiac output. The cardiologist recommends an intraaortic balloon pump to increase the cardiac output. Which condition is a complication associated with the use of intraaortic balloon pumps? Sickle cell anemia Hemolytic anemia Megaloblastic anemia Iron-deficiency anemia Rationale: Intraaortic balloon pumps are used to increase cardiac output through pumping action. The mechanical force of the intraaortic balloon pump may destroy excess red blood cells, causing hemolytic anemia. Sickle cell anemia is caused by a deficiency of the glucose-6-phosphate-dehydrogenase (G6PD) enzyme and may not be caused by intraaortic balloon pumps. Megaloblastic anemia is caused by a deficiency of vitamin B12. Iron-deficiency anemia is caused by lack of iron in the diet. (р. 850) 19) The complete blood count of a patient who is on chemotherapy shows that the patient's red blood cells (RBCs) are paler and smaller than normal. Which medications would the nurse expect to be prescribed to treat anemia in the patient? Epoetin alfa with darbepoetin Epoetin alfa with ferric gluconate Cyanocobalamin (vitamin B12) with iron sucrose Cyanocobalamin (vitamin B12) with ferric gluconate Rationale: For patients with chemotherapy-induced anemia, epoetin alfa is administered to increase RBC production. This medication should be administered along with the iron supplement ferric gluconate, because the drug is ineffective in the absence of iron. Epoetin alfa and darbepoetin are similar formulations that differ in their duration of action. They are ineffective in the absence of iron supplements. Cyanocobalamin (vitamin B12) is administered for megaloblastic anemia, and its combination with iron sucrose or ferric gluconate may be ineffective for chemotherapy-induced anemia. (р. 850) 20) Which type of anemia is associated with cytoplasmic maturation defects? Sickle cell anemia Pernicious anemia Megaloblastic anemia Iron-deficiency anemia Rationale: Iron-deficiency anemia is a type of anemia associated with cytoplasmic maturation defects. Cytoplasmic maturation anemia occurs as a result of reduced or abnormal hemoglobin synthesis. Because hemoglobin is synthesized from both iron and globin, a deficiency in either one can lead to a hemoglobin deficiency. Sickle cell anemia is a red blood cell abnormality caused by a genetic disorder. Pernicious anemia and megaloblastic anemia are caused by nuclear maturation detects. (р. 850) 21) Which statement explains the difference between ferumoxytol and other anemia drugs? It can be diluted and infused over 2.5 to 3.5 hours. It can be given to the patient only after a test dose. It can be used only for nutrition-related iron-deficiency anemia. It can be administered undiluted as an intravenous push over 1 minute. Rationale: Ferumoxytol is an injectable iron product that can be injected directly through the intravenous route without dilution. It has the advantage of being given as an intravenous push over 1 minute. Unlike iron sucrose, ferumoxytol need not be diluted and infused over 2.5 to 3.5 hours to prevent adverse effects. Ferumoxytol does not need a test dose, because it does not trigger an anaphylactic reaction. Ferumoxytol can be used to treat anemia caused by renal failure. (Pg. 853) 22) Which type of anemia is associated with erythrocytes appearing as spherocytes on a blood smear? Sickle cell anemia Pernicious anemia Megaloblastic anemia Iron-deficiency anemia Rationale: Sickle cell anemia is a genetic disorder associated with excessive red blood cell (RBC) destruction in which the erythrocytes appear as spherocytes. In pernicious anemia and megaloblastic anemia, the erythrocytes appear normochromic and macrocytic. Iron-deficiency anemia occurs from iron deficiency and results in defective globin synthesis. (р. 850) 23) Which route of administration results in a slow onset of action of epoetin alta? Oral Intravenous Intramuscular Subcutaneous Rationale: Epoetin alfa has a slower onset of action when administered through the subcutaneous route compared with other routes. The drug requires more time to be absorbed in the bloodstream when given via the subcutaneous route. Epoetin alfa is not prescribed via the oral route. The intravenous route shows a quick onset of action, and the intramuscular route provides prolonged action. (р. 856) 24) A nurse is assessing an athlete who has been admitted for cardiac arrest. The investigation reports reveal increased blood viscosity. Which drug did the patient likely receive? Folic acid Epoetin alfa Ferrous fumarate Cyanocobalamin (vitamin B12) Rationale: Athletes tend to abuse erythropoietin to increase oxygen-carrying capacity and thus improve their athletic performance. Epoetin alfa is administered to patients with iron-deficiency anemia. It increases the oxygen-carrying capacity of the blood and increases blood viscosity. This may lead to stroke and myocardial infarction. Folic acid is administered in cases of pernicious anemia, but it does not increase blood viscosity. Ferrous fumarate is administered along with epoetin alfa to increase the absorption of epoetin alfa in the gastrointestinal tract. Administration of ferrous fumarate alone cannot increase blood viscosity. Cyanocobalamin (vitamin B12) is administered for megaloblastic anemia and is not associated with increased blood viscosity. 25) A patient had a total gastrectomy 12 months ago. The nurse learns that the patient has been eating a well- balanced diet rich ir vitamin B12, folic acid, iron, and other micronutrients. Despite this, the patient is diagnosed with anemia. Which condition is the likely cause of anemia in this patient? Fecal occult blood loss Bone marrow depression Poor absorption of vitamin B12. Deficiency of renal erythropoietin Rationale: Intrinsic factor is required for the absorption of vitamin B12. It is produced by the stomach lining. Patients who have undergone gastrectomy may have a deficiency of intrinsic factor, resulting in poor absorption of vitamin B12. It may lead to pernicious anemia, wherein the new red blood cells appear larger than normal. The anemia was probably not caused by fecal occult blood loss, bone marrow depression, or renal pathology, because the patient does not have a corresponding history for these conditions. (р. 855) 26) An oral iron supplement (100 mg) is prescribed to a patient with iron-deficiency anemia. The nurse advises the patient to take six to eight tablets per day. Which iron supplement is most likely prescribed to the patient? Ferumoxytol Ferrous sulfate. Ferric gluconate Ferrous fumarate Rationale: Ferrous fumarate is the oral iron supplement available in the form of 100-mg and 325-mg tablets. The 100-mg tablets should be administered as six to eight tablets per day. Patients can take two to three  325-mg tablets per day. Ferrous sulfate is also an oral iron supplement available in the form of tablets and is administered as two to three tablets per day. Ferumoxytol and ferric gluconate are available in the form of injections given via the intravenous or subcutaneous route. (р. 851) 27) Which group of individuals is at highest risk for developing iron-deficiency anemia? Select all that apply. One, some, or all responses may be correct. Children Pregnant women Men over age 50 years Men age 20 to 40 years Female patients age 12 to 40 years Rationale: Individuals who require the highest amount of iron are women (especially pregnant women) and children, and they are the groups most likely to develop iron-deficiency anemia. For women, this is partly because of ongoing menstrual blood loss. Most vitamin supplements for men contain little or no iron, because men are much less likely to develop iron-deficiency anemia. (р. 851) 28) Which food will the nurse suggest be excluded from the diet of a patient who is taking oral iron tablets? Select all that apply. One, some, or all responses may be correct. Milk Soda Lime juice Milkshakes Orange juice Rationale: Milk, soda, and milkshakes should be avoided because they decrease the absorption of iron in the stomach. Lime juice and orange juice are rich in vitamin C, which is known to increase the absorption of iron in the stomach. Therefore, the patient is advised to drink a glass of orange juice or water with oral iron tablets (р. 854) 29) Which instructions are given to a patient who is prescribed oral iron tablets? ”Take the iron tablets with plenty of fluids." "Take the iron tablets in a powdered form." "Take an iron tablet just before going to bed." "Dissolving the iron tablet in water and consume using a straw." Rationale: Adequate fluid intake with iron tablets decreases the chances of stomach upset and increases drug absorption. The oral tablets are consumed in the correct prescribed dosage; therefore they are not to be crushed and consumed in a powdered form. The patient needs to maintain a sitting position at least for 30 minutes after taking the oral dose to prevent esophageal irritation. Liquid solutions of iron need to be diluted with fluids according to the manufacturer's instructions and consumed using a straw to prevent discoloration of the teeth (р. 856) 30) When reviewing the medical records of several patients receiving epoetin alfa, which condition, if present, leads the nurse question an order for epoetin alfa? Chemotherapy-induced anemia End-stage renal failure with anemia Uncontrolled hypertension with anemia Human immunodeficiency virus being treated with zidovudine (AZT) Rationale: Epoetin alfa is a biosynthetic form of the natural hormone erythropoietin, which is normally secreted by the kidneys in response to decreased circulating red blood cells (RBCs). It promotes the synthesis of RBCs by stimulating RBC progenitor cells in the bone marrow. Epoetin alfa should not be used for patients with uncontrolled hypertension, because it may cause a further rise in blood pressure. Epoetin alfa is used to treat anemia caused by chronic end-stage renal disease or chemotherapy, and it is also used in combination with azidothymidine (AZT) to treat human immunodeficiency virus (HIV). Chronic end-stage  renal disease results in decreased or lack of production of erythropoietin hormone, which stimulates RBC production. Chemotherapy destroys blood cells. Azidothymidine (AZT) is used to prevent or treat HIV and may cause anemia that can be managed with epoetin alfa. (р. 851) 31) The hemoglobin level in a patient undergoing chemotherapy is 8.5 g/dL. After intravenously administering epoetin alfa for a week, the nurse observes that the patient's hemoglobin levels have increased to 11.7 g/dL. Which potential complication might result if the nurse continues with the drug administration? The patient may experience hematemesis. The patient may have difficulty defecating. The patient may have increased sugar levels. The patient may have increased blood pressure. Rationale: Overdose of epoetin alfa in patients undergoing chemotherapy causes hypertension, vomiting, and nausea. Administration of epoetin alfa in a patient who has a hemoglobin level of 12 g/dL or more can lead to serious adverse effects like stroke and myocardial infarction from high blood pressure. Hematemesis (vomiting blood) is a sign of toxicity caused by iron supplements. Excess iron supplementation can cause constipation. This difficulty in defecation can be minimized by increasing fluid and fiber intake. Hyperglycemia is an immediate effect of injecting iron preparations, such as iron sucrose and iron dextran. (Pg. 851) 32) A pregnant patient is diagnosed with folic acid deficiency anemia. The health care provider prescribes oral folic acid. Which other instructions will the nurse give the patient to promote health? "Take the drug along with antacid medications." "Include fruits and green vegetables in your diet." "Sit upright for at least I hour after taking the drug." "Report immediately if your stools are tarry and black." Rationale: The nurse advises the patient to eat green leafy vegetables and fruits. Consuming a diet rich in folic acid will help the patient to recover quickly. Antacids consumed with folic acid are known to decrease drug absorption. Maintaining a sitting position for about an hour is not needed with folic acid; however, a sitting position would relieve esophageal irritation in patients consuming iron supplements. Consuming folic acid would result in yellow discoloration of the urine but does not have any effect on the color of stools. (р. 853) 33) Which food would the nurse encourage the patient to include in their diet as a source of folate? Cheese Apples Red meat Dried beans Rationale: Dried beans, green vegetables, and oranges are some of the common folate-containing foods. Cheese, apples, and red meat are not significant sources of folate. (р. 853) 34) A patient informs the nurse that she must take her iron with a meal to prevent stomach upset. To increase the uptake of oral iron, which food group will the nurse instruct the patient to avoid? Dairy Fruits Proteins Vegetables Rationale: Many individuals find that they need to take oral iron products with meals or food because of the commonly encountered adverse effect of gastrointestinal upset, even though altered absorption occurs. However, the patient should avoid taking iron with dairy products; antacids or milk products should be consumed at least 1 to 2 hours before or after the oral dosage of iron. Fruits, proteins, and vegetables all can alter the absorption of iron but not to the extent of milk or antacids. (Pg. 854) 35) Which disease would the nurse assess in a patient before administering ferrous fumarate? Cirrhosis Heart attack Renal failure Ovarian cancer Rationale: Ferrous fumarate is contraindicated in patients with cirrhosis of the liver. The liver is the storage site for iron. During cirrhosis, the liver lacks the ability to store iron, and all of the iron taken as ferrous fumarate accumulates in the blood, leading to toxicity. Heart attack is an adverse event if epoetin alfa is administered in patients with hemoglobin levels above 12 g/dL. Renal failure is associated with a decrease in the hormone erythropoietin. In this case, iron supplements are given along with epoetin alfa. Anemia caused by ovarian cancer can be treated with epoetin alfa along with iron supplements. (Pg. 851) 36) A patient with end-stage renal failure is diagnosed with hypochromic and microcytic anemia. Which drug would the nurse expect in the patient's prescription? Folic acid Iron sucrose Ferrous fumarate Cyanocobalamin (vitamin B12) Rationale: Iron sucrose is an injectable iron supplement prescribed for patients with iron-deficiency anemia and chronic renal failure. It can be easily eliminated from the body. Folic acid and cyanocobalamin are prescribed for megaloblastic anemia, which is characterized by normochromic and macrocytic red blood cells. Ferrous fumarate is used for the treatment of severe iron-deficiency anemia. (р. 852) 37) A child who accidentally ingested an enteric-coated iron supplement develops seizures and is immediately hospitalized. The serum iron concentration is found to be 350 mcg/dL. Which intervention would the nurse expect the health care provider to prescribe to reduce the serum iron levels? Bowel irrigation An electrolyte infusion Abdominal radiographs Administration of deferoxamine Rationale: Severe iron toxicity results in coma, shock, or seizures. The primary health care provider should initiate the chelation therapy with deferoxamine immediately to decrease the serum iron levels. The decontamination of the gastrointestinal (Gl) tract will remove any traces of iron present in the Gl tract but cannot reduce the serum concentration of iron. Electrolyte infusion will not reduce the serum levels of iron. It is used to maintain the electrolyte balance in the body. Abdominal radiographs are used to determine the presence of any traces of iron in the gastrointestinal tract. (р. 852) 38) A patient who was diagnosed with anemia is prescribed folic acid supplements but shows no improvement in hemoglobin levels. The patient's blood smear shows normochromic and macrocytic red blood cells (RBCs). Which syndrome may be present in the patient? Sickle cell anemia Pernicious anemia Megaloblastic anemia Iron-deficiency anemia Rationale: The presence of normochromic and macrocytic RBCs in the blood smear indicates that the patient has RBC nuclear maturation defects. These defects are caused by a deficiency of folic acid or vitamin B12. Pernicious anemia is caused by a deficiency of vitamin B12. Hence, folic acid supplements are ineffective in patients with pernicious anemia. Sickle cell anemia is an RBC abnormality caused by a genetic disorder. Megaloblastic anemia is caused by folic acid deficiency. If the patient had megaloblastic anemia,  there would have been an improvement in the patient's condition with the use of folic acid supplements. Iron- deficiency anemia involves hypochromic and microcytic RBCs. (р. 850) 39) Which precaution will the nurse take before starting intravenous (IV) iron therapy? Select all that apply. One, some, or all responses may be correct. Flush the IV line with normal saline. Monitor blood pressure periodically. Keep resuscitative equipment available. Suggest exercising right before the injection. Administer the injection using the Z-track method. Rationale: The intravenous line should be flushed with 10 mL of normal saline to remove any other medications or substances in the IV line prior to iron administration. IV iron therapy may cause an anaphylactic reaction in some patients. Epinephrine is a beta agonist that helps manage the symptoms of anaphylactic reactions. IV iron therapy can also cause hypotension. Therefore the patient's blood pressure should be constantly monitored. The patient is advised to move slowly and purposefully during this therapy to prevent injury. The Z-track method is used for intramuscular administration of injectable iron. (Pg. 853) 40) The nurse notices that a patient exhibits severe fatigue. The medication history shows that the patient has been taking a nonsteroidal antiinflammatory drug (NSAID) for 3 months. Which type of anemia may be present in the patient? Sickle cell anemia Pernicious anemia Iron-deficiency anemia. Folic acid deficiency anemia Rationale: Fatigue is one of the symptoms of anemia. Cytoplasmic defects in the red blood cells (RBCs) make them appear hypochromic (paler in color than normal). The patient is on NSAID therapy; therefore the patient has a risk of developing gastrointestinal bleeding. This may lead to iron-deficiency anemia. Sickle cell anemia is a genetic disorder caused by a deficiency of glucose-6-phosphate dehydrogenase. Pernicious anemia is caused by a deficiency of vitamin B12. Folic acid deficiency anemia is caused by a deficiency of folic acid; however, it may not lead to fatigue. (р. 849) 41) Which information would the nurse include when developing a teaching plan for a patient receiving epoetin alfa for anemia secondary to chemotherapy side effects? Select all that apply. One, some, or all responses may be correct. Some correct answers were not selected Report fever greater than 101.0° F (38.3° C). Change positions slowly. Monitor blood pressures daily. Demonstrate subcutaneous injection technique. Consume foods high in vitamin B12. Rationale: Epoetin alfa can cause fevers, nausea, vomiting, arthralgia, and hypertension. Therefore, the nurse would instruct the patient to report a temperature greater than 101.0° F to rule out infection versus drug side effects. The nurse would instruct the patient to check the blood pressure daily to monitor for hypertension. The medication comes in the subcutaneous form, so the nurse would teach the patient how to administer the injection. The drug causes hypertension, not hypotension, so the nurse would not instruct the patient to change positions slowly. Foods rich in vitamin B12 would not increase the red blood cell count in patients with anemia related to chemotherapy administration. 42) Which information would the nurse include regarding possible adverse effects when providing discharge instructions for a patient with a prescription for ferrous sulfate 324 mg PO TID due to anemia? Select all that apply. One, some, or all options may be correct. Myalgias Constipation Black, tarry stools. Hypertension Nausea and vomiting Rationale: Oral iron supplements cause constipation; black, tarry stools; and nausea and vomiting. Epoetin alfa causes myalgias and can cause hypertension if given with a hemoglobin greater than 11 mg/dL. (р. 852) 43) Which action would the nurse take prior to giving the first dose of intravenous iron dextran to a patient with iron deficiency anemia? Select all that apply. One, some, or all responses may be correct. Monitor liver function Instruct the patient to change positions slowly Administer diphenhydramine Give a test dose of medication Place patient in supine position Rationale: The nurse would administer diphenhydramine and acetaminophen prior to the dose to prevent allergic reactions. The nurse should also give a small test dose to assess the patient's reaction. If the patient tolerates this well, the nurse will administer the remaining dose an hour later. The nurse would monitor the complete blood count and iron and ferritin levels, not the liver function. The nurse would instruct the patient to change positions slowly and to lay down for 30 minutes after the dose, not before. (р. 856) 44) During a follow-up six months after starting oral iron supplements for anemia, which patient statement indicates the treatment is effective? "I notice I have black, tarry stools." "I have less nausea when taking the iron." "I get slightly short of breath climbing stairs." “| have not needed a nap for the past month." Rationale: One of the clinical manifestations of anemia is fatigue due to an insufficient amount of red blood cells or inadequate iron stores to provide oxygen. Therefore, when the patient states they have not needed to take a nap for the past month, this indicates the patient's endurance is increasing. Black, tarry stools are a normal side effect of iron and does not indicate the patient is improving. Less nausea can occur as the patient becomes used to taking the medication. Slight shortness of breath reflects the inadequate oxygen-carrying capacity of the red blood cells, and the treatment is not 100% effective. (P.855) 45) Which statement describes the likely reason for a patient with chronic renal failure who eats a well-balanced diet to report experiencing fatigue and lightheadedness? The patient has been exercising. The patient lacks erythropoietin. The patient lacks folic acid in the diet. The patient has iron-deficiency anemia. Rationale: Erythropoiesis is the process of maturation of red blood cells. It is facilitated by erythropoietin, which is secreted by the kidneys. The secretion of erythropoietin decreases in chronic renal failure, leading to anemia, which manifests as fatigue. Exercise may cause temporary fatigue that subsides after rest. Because the patient eats a well-balanced diet, folic acid deficiency is unlikely. The anemia is probably not caused by a deficiency of iron, because the patient has a well-balanced diet. (р. 850) 46) Which intervention will the provider prescribe to increase the effectiveness of epoetin alfa?  Administer folic acid along with epoetin alfa. Administer folic acid 1 to 2 hours after epoetin alfa. Administer ferrous fumarate along with epoetin alfa. Administer ferrous fumarate 1 to 2 hours after epoetin alfa. Rationale: Epoetin alfa should always be administered along with oral supplements like ferrous fumarate to increase the effectiveness of the drug. Folic acid administration along with epoetin alfa is not effective in relieving anemia. Ferrous fumarate administered 1 to 2 hours after epoetin alfa is ineffective because ferrous fumarate is required for the better absorption of epoetin alfa in the gastrointestinal tract. 47) The nurse began an infusion of iron sucrose at 0900 to a patient with severe iron deficiency anemia. Based on the assessment data below, which action would the nurse take? Vital Signs 0900 Vital Signs 1000 Temperature 97.5° F (36.4° Temperature 98.0° F C) (36.7° C) Heart rate 74 beats/min Heart rate 89 beats/min Respirations 15 breaths/min Respirations 16 Blood pressure 128/76 breaths/min mmHg Blood pressure 106/59 Oxygen saturation 97% room mmHg air Oxygen saturation 97% room air Administer oxygen Stop the medication Give acetaminophen Slow the infusion rate Rationale: The patient's blood pressure has dropped significantly, indicating the patient is experiencing hypotension, which usually occurs when the medication is infusing too fast. Therefore, the nurse would slow the infusion rate. The patient still has a normal oxygen saturation and would not require supplemental oxygen. The nurse would slow down, not stop, the infusion. The patient does not have a fever, so acetaminophen is not needed. (р. 853) 48) Which phrase describes known contraindications for use of erythropoiesis-stimulating agents in patients? Select all that apply. One, some, or all responses may be correct. Renal failure Cancer of the neck History of thrombosis I Uncontrolled hypertension Hemoglobin level of 15 g/dL Rationale: Contraindications for erythropoiesis-stimulating agents (ESAs) include known drug allergy. Use in patients with head or neck cancers or in patients at risk for thrombosis is controversial because these medications increase tumor growth and risk for thrombosis. Use of epoetin and darbepoetin is contraindicated in cases of uncontrolled hypertension and when hemoglobin levels are above 10 g/dL for patients with cancer and 12 g/dL for patients with renal failure. Renal failure is not a contraindication for erythropoiesis-stimulating agents. 49) Which assessment is performed on a patient before prescribing darbepoetin? Select all that apply. One, some, or all responses may be correct. Radiograph of bones Blood pressure Hemoglobin test D Creatinine levels Bowel movements Rationale: Darbepoetin is a long-acting biosynthetic form of the natural hormone erythropoietin, which is secreted by the kidneys in response to a decrease in red blood cells (RBCs). It is contraindicated in patients with uncontrolled hypertension, high hemoglobin levels, or renal failure. Before darbepoetin is prescribed, the patient's blood pressure should be checked to rule out hypertension. Hemoglobin levels should be checked because the drug may not be needed if the hemoglobin levels are adequate. Creatinine levels should be tested to determine renal function, because darbepoetin is not used in patients with renal failure. A radiograph of bones is useful in assessing calcium deficiency and bone marrow suppression. Assessing bowel movements is useful in assessing gastric-related diseases. However, these tests are not prerequisites for darbepoetin administration. (р. 854) 50) Which advice would the nurse give to a patient about taking iron supplements: "Take the supplement with milk." "Take the supplement at bed time." "Take the supplement with orange juice." "Take the supplement in the early morning." Rationale: The iron in oral iron supplements is absorbed better when taken along with foods rich in ascorbic acid. The absorption of iron is enhanced in the presence of the ascorbic acid in orange juice. The absorption of iron from iron supplements does not depend on the time of the day but rather on the food items taken along with it. The calcium present in milk decreases the absorption of iron; therefore milk should be avoided. (р. 854) 51) Which condition is a clinical complication associated with the continued use of epoetin alfa when the hemoglobin levels are above 12 g/dL? Diarrhea Heart attack Ulcerative colitis Metabolic and hemodynamic effects Rationale: Epoetin alfa is an erythropoiesis-stimulating agent that results in serious adverse effects such as heart attack, stroke, and death when used excessively. Diarrhea is the most common adverse effect associated with the use of oral iron preparations. Iron preparations such as ferrous fumarate salts are contraindicated in patients with ulcerative colitis. Toxicity from excessive iron ingestion results in metabolic and hemodynamic effects. 52) A patient is prescribed iron sucrose for iron-deficiency anemia. Which drug history will the nurse assess in the patient? Tetracycline Methotrexate Trimethoprim Acetaminophen Rationale: Injectable iron supplements like iron sucrose are known to decrease the absorption of tetracycline. Before starting iron therapy in a patient, the nurse would look for these drugs in the patient's medication history to evaluate any possible interactions. Methotrexate and trimethoprim are known to interact with folic acid. Acetaminophen will not interact with iron sucrose. (р. 852) 53) Which symptom is a common adverse effect of iron sucrose? Dyspnea Anaphylaxis Hypotension Yellow discoloration of urine Rationale: Hypotension is the most common adverse effect of iron sucrose. Dyspnea is associated with doses higher than 125 mg of ferric gluconate. Anaphylactic reactions are associated with iron dextran and  have been reported in 0.3% of patients. Adverse effects associated with folic acid are rare, but yellow discoloration of urine is observed. (р. 853) 54) Which type of anemia is associated with normochromic and macrocytic red blood cells (RBCs)? Hemolytic anemia Drug-induced anemia Megaloblastic anemia Iron-deficiency anemia Rationale: Megaloblastic anemia or macrocytic anemia is caused by a deficiency of vitamin B12 and folic acid. It is associated with normochromic and macrocytic red blood cells (RBCs), in which case the RBCs have a normal color but are of larger-than-normal size. Hemolytic anemia is caused by the destruction of RBCs. Sickle cell anemia and drug-induced anemia are associated with RBCs appearing as spherocytes. Iron-deficiency anemia is associated with hypochromic and microcytic RBCs. (р. 850) 55) Which drug requires a test dose to ensure safe medication administration? Iron dextran Iron sucrose Ferric gluconate Ferrous fumarate Rationale: Iron dextran is an injectable iron formulation that may cause an anaphylactic reaction in the patient. Therefore a test dose of iron dextran is injected and the patient is monitored for any adverse reactions. The risk of precipitating an anaphylactic reaction is much lower with iron sucrose. Therefore a test dose is not required for this iron formulation. Ferric gluconate injectable formulations have fewer adverse effects; hence, the complete prescribed dose can be administered. Ferrous fumarate is an oral formulation that is 33% elemental iron. This oral drug is not known to cause anaphylactic reactions (р. 853) 56) Which laboratory finding would lead the nurse to hold the dose of epoetin alfa for a patient with end-stage renal disease and contact the health care provider? Iron level 62 mcg/dL Hemoglobin 11.5 g/dL Ferritin level 10 mcg/L Vitamin B12 level 175 pg/mL Rationale: Epoetin alfa is used to increase the red blood cell count in patients with end-stage renal disease. When the hemoglobin is higher than 11 g/dL, the medication should be discontinued as continued RBC production can cause a heart attack, stroke, or death. Oral iron supplementation would be administered if the iron and ferritin levels are low. Cobalamin would be administered intramuscularly if the patient's B12 levels are low. 57) A patient informs the nurse about taking oral over-the-counter iron supplements starting 3 weeks ago due to constant fatigue, but nothing is helping. Which response would the nurse provide first? o "What dose of medication are you taking?" o "Iron supplements take time to take effect." o "When did you start taking the oral iron supplements?" o "Before taking iron, we need to determine why you are so tired." Rationale: The nurse would first tell the patient that it is important to determine the cause of the fatigue prior to taking any over-the-counter medication as the fatigue could be unrelated to anemia. If anemia is diagnosed, then the nurse would ask which medication, which dose the patient is taking, and when the iron supplements were started. The nurse would instruct that although iron supplements take time to work, the source of the fatigue must be identified first. (р. 851) 58) Which information would the nurse provide to promote drug absorption when educating a patient about a new prescription for ferrous sulfate 324 mg PO three times a day? Use an antacid if the drug causes nausea. Drink orange juice with the medication. Take medication with morning calcium. Eat a meal prior to taking the medication. Rationale: Iron supplements are better absorbed when taken with ascorbic acid (vitamin C). Therefore, the nurse would instruct the patient to drink orange juice with the medication. Antacids and calcium supplements interfere with absorption and should not be taken within 2 hours of the iron dose. Eating a meal will decrease absorption. (р. 854) 59) After providing nutrition education to a patient with a folic acid deficiency, which meal plan made by the patient indicates an understanding of appropriate food choices that can increase dietary intake of folic acid? Turkey and cheese sandwich with an apple Spaghetti with meat sauce and garlic bread Hamburger with French fries and cooked carrots Kale, spinach, and cabbage salad with grilled chicken Rationale: Foods that are high in folic acid are green vegetables such as kale, spinach, and cabbage. Therefore, the food choice of kale, spinach, and cabbage salad with grilled chicken would be an excellent source of folic acid. A turkey and cheese sandwich with an apple, spaghetti with meat sauce and garlic bread, and a hamburger with French fries and cooked carrots are low in folic acid and do not reflect an understanding of the teaching provided. (р. 853) 60) The nurse is reviewing the health histories of four patients presenting to an outpatient clinic prior to their scheduled appointment. Which patient would require supplemental folic acid? 25-year-old female trying to conceive 40-year-old male with hypertension 55-year-old female with pneumonia 70-year-old male with heart failure Rationale: Women who are trying to conceive should begin folic acid supplementation at least 1 month before becoming pregnant and throughout the pregnancy. This decreases the risk for neural tube detects. A patient with hypertension, pneumonia, or heart failure would not need folic acid supplements (р. 853). 61) As the nurse obtains the health history from a patient taking an oral iron supplement every day, which finding would lead the nurse to instruct the patient to stop taking the medication and contact the health care provider? Depression Hemochromatosis. Peripheral vascular disease Inflammatory bowel disease Rationale: Hemochromatosis is a disorder that causes too many red blood cells to form. These patients usually have excess iron, which can deposit in the liver and cause liver impairment. Therefore, the nurse would instruct the patient to discontinue the use of this medication and contact the health care provider. It would be safe for patients with depression, peripheral vascular disease, and inflammatory bowel disease to take iron supplements. (р. 854) 62) Which advice would the nurse provide about taking oral iron supplements? "Take them with milk." "Take them before eating." "Take them with fibrous food." "Take them with orange juice."  Rationale: Orange juice is rich in vitamin C, which increases the absorption of iron and also helps maintain blood pressure. Thus the nurse would ask the patient to take the iron tablets along with a glass of orange juice. Milk and antacids decrease iron absorption and thus should be avoided. Iron supplements, if taken before food or on an empty stomach, can cause gastric upset. Fibrous food helps prevent constipation caused by iron supplements. Fibrous food does not affect the absorption of iron tablets (р. 854) 63) A patient with hyperacidity is diagnosed with iron-deficiency anemia. The prescription contains oral antacid preparations and oral iron supplements. Which statement is important advice the nurse would give to the patient? "Take the iron supplements with meals." "Take the iron supplements along with antacids." "Take the iron supplements with plenty of water.!" "Take the iron supplements at least 2 hours after taking antacids." Rationale: Oral iron supplements should be taken at least 2 hours after taking antacids, because the presence of antacids decreases the absorption of iron. Iron supplements should not be administered along with meals, because the presence of food also decreases the absorption of iron from the gastrointestinal tract. The absorption of iron is inhibited if administered with antacids. Therefore iron should not be administered along with antacids. It is advisable to dilute the iron supplements with plenty of water to avoid discoloration of tooth enamel. However, this is not the nurse's most important advice. (р. 855) 64) In which condition are erythropoiesis-stimulating agents contraindicated? Stomach cramping Hemolytic anemia Pernicious anemia Uncontrolled hypertension Rationale: The use of erythropoiesis-stimulating agents, such as epoetin alfa and darbepoetin, is contraindicated in patients with uncontrolled hypertension because it increases hemoglobin levels, which causes polycythemia. Stomach cramping is an adverse effect of iron preparations such as iron sucrose and ferric gluconate. Hemolytic anemia is one of the conditions in which iron products are contraindicated. Pernicious anemia is a nuclear maturation defect caused by the deficiency of vitamin B12, which is required for protein synthesis. (р. 851) 65) The nurse would tell the patient to expect which condition during folic acid therapy? Diarrhea Vomiting Yellow urine Stomach cramps Rationale: Folic acid therapy may make the urine yellow. The nurse would tell the patient not to panic if the urine turns yellow; it is normal for a patient on folic acid therapy. Diarrhea, vomiting, and stomach cramps are effects associated with oral iron therapy. 66) Which genetic disorder is associated with excessive red blood cell (RBC) destruction? Pernicious anemia Sickle cell anemia Megaloblastic anemia Iron-deficiency anemia Rationale: Sickle cell anemia is a genetic disorder associated with excessive RBC destruction. It results from defects in the intrinsic factors of RBCs, which causes excessive RBC destruction. Pernicious anemia is  caused by a deficiency of folic acid. Megaloblastic anemia is caused by a deficiency of vitamin B12 or folic acid. Iron-deficiency anemia is caused by blood loss, childbirth, or a deficiency of dietary iron. (р. 849) 67) Which medication contains the largest amount of iron per gram of salt? Folic acid Epoetin alfa Iron dextran Ferrous fumarate Rationale: Ferrous fumarate contains the largest amount of iron per gram of salt consumed. It contains 33% elemental iron. Folic acid is a water-soluble B-complex vitamin used for the treatment and prevention of folic acid deficiency. Epoetin alfa is a biosynthetic form of natural hormone erythropoietin that helps in the synthesis of red blood cells (RBCs). Iron dextran is a colloidal solution of iron (ferric hydroxide) and dextran, which is used for the treatment of iron deficiency. (р. 851) 68) Which drug is used to treat iron overdose? Deferiprone Tetracycline Methotrexate Trimethoprim Rationale: Deferiprone is the drug approved by the US Food and Drug Administration to treat iron overdose. It acts by chelating the excess iron and forming complexes. Tetracycline interacts with iron and reduces its absorption. Methotrexate is an antineoplastic drug used in cancer therapy. Trimethoprim is also an antibiotic. Iron supplements decrease the absorption of antibiotics. (р. 852) 69) Which condition is the extrinsic factor that causes excessive red blood cell (RBC) destruction? Thalassemia Septic shock Sickle cell anemia Hereditary spherocytosis Rationale: Septic shock is an extrinsic factor that produces disseminated intravascular coagulation, thereby causing excessive red blood cell (RBC) destruction. Sickle cell anemia is an example of a genetic defect and an intrinsic factor that causes excessive RBC destruction. Thalassemia is a genetic disorder caused by cytoplasmic maturation defects, which result in defective globin synthesis. Hereditary spherocytosis is an intrinsic factor that results in abnormal RBCs