Anemias — Iron Deficiency, Pernicious, Aplastic, Sickle Cell — NCLEX Lesson A&P · Assessment · Hematologic/Immune/Lymphatic · Anemias Condition Lesson · NCLEX-PN / NCLEX-RN

Different roads to the same problem — not enough oxygen delivery. One lacks iron for small pale cells, one lacks B12 for giant dysfunctional cells, one has empty marrow, and one has crescent cells that clog vessels and scream in pain.

In this lesson

Lesson Objectives
Why This Matters
Disease Overview
Pathophysiology
Risk Factors
Signs & Symptoms
Nursing Assessment
Diagnostic Tests
Laboratory Tests
Medications
Nursing Interventions
Potential Complications
Patient Education
Clinical Judgment
Clinical Connections
NCLEX High-Yield
Memory Aids
Case Study
Practice Questions
Key Takeaways
References

Lesson Objectives

Differentiate iron deficiency, pernicious, aplastic, and sickle cell anemia by cause, lab pattern, and clinical presentation and explain WHY each occurs.
Explain how each anemia impairs oxygen delivery and why compensatory tachycardia, tachypnea, and pallor occur.
Interpret CBC, iron studies, B12, retic count, and hemoglobin electrophoresis to identify anemia type.
Prioritize safe nursing care: oxygenation, transfusion safety, chelation, B12 administration, neutropenic and bleeding precautions, and sickle cell crisis management.
Teach patients about diet, medication adherence, crisis prevention, and when to seek emergency care.

Why This Disease Matters

Prevalence: Anemia affects 2 billion people globally. Iron deficiency is the most common nutritional deficiency worldwide, affecting 25% of the population, especially women, children, and low-income groups. Pernicious anemia affects 1-2% of adults over 60, often autoimmune. Aplastic anemia is rare 2-6 per million but fatal without treatment. Sickle cell disease affects 100,000 Americans, 1 in 365 Black births, and millions globally.

Patient safety: Anemia causes tissue hypoxia → falls, myocardial ischemia, high-output heart failure. Iron deficiency impairs immunity and cognition. Pernicious anemia causes irreversible nerve damage if B12 not replaced. Aplastic anemia causes life-threatening pancytopenia — bleeding, sepsis. Sickle cell crisis causes severe pain, acute chest syndrome, stroke, splenic sequestration, and death. Transfusion errors are a leading cause of death from transfusion.

NCLEX importance: The NCLEX Test Plan places anemias under Physiological Adaptation and Reduction of Risk Potential. Tested: lab interpretation (microcytic vs macrocytic, retic), iron administration with vitamin C on empty stomach away from milk/antacids, B12 IM monthly and neurologic assessment, pancytopenia precautions, sickle cell crisis triggers and hydration/oxygen/pain management, transfusion reaction signs and priority actions.

Why nurses encounter them constantly: Women with heavy menses, pregnant patients, vegans, older adults, chemotherapy patients, dialysis patients, and Black patients with sickle cell present in ED, primary care, med-surg, oncology, and pediatrics. You will give iron, B12, transfuse, and manage crises weekly.

Connecting to prior lessons From A&P: RBCs made in red marrow need iron for heme, B12 and folate for DNA synthesis, EPO from kidneys to stimulate production, 120-day lifespan, destroyed in spleen → bilirubin. Low Hgb → ↓ O2 delivery → compensatory tachycardia, tachypnea. From assessment: pallor best in conjunctiva/palms, spoon nails, smooth beefy tongue, petechiae vs ecchymosis, vitals orthostatics, fatigue scale.

Disease Overview

Anemia	What it is	RBC morphology	Core problem
Iron Deficiency	Not enough iron to make heme → small pale RBCs	Microcytic hypochromic MCV <80	↓ O2 delivery + tissue hypoxia
Pernicious (B12 deficiency)	Autoimmune lack of intrinsic factor → no B12 absorption → DNA synthesis fails → large dysfunctional RBCs + nerve demyelination	Macrocytic MCV >100	↓ O2 delivery + irreversible neuro damage if untreated
Aplastic	Marrow failure → empty marrow → pancytopenia (RBC, WBC, platelets all low)	Normocytic MCV normal but few cells	↓ O2 + infection + bleeding
Sickle Cell Disease	Genetic HgbS autosomal recessive → RBCs sickle under low O2/acidosis/dehydration → hemolysis + vaso-occlusion	Normocytic but sickle-shaped on smear	Hemolytic anemia + vaso-occlusive pain + organ infarction

Analogy — the truck fleet

Iron deficiency = building trucks with no steel — tiny, pale, weak trucks. Pernicious = building trucks with faulty blueprints (no B12) — giant, clumsy, doors fall off, plus roads (nerves) crumble. Aplastic = factory burns down — no trucks, no police (WBC), no repair crew (platelets). Sickle cell = crescent-shaped trucks that jam intersections — they break apart (hemolysis) and block traffic (pain crisis, chest, stroke).

Pathophysiology

Normal physiology: Kidney senses low O2 → EPO → marrow stem cells divide → need iron for heme (Hgb structure), B12 + folate for DNA synthesis and cell division → mature RBC 120 days → carries 4 O2 per Hgb → spleen removes old RBCs → iron recycled, heme → bilirubin → liver → bile. Normal Hgb 12-16 F, 14-18 M, MCV 80-100. ↓ Iron deficiency — What goes wrong: Blood loss (heavy menses, GI bleed, pregnancy demand), poor intake, malabsorption (celiac, gastric bypass) → iron low → ferritin low → no heme → RBCs small (microcytic) pale (hypochromic) with low Hgb → ↓ O2 delivery. Body tries tachycardia, tachypnea, ↑ cardiac output. Long-term: epithelial changes — spoon nails koilonychia, angular cheilitis, glossitis because iron needed for epithelial turnover. WHY pica? Brain craves iron — ice, starch, clay. ↓ Pernicious — What goes wrong: Autoimmune destruction of gastric parietal cells → no intrinsic factor → B12 not absorbed in terminal ileum → DNA synthesis fails → RBC precursors cannot divide → large macrocytic RBCs MCV >100 with dysfunctional Hgb, also WBC and platelets low, plus myelin synthesis fails → demyelination of dorsal columns, corticospinal tracts, peripheral nerves → paresthesias, ataxia, loss of position sense, confusion, irreversible if delayed. Folate deficiency similar but no neuro damage. WHY beefy red tongue? Epithelial turnover fails. ↓ Aplastic — What goes wrong: Autoimmune, drugs (chemo, chloramphenicol, anticonvulsants), viruses (hepatitis, EBV, HIV), chemicals (benzene, radiation), idiopathic → hematopoietic stem cells destroyed → hypocellular empty marrow with fat → pancytopenia: RBC low → anemia, WBC low especially neutrophils → infection/no pus/fever may be absent, platelets low → bleeding petechiae. WHY life-threatening? No reserve to respond to bleeding/infection. ↓ Sickle Cell — What goes wrong: Inherited HgbS mutation — under low O2, dehydration, acidosis, cold, stress, infection → HgbS polymerizes → RBC sickles rigid → hemolysis (short life 10-20 days vs 120) → anemia + bilirubin ↑ jaundice + retic ↑ marrow tries to compensate + gallstones, and vaso-occlusion → microvascular obstruction → severe pain crisis, acute chest syndrome (lungs), stroke, avascular necrosis, splenic sequestration (blood trapped in spleen → shock), priapism, leg ulcers, organ damage. WHY pain? Tissue ischemia from blocked vessels. ↓ Progression: Untreated iron deficiency → high-output heart failure. Untreated pernicious → irreversible neuro damage, infertility, gastric cancer risk. Untreated aplastic → fatal infection/bleeding within weeks-months without transplant/immunosuppression. Untreated sickle crisis → acute chest, stroke, splenic sequestration death.

Risk Factors

Non-modifiable	Modifiable / Preventable	High-risk populations
Female sex for iron deficiency, age >60 for pernicious, genetic inheritance sickle cell autosomal recessive (both parents trait), family history aplastic/B12 deficiency, autoimmune disease	Heavy menstrual bleeding, GI bleed from NSAIDs/ulcers/cancer, pregnancy, vegan diet no B12, alcoholism, gastric bypass/celiac/malabsorption, medications chemo/radiation/benzene/anticonvulsants/chloramphenicol, dehydration/cold/high altitude/stress for sickle crisis, poor intake iron/folate	Women of childbearing age, infants/toddlers, pregnant, elderly, vegans, gastric bypass, alcohol use disorder, chemo/radiation exposure, Black/African, Mediterranean, Middle Eastern descent sickle cell trait/disease, CKD, IBD, celiac, autoimmune polyglandular syndrome

Signs and Symptoms

Category	Iron Deficiency — WHY	Pernicious — WHY	Aplastic — WHY	Sickle Cell — WHY
Early	Fatigue, weakness, pallor conjunctiva/palms, exertional dyspnea — low O2 delivery. Pica ice, clay.	Fatigue, pallor, sore beefy red tongue, mild paresthesias fingers — epithelial turnover fails, myelin early damage.	Fatigue, pallor, frequent infections, low-grade fever — marrow fails to make RBCs and WBCs.	Fatigue, pallor, jaundice mild, dactylitis in infants hand-foot — hemolysis + early vaso-occlusion.
Expected	Spoon nails koilonychia, angular cheilitis, brittle nails, hair loss, tachycardia, tachypnea, exertional chest pain, cold intolerance. WHY: iron needed for epithelial and cardiac compensation.	Beefy red smooth tongue, angular cheilitis, diarrhea, paresthesias, numbness, ataxia, loss of proprioception, confusion, depression, tachycardia, low Hgb. WHY: B12 needed for myelin + RBC DNA.	Pancytopenia: anemia symptoms + neutropenia fever/sore throat/no pus + thrombocytopenia petechiae/purpura/epistaxis/gum bleed/menorrhagia. WHY: all lines fail.	Chronic anemia symptoms + pain crisis severe joint/chest/abdominal/back pain, jaundice icteric sclera, splenomegaly early then autosplenectomy, leg ulcers, delayed growth. WHY: hemolysis + vaso-occlusion.
Emergency	HR >120, BP <90/60, chest pain, dyspnea at rest, syncope, Hgb <6 — high-output failure, MI, shock. WHY: severe ↓ O2.	Severe paresthesias, gait ataxia, inability to walk, severe confusion, HR >120, heart failure — neuro irreversible + cardiac.	Fever ≥100.4°F with ANC <500 → febrile neutropenia sepsis, active bleeding platelets <20k → intracranial bleed, Hgb <7 with hemodynamic instability.	Pain crisis unrelieved + fever + chest pain + dyspnea + SpO2 drop → acute chest syndrome, stroke signs, splenic sequestration LUQ pain + hypotension + splenomegaly + sudden Hgb drop → shock, priapism >4hr.

Red flags — notify provider STAT Hgb <7 with symptoms, HR >120, hypotension, chest pain, dyspnea at rest, syncope. ANC <500 + fever ≥100.4°F once. Platelets <20k + active bleeding, petechiae widespread. Sickle chest pain + fever + SpO2 <94% + infiltrate → acute chest. Sickle sudden severe headache, weakness, speech change → stroke. Sickle LUQ pain + sudden pallor + hypotension + splenomegaly → sequestration.

Nursing Assessment

Subjective: fatigue, weakness, dyspnea on exertion, palpitations, dizziness, pica, diet history iron/B12/folate intake, vegan, alcohol, GI bleed melena/hematochezia, heavy menses, pregnancy, gastric surgery, family history anemias/sickle trait, medication chemo/radiation/NSAIDs/anticonvulsants, benzene exposure, frequent infections, bleeding/bruising, sickle crisis triggers (cold, dehydration, stress, infection, high altitude), pain location/severity 0-10, fever, night sweats, weight loss, jaundice, dark urine, leg ulcers, priapism, stroke history.

Objective: vitals including orthostatics, HR, RR, BP, Temp, SpO2, weight, BMI. General appearance fatigue, pallor. Skin: conjunctiva pallor, nail beds, palms (dark skin assessment), jaundice, spoon nails, bruises/petechiae/purpura, leg ulcers, edema. Mouth: angular cheilitis, glossitis beefy red, smooth tongue, gum bleeding, oral ulcers. Neuro: paresthesias, proprioception, gait ataxia, Romberg, confusion, depression. Abdomen: splenomegaly early sickle then autosplenectomy, splenomegaly aplastic? Actually no, but assess Traube, hepatomegaly, tenderness. Lungs: crackles if fluid overload/transfusion. Heart: tachycardia, flow murmur, S3 high-output failure. Joints: pain, swelling sickle crisis.

Focused	What / Why
Vitals / Perfusion	Tachy, tachypnea, orthostasis, hypotension, low SpO2 → tissue hypoxia compensation. Fever → infection in aplastic/neutropenia or sickle crisis precipitant.
Skin / Nails / Mucosa	Pallor conjunctiva best, spoon nails iron, beefy tongue B12, jaundice sickle hemolysis, petechiae platelets aplastic, leg ulcers sickle.
Neuro	Paresthesias, gait ataxia, loss of position sense → B12 pernicious irreversible if delayed. Stroke signs sickle.
Pain (sickle)	Location, severity, triggers, what relieves, use scale, assess chest/abdominal/back/joint pain — vaso-occlusion.
Bleeding / Infection (aplastic)	Petechiae, epistaxis, gum bleed, hematuria, melena, menorrhagia, fever, sore throat, wounds — pancytopenia.

Diagnostic Tests

Test	Purpose / Why ordered / Findings / Nursing
CBC with differential, MCV, MCH, RDW, Retic count	Core anemia screen. Iron deficiency: low Hgb/Hct, MCV <80 microcytic, MCH low hypochromic, RDW high anisocytosis, retic low initially then high after iron. Pernicious: low Hgb, MCV >100 macrocytic, MCH high, WBC/platelets low, retic low. Aplastic: pancytopenia low RBC/WBC/platelets, MCV normal, retic very low <1%. Sickle: low Hgb 6-9, normal MCV, retic high 5-20% compensation, WBC high even without infection. Nursing: no special prep, trend.
Peripheral smear	See cell morphology. Iron: small pale cells, pencil cells. Pernicious: large oval macrocytes, hypersegmented neutrophils. Sickle: sickle cells, target cells, Howell-Jolly bodies (no spleen).
Bone marrow biopsy — gold standard aplastic	Evaluates cellularity. Aplastic: hypocellular empty marrow with fat replacement, decreased all precursors. Purpose to rule out leukemia/myelodysplasia. Prep: informed consent, NPO per facility, assess bleeding risk platelets, position prone, post-procedure pressure, monitor bleeding/infection, pain control. Teaching: pressure 30 min, flat, avoid NSAIDs.
Hemoglobin electrophoresis	Sickle diagnosis. HgbS >50% disease, HgbA 0% in SS disease, HgbS 35-45% trait. Also newborn screening.

Laboratory Tests

Lab	Purpose / Normal / Abnormal / Significance / Priority
Iron studies: Ferritin 20-300 ng/mL, Serum iron 60-170 mcg/dL, TIBC 250-450, Transferrin sat 20-50%	Iron deficiency: ferritin low <15 early marker, iron low, TIBC high ↑ (body makes more carriers), transferrin sat low <20%. Anemia chronic disease ferritin high. Trend: ferritin rises with iron therapy. Priority: ferritin <15 confirms iron deficiency — find bleed source especially GI in older adults.
Vitamin B12 200-900 pg/mL, Folate 2-20 ng/mL, Methylmalonic acid (MMA), Homocysteine	Pernicious: B12 low <200, MMA high, homocysteine high. Folate normal helps differentiate B12 vs folate (folate low folate deficiency but MMA normal). Intrinsic factor antibody and parietal cell antibody positive in pernicious. Priority: B12 low + neuro symptoms = urgent replacement to prevent irreversible nerve damage. Folate deficiency similar labs but no neuro + folate low.
Retic count 0.5-1.5% (25-75k)	Measures marrow response. Low retic in iron, B12, aplastic before treatment → marrow not making RBCs. High retic in sickle hemolysis and after iron/B12 therapy indicates response — good sign. Sickle high retic 5-20% chronic hemolysis.
Bilirubin (total 0.3-1.2, indirect ↑ in hemolysis), LDH ↑ hemolysis, Haptoglobin low in hemolysis, Hgb electrophoresis	Sickle: indirect bilirubin high, LDH high, haptoglobin low (binds free Hgb consumed), retic high. Iron deficiency bilirubin normal. Priority: jaundice + high LDH/low haptoglobin = hemolysis.
CBC trends: Hgb/Hct, MCV, MCHC, WBC, ANC, Platelets	Trends tell therapy response: Hgb should rise 1 g/dL in 2-4 weeks with iron/B12. WBC <4k, ANC <500, platelets <20k in aplastic emergency. Sickle Hgb baseline 6-9, drop 2g sudden = sequestration emergency.

Medications

Iron Deficiency

Class / Meds	Mechanism / Safety / Teaching
Oral Iron: Ferrous sulfate 325mg TID, Ferrous fumarate, Ferrous gluconate	Mechanism: provides elemental iron for heme synthesis → Hgb ↑. Indications: iron deficiency from bleed, pregnancy, poor intake. Side: nausea, constipation (most common), dark stools (expected), metallic taste. Serious: iron overload if excess, GI bleed masked by dark stools? Actually dark stools expected, but assess. Nursing: give on empty stomach 1hr before or 2hr after meals for absorption, but can give with small meal if GI upset. Give with vitamin C (OJ) ↑ absorption, away from milk, antacids, calcium, tea/coffee ↓ absorption. Use straw for liquid to avoid teeth staining. Teach constipation prevention fluids, fiber, activity, stool softener if needed. Monitor Hgb, ferritin, retic in 3-7 days should rise. Teaching: dark stools normal, take 2-3 months after Hgb normal to refill stores, don't stop early, keep away from children overdose fatal. Black box: none but overdose fatal in children.
IV Iron: Iron sucrose (Venofer), Ferric gluconate, Iron dextran (INFeD) — with black box	Mechanism: IV iron for severe deficiency, CKD dialysis, intolerance to PO, ongoing blood loss. Side: hypotension, nausea, arthralgia, anaphylaxis especially iron dextran. Black Box (iron dextran): fatal anaphylaxis risk — test dose required, only in setting with resuscitation. Nursing: check for allergy history, give test dose per order for dextran, monitor vitals q15min during infusion, have epi available, monitor for chest pain, dyspnea. Monitor Hgb, ferritin, iron saturation. Teach to report chest tightness, dyspnea, rash.

Class / Meds

Mechanism / Safety / Teaching

Oral Iron: Ferrous sulfate 325mg TID, Ferrous fumarate, Ferrous gluconate

Mechanism: provides elemental iron for heme synthesis → Hgb ↑. Indications: iron deficiency from bleed, pregnancy, poor intake. Side: nausea, constipation (most common), dark stools (expected), metallic taste. Serious: iron overload if excess, GI bleed masked by dark stools? Actually dark stools expected, but assess. Nursing: give on empty stomach 1hr before or 2hr after meals for absorption, but can give with small meal if GI upset. Give with vitamin C (OJ) ↑ absorption, away from milk, antacids, calcium, tea/coffee ↓ absorption. Use straw for liquid to avoid teeth staining. Teach constipation prevention fluids, fiber, activity, stool softener if needed. Monitor Hgb, ferritin, retic in 3-7 days should rise. Teaching: dark stools normal, take 2-3 months after Hgb normal to refill stores, don't stop early, keep away from children overdose fatal. Black box: none but overdose fatal in children.

IV Iron: Iron sucrose (Venofer), Ferric gluconate, Iron dextran (INFeD) — with black box

Mechanism: IV iron for severe deficiency, CKD dialysis, intolerance to PO, ongoing blood loss. Side: hypotension, nausea, arthralgia, anaphylaxis especially iron dextran. Black Box (iron dextran): fatal anaphylaxis risk — test dose required, only in setting with resuscitation. Nursing: check for allergy history, give test dose per order for dextran, monitor vitals q15min during infusion, have epi available, monitor for chest pain, dyspnea. Monitor Hgb, ferritin, iron saturation. Teach to report chest tightness, dyspnea, rash.

Pernicious / B12 Deficiency

Class / Meds	Mechanism / Safety
Cyanocobalamin / Hydroxocobalamin IM or high-dose PO/nasal (for pernicious lifelong)	Mechanism: replaces B12 → DNA synthesis → RBC maturation and myelin synthesis. Indications: pernicious (intrinsic factor lack) → lifelong IM monthly after loading, also vegan deficiency, gastric bypass. Side: mild diarrhea, hypokalemia early as marrow makes RBCs (K+ shifts into cells), injection site pain. Nursing: give IM deep into muscle (vastus lateralis/gluteal) when deficiency severe, oral high-dose if absorption intact but pernicious needs IM because no intrinsic factor. Loading dose daily x1 week then weekly then monthly. Monitor K+ early (hypokalemia as RBCs produced), Hgb rise, retic rise in 3-4 days, neuro improvement may take months but irreversible if delayed >6-12 months. Teaching: lifelong monthly injections for pernicious, don't stop, foods high B12 meat, dairy, eggs but pernicious cannot absorb so diet alone insufficient, report paresthesias, ataxia, confusion improvement. No black box.
Folic acid PO	Often given with B12 because folate needed for DNA. Do NOT give folate alone before B12 — why: folate can correct anemia but worsen neuro damage by masking B12 deficiency. Always check B12 before folate. Monitor.

Class / Meds

Mechanism / Safety

Cyanocobalamin / Hydroxocobalamin IM or high-dose PO/nasal (for pernicious lifelong)

Mechanism: replaces B12 → DNA synthesis → RBC maturation and myelin synthesis. Indications: pernicious (intrinsic factor lack) → lifelong IM monthly after loading, also vegan deficiency, gastric bypass. Side: mild diarrhea, hypokalemia early as marrow makes RBCs (K+ shifts into cells), injection site pain. Nursing: give IM deep into muscle (vastus lateralis/gluteal) when deficiency severe, oral high-dose if absorption intact but pernicious needs IM because no intrinsic factor. Loading dose daily x1 week then weekly then monthly. Monitor K+ early (hypokalemia as RBCs produced), Hgb rise, retic rise in 3-4 days, neuro improvement may take months but irreversible if delayed >6-12 months. Teaching: lifelong monthly injections for pernicious, don't stop, foods high B12 meat, dairy, eggs but pernicious cannot absorb so diet alone insufficient, report paresthesias, ataxia, confusion improvement. No black box.

Folic acid PO

Often given with B12 because folate needed for DNA. Do NOT give folate alone before B12 — why: folate can correct anemia but worsen neuro damage by masking B12 deficiency. Always check B12 before folate. Monitor.

Aplastic Anemia

Class	Mechanism / Safety
Immunosuppressants: Antithymocyte globulin (ATG), Cyclosporine	Suppress autoimmune attack on stem cells → marrow recovers. For patients not transplant candidates. Side: serum sickness ATG fever/rash, nephrotoxicity cyclosporine, HTN, infection risk. Nursing: monitor vitals, renal function, cyclosporine levels, infection precautions, bleeding precautions. Black box: anaphylaxis ATG, nephrotoxicity.
Growth factors: Filgrastim (Neupogen) G-CSF, Eltrombopag, Supportive: transfusions RBCs/platelets	G-CSF stimulates neutrophils ↑ WBC. Eltrombopag stimulates platelets. RBC transfusion for Hgb <7 or symptomatic, platelets <10k or <20k with bleeding/fever. Nursing: transfusion safety ABO verification, vitals q15min first 15 min, stop if reaction (fever, chills, chest pain, dyspnea, hypotension). Monitor for transfusion reaction, iron overload with many transfusions.
Hematopoietic stem cell transplant (HSCT) — definitive	Replaces marrow. Requires conditioning chemo, immunosuppression. Complications: GVHD, infection.

Sickle Cell Disease

Class	Mechanism / Safety / Teaching
Hydroxyurea (Droxia, Hydrea)	Mechanism: increases HgbF fetal hemoglobin → less sickling → ↓ pain crises, acute chest, transfusions. Indication: moderate-severe sickle SS disease age ≥9 months. Side: myelosuppression dose-limiting low WBC/platelets, teratogenic, secondary malignancy rare. Black box: myelosuppression — monitor CBC q2weeks initially. Nursing: monitor CBC, retic, LFTs, hold if ANC <2000 or platelets <80k per order, teach adherence, contraception, hydration, report fever/infection.
Voxelotor (Oxbryta), Crizanlizumab (Adakveo), L-glutamine (Endari)	Voxelotor increases Hgb affinity for O2 → less polymerization → ↑ Hgb. Crizanlizumab blocks P-selectin → ↓ vaso-occlusion adhesion. L-glutamine reduces oxidative stress → fewer crises. Nursing: monitor Hgb, LFTs, infusion reactions for crizanlizumab, adherence teaching.
Analgesics for crisis: Opioids (morphine, hydromorphone), NSAIDs (if not contraindicated), Ketorolac short-term	Crisis severe pain 7-10/10 → around-the-clock opioids + breakthrough + nonpharm (heat, hydration, O2). Why opioids needed: vaso-occlusive ischemia severe. Nursing: assess pain q15-30min, PCA often, monitor sedation/RR, bowel regimen for constipation, non-judgmental care — addiction rare when pain treated. Hydration: NS or ½ NS per order to ↓ sickling — WHY: hydration ↓ viscosity, ↓ sickling.
Supportive: Folic acid daily, Penicillin prophylaxis children <5, Vaccines (pneumococcal, meningococcal, Hib, flu), Chelation Deferasirox for iron overload from transfusions	Folic acid supports increased RBC turnover. Penicillin prevents encapsulated bacteria due to autosplenectomy. Vaccines critical. Chelation binds excess iron from multiple transfusions. Teaching: lifelong folic acid, penicillin adherence in kids, vaccines up to date, hydration 3L/day if not contraindicated, avoid triggers (cold, dehydration, high altitude, stress, infection, alcohol, smoking).

Nursing Interventions — Prioritized

Priority	Intervention & WHY
Airway/Breathing/Circulation	All anemias: O2 per order if SpO2 <94% or dyspnea, but O2 doesn't fix anemia — treats compensatory hypoxia. Vitals q4h including orthostatics, Hgb/Hct trends, type & screen. Tachycardia/tachypnea = compensation. Severe Hgb <7 with symptoms → prepare RBC transfusion: verify consent, blood type, vitals baseline q15min first 15 min then q30min, check for reaction (fever, chills, back pain, dyspnea, hypotension, chest pain) → STOP transfusion, keep IV NS, notify provider, recheck ID. Iron deficiency: hydration if GI bleed. Aplastic: bleeding precautions. Sickle: O2 to keep SpO2 ≥95% to prevent sickling, IV hydration NS or ½ NS per order 1.5x maintenance if not cardiac/renal, avoid overhydration pulmonary edema.
Safety — Bleeding / Infection (Aplastic, Sickle)	Aplastic pancytopenia: bleeding precautions <50k platelets — soft toothbrush, electric razor, no IM, no NSAIDs, avoid trauma, pressure 10 min after venipuncture, check urine/stool for blood, fall precautions. Infection: neutropenic precautions — hand hygiene #1, private room, no fresh flowers/raw fruits per facility, no live vaccines, avoid sick contacts, no rectal temps/suppositories, daily mouth care, monitor temp q4h (fever may be only sign, no pus). Sickle: infection precautions — autosplenectomy → encapsulated bacteria risk → fever = emergency, blood cultures, antibiotics within 60 min.
Comfort — Pain (Sickle)	Believe pain, assess PQRST 0-10 q15-30min, around-the-clock opioids + breakthrough PCA per order, nonpharm heat (not cold — cold causes sickling), hydration, relaxation, reposition, diversional. Why heat helps: vasodilation → ↑ flow. Why cold harms: vasoconstriction → sickling. Monitor sedation scale, RR, bowel regimen, pruritus.
Nutrition / Meds	Iron: diet high iron (red meat, liver, beans, fortified cereals) + vit C OJ ↑ absorption, avoid milk/antacids/tea with iron. B12: meat, dairy, eggs but pernicious needs IM lifelong — teach not diet alone. Folic acid leafy greens. Sickle: hydration 2-3L/day if not contraindicated, folic acid daily, avoid alcohol. Give meds as above with monitoring.
Patient education / Interdisciplinary	Heme, dietitian, transfusion service, pain service, genetics for sickle trait counseling, social work, case management. Teach energy conservation: cluster activities, rest periods, assist ADLs.

Potential Complications

Complication	Early signs	Nursing response / Emergency
High-output heart failure (all anemias severe)	Tachycardia >120, dyspnea, crackles, S3, edema, fatigue, Hgb <7	O2, vitals q1-4h, I&O, daily weight, lung sounds, EKG, Hgb/Hct, prepare transfusion per order, fall precautions, energy conservation, notify provider, avoid fluid overload.
Irreversible neuro damage (pernicious)	Paresthesias, ataxia, loss of proprioception, confusion, gait unsteady	STAT B12 level, neuro exam, give B12 IM per order, monitor K+ early (hypokalemia as cells produced), safety fall precautions, PT/OT, teach lifelong therapy, no folate alone before B12.
Febrile neutropenia / Sepsis (aplastic)	Fever ≥100.4°F once with ANC <500, tachycardia, hypotension, sore throat, no pus	Emergency: cultures blood/urine/sputum/wounds BEFORE antibiotics per protocol, broad-spectrum antibiotics within 60 min, vitals q15min-1h, neutropenic precautions, no rectal temps, monitor WBC/ANC, I&O, daily weight.
Severe bleeding / ICH (aplastic platelets <20k)	Petechiae widespread, purpura, epistaxis, gum bleed, hematuria, melena, headache, neuro changes, hypotension	Apply pressure, call rapid, CBC, PT/INR/aPTT, type & cross, hold anticoagulants/NSAIDs, bleeding precautions, prepare platelets/RBCs per order, neuro checks, head CT if neuro change.
Acute Chest Syndrome (sickle)	Fever, chest pain, cough, dyspnea, tachypnea, SpO2 <94%, new infiltrate on CXR, chest wall pain from rib infarcts	Emergency: O2 to keep ≥95%, incentive spirometry q2h, IV hydration, antibiotics per order, pain control, type & screen, prepare exchange transfusion, notify provider/ICU, monitor vitals, I&O, ABGs.
Splenic sequestration / Stroke (sickle)	Sequestration: sudden LUQ pain, pallor, hypotension, tachycardia, splenomegaly, Hgb drop 2g. Stroke: facial droop, weakness, speech change, severe headache	Sequestration: large-bore IV, NS bolus per order, type & cross, prepare transfusion, vitals q5-15min, shock management, do NOT do vigorous spleen palpation. Stroke: rapid neuro assessment, call stroke alert, O2, vitals, prepare exchange transfusion, CT/MRI.
Transfusion reaction	Fever, chills, back/flank pain, dyspnea, chest pain, hypotension, urticaria, jaundice within minutes-hours	STOP transfusion immediately, keep IV open with NS new tubing, vitals, notify provider/blood bank, check IDs, send blood back, monitor I&O, renal function, treat per reaction type.

Patient Education

Iron deficiency: Cause often GI bleed — report black tarry stools (melena) vs dark stools from iron (expected dark but not tarry). Take iron on empty stomach 1hr before or 2hr after meals with OJ, away from milk/antacids/calcium. Dark stools normal, constipation common — fluids, fiber, activity, stool softener. Take 2-3 months beyond Hgb normal to refill stores. High iron foods: red meat, liver, beans, spinach, fortified cereals. Avoid tea/coffee with meals. Keep away from children — fatal overdose. Follow up Hgb/ferritin.
Pernicious: Autoimmune no intrinsic factor → cannot absorb B12 by diet alone → lifelong monthly IM B12 after loading, even if feeling better. Do not take folate alone before B12 checked — can mask anemia but worsen nerves. Foods B12 meat, dairy, eggs but still need injections. Report paresthesias, gait changes, confusion — may improve but can be irreversible if delayed. Safety fall precautions. Need gastric cancer screening (atrophic gastritis risk).
Aplastic: Avoid sick contacts, hand hygiene, no live vaccines, no fresh flowers/raw foods per facility, no rectal temps/suppositories, bleeding precautions soft toothbrush/electric razor/no NSAIDs/no IM. Report fever ≥100.4°F once, bleeding, bruising, fatigue, dyspnea. Need frequent labs CBC/ANC/platelets. Wear medical alert. Bone marrow transplant discussion if candidate.
Sickle cell: Autosomal recessive inheritance — genetic counseling for trait/disease, partner testing. Crisis triggers: dehydration, infection, cold, stress, high altitude, alcohol, smoking, overexertion — avoid. Hydrate 2-3L/day if not contraindicated, avoid cold exposure, dress warmly, avoid high altitudes, get rest, manage stress, hand hygiene, vaccines pneumococcal/meningococcal/Hib/flu/COVID, penicillin prophylaxis in children <5 per provider. Pain crisis plan: start pain meds early at home per plan, heat not cold, hydration, when to go ED (pain unrelieved 2 doses, fever ≥101°F, chest pain/dyspnea, severe headache, weakness, speech change, LUQ pain + pallor, priapism >4hr, jaundice worsening). Adherence hydroxyurea with CBC monitoring, contraception, avoid pregnancy without provider discussion. Folic acid daily.
General: Energy conservation cluster activities, rest periods, assist ADLs. Follow-up labs, appointments. Medical alert bracelet for sickle, aplastic, pernicious. When to seek emergency: chest pain, dyspnea, syncope, HR >120, hypotension, fever with neutropenia, active bleeding, neuro changes, sickle chest pain/dyspnea/neuro/ LUQ pain/priapism.

Clinical Judgment (NCSBN CJMM)

Recognize Cues: 24-year-old Black man with sickle cell SS disease reports 3-hour severe back and leg pain 9/10 after playing basketball in cold weather yesterday, drank little water, now fever 100.9°F, HR 112, BP 98/62, RR 24, SpO2 91% RA, appears in pain, jaundice sclera, chest tightness, cough, crackles left base, Hgb 6.8 (baseline 8.5), retic high, indirect bilirubin high.
Analyze Cues: Cold exposure + dehydration + exertion → sickling triggers. Pain crisis vaso-occlusive → severe back/leg pain. Fever 100.9°F infection triggers crisis + autosplenectomy infection risk. SpO2 91% low + chest tightness + cough + crackles + fever → acute chest syndrome, life-threatening. Hgb drop 8.5→6.8 → hemolysis + possible sequestration or acute chest. Tachycardia/hypotension early shock.
Prioritize Hypotheses: #1 Acute chest syndrome with vaso-occlusive crisis and hypoxia. #2 Infection precipitating crisis. #3 Anemia worsening with hemolysis.
Generate Solutions: ABCs — O2 to keep SpO2 ≥95%, IV hydration NS per order 1.5x maintenance if not overloaded, pain control around-the-clock opioids per order + PCA, cultures blood/sputum before antibiotics, broad-spectrum antibiotics within 60 min per order, incentive spirometry q2h, type & crossmatch, prepare for simple or exchange transfusion per order, monitor vitals q15min-1h, I&O hourly, neuro checks, avoid cold, keep warm, nonpharm heat, hydration, no overhydration pulmonary edema, VTE prophylaxis per order despite anemia, notify hematology/ICU.
Take Action: Call rapid/provider STAT, O2 2L NC → non-rebreather to keep ≥95%, large-bore IV NS bolus per order, morphine IV per order, blood cultures x2, sputum culture, CBC/retic/bilirubin/LDH/haptoglobin, ABG, chest X-ray, incentive spirometry, warm blankets, strict I&O, daily weight, pain reassess q15-30min, fall precautions.
Evaluate Outcomes: Pain decreases 9→4/10, SpO2 91%→96%, RR 24→20, HR 112→88, chest pain improved, crackles decreasing, Hgb stable 7.2 after transfusion, retic decreasing, bilirubin down, no new infiltrate, no stroke/sequestration signs. Continue hydroxyurea teaching, trigger avoidance, vaccine status, discharge plan with follow-up heme, pain plan, hydration, when to seek emergency.

Clinical Connections — Commonly Confused on NCLEX

Feature	Iron Deficiency	Pernicious (B12)	Aplastic	Sickle Cell
Cause	Lack iron — bleed, poor intake, malabsorption	Lack intrinsic factor → no B12 absorption autoimmune	Marrow failure empty marrow — drugs, viruses, chemicals, autoimmune	HgbS genetic → sickling under low O2/dehydration
Lab hallmark	Microcytic MCV <80, MCH low hypochromic, RDW high, ferritin low <15, iron low, TIBC high, transferrin sat low, retic low then ↑ after iron	Macrocytic MCV >100, MCH high, hypersegmented neutrophils, B12 low <200, MMA high, homocysteine high, intrinsic factor antibody +, retic low then ↑ after B12	Pancytopenia low RBC/WBC/platelets, MCV normal, retic very low <1%, marrow hypocellular fatty	Hgb low 6-9 baseline, retic high 5-20%, indirect bilirubin high, LDH high, haptoglobin low, HgbS on electrophoresis, smear sickle cells
Assessment hallmark	Pallor, fatigue, spoon nails, pica, angular cheilitis, tachycardia	Pallor, beefy red smooth tongue, paresthesias, ataxia, loss of proprioception, confusion — neuro irreversible	Fatigue + fever/infection/no pus + petechiae/bleeding — pancytopenia	Pain crisis + jaundice + high retic + triggers cold/dehydration/infection, dactylitis infants, leg ulcers, autosplenectomy
Treatment	Find bleed source, oral iron on empty stomach + vit C away from milk/antacids, IV iron if severe, diet high iron, constipation prevention	Lifelong IM B12 monthly after loading, monitor K+ early, neuro exam, safety, no folate alone before B12, diet but diet insufficient for pernicious	Bleeding + neutropenic precautions, transfusions RBCs/platelets, growth factors G-CSF, immunosuppressants ATG/cyclosporine, HSCT definitive, no rectal temps	Hydration, O2 SpO2 ≥95%, pain opioids + heat not cold, incentive spirometry, antibiotics for fever, hydroxyurea ↑ HgbF, folic acid, vaccines, chelation if iron overload, avoid triggers, transfusion/exchange for severe complications
Priority nursing	O2 perfusion, orthostatics, dark stools expected vs melena, constipation prevention, transfusion safety	Neuro safety fall precautions, K+ monitoring early, lifelong teaching, cancer screening	Emergency fever + ANC <500 and platelets <20k + bleeding, hand hygiene, private room, no live vaccines, bleeding precautions	Believe pain, hydrate, O2, pain control, incentive spirometry q2h acute chest prevention, infection prevention, stroke/sequestration watch

NCLEX High-Yield Review — What the NCLEX Wants You to Know

Iron deficiency = small pale + low ferritin Microcytic <80 hypochromic low ferritin low iron high TIBC low sat. Spoon nails, pica. Iron empty stomach + OJ, away from milk/antacids, dark stools expected, constipation fluids/fiber.
Pernicious = big cells + neuro damage Macrocytic >100 hypersegmented neutrophils low B12 high MMA high homocysteine intrinsic factor antibody +, beefy red tongue, paresthesias, ataxia, irreversible if delayed. Lifelong IM B12 monthly, monitor K+ early, never folate alone before B12.
Aplastic = pancytopenia + empty marrow Low RBC + low WBC + low platelets + retic very low + hypocellular marrow. Bleeding precautions <50k, <20k spontaneous, neutropenic precautions ANC <500 + fever emergency, no rectal temps, hand hygiene #1.
Sickle = pain + hemolysis + triggers Triggers cold, dehydration, infection, stress, high altitude, exertion. Crisis: severe pain, acute chest fever/chest pain/dyspnea/SpO2 <94% infiltrate emergency, stroke signs, splenic sequestration LUQ pain + Hgb drop 2g + hypotension emergency. Treatment: hydrate, O2 ≥95%, pain opioids + heat not cold, incentive spirometry q2h, antibiotics fever, hydroxyurea ↑ HgbF black box myelosuppression.
Transfusion safety Verify consent, type & screen, vitals baseline and q15min first 15 min, stay 15 min, stop if reaction fever/chills/back pain/dyspnea/hypotension/chest pain, keep IV NS new tubing, notify provider/blood bank, recheck IDs.

Common distractors: Dark stools from iron = expected vs melena tarry sticky GI bleed abnormal. Cold for sickle pain (wrong — heat not cold). Folate alone for macrocytic anemia without checking B12 (worsens neuro). Oral iron with milk/antacids (↓ absorption). Stopping iron early when Hgb normal (need 2-3 months more to refill stores). Dismissing sickle pain as drug-seeking — believe pain.

Delegation: RN assesses neuro, interprets CBC/MCV/ferritin/B12/retic, manages crisis/transfusion reaction, teaches lifelong B12/hydroxyurea. LPN/VN can check vitals, I&O, daily weight, give PO iron/B12 per order, reinforce teaching, report bleeding/fever/pain. UAP can take vitals, weight, I&O, assist hygiene, report bleeding/fever/pain/swelling — cannot interpret labs, manage crisis, or teach initial.

Memory Aids

Iron deficiency: T I R D — Tiny Iron-lacking RBCs, Iron low Ferritin low, RDW high, Dark stools expected, Spoon nails, Pica ice.
Pernicious: B12 BIG — Big MCV >100, Beefy tongue, Intrinsic factor absent, Gait ataxia, Paresthesias irreversible.
Aplastic: A P A — All cell lines low Pancytopenia, Pretty empty marrow, Precautions bleeding + neutropenic.
Sickle crisis triggers: C O L D S H I P — Cold, Overexertion, Low O2/high altitude, Dehydration, Stress, High altitude, Infection, Pain already.
Sickle treatment: H O P I S — Hydrate, Oxygen ≥95%, Pain opioids + heat, Incentive spirometry q2h, Sequestration/stroke watch.
Iron administration: Empty stomach + OJ, Away from milk/antacids, Constipation prevention, Keep away from kids.
Never give folate alone before checking B12 — folate fixes anemia but not nerves, nerve damage becomes irreversible.

Case Study — from admission to discharge

Patient: Elena, 68, vegan 20 years, no B12 supplements, reports 3-month progressive fatigue, dyspnea on exertion, sore tongue, numbness tingling feet, difficulty walking, HR 108, BP 100/62, pallor conjunctiva, beefy red smooth tongue, decreased vibration sense feet, positive Romberg, ataxic gait, Hgb 7.8, MCV 112 high macrocytic, WBC 3.2 low, platelets 110k low, B12 98 low, MMA high, homocysteine high, intrinsic factor antibody positive, retic low.

Recognize & Analyze Cues

Cues: vegan no B12 + autoimmune pernicious risk, fatigue/dyspnea/pallor/tachy anemia, beefy red tongue epithelial failure, paresthesias/ataxia/loss proprioception/Romberg/confusion neuro demyelination, macrocytic MCV 112, low B12 98 high MMA/homocysteine, pancytopenia mild, intrinsic factor antibody positive → pernicious anemia with neurologic involvement. Low retic marrow not making cells. Risk: irreversible neuro damage if delayed, high-output heart failure.

Prioritize & Plan

Priorities: #1 Tissue hypoxia anemia #2 Neuro safety fall risk irreversible damage #3 Nutrition deficiency. Plan: O2 if SpO2 <94%, vitals q4h orthostatics, fall precautions, safety, PT/OT, type & screen, give B12 IM per order loading dose daily x1 week then weekly then monthly lifelong, monitor K+ early (hypokalemia as RBCs made), Hgb/retic q3-4 days retic should rise, neuro checks proprioception/gait qday, no folate alone before B12, diet teaching but pernicious needs IM, teach about gastric cancer risk screening, energy conservation.

Take Action & Evaluate

Actions: Provider notified, B12 1000mcg IM daily x7 days per order, K+ checked 4.2 then 3.4 after 2 days → replaced per order, vitals HR 108→88 after 1 week, Hgb 7.8→9.2, retic 0.8%→3.2% ↑ good response, neuro paresthesias still present but gait improved slightly, tongue less sore, safety maintained no falls, teaching done. Discharge: monthly B12 IM lifelong, don't stop, foods B12 but injections still needed, report worsening neuro, fall precautions at home, follow-up CBC/B12/MMA, PT, GI referral for atrophic gastritis/cancer screening, medical alert, when to seek emergency Hgb drop, chest pain, dyspnea, neuro worsening.

NCLEX Practice Questions

Answers shuffled randomly — no sequential pattern. Correct answer number given in rationale.

1. A client with iron deficiency anemia is prescribed ferrous sulfate 325mg TID. Which teaching is correct?

Take with milk to prevent stomach upset and expect red stools
Take with antacids to reduce nausea and stop when Hgb normal
Take on empty stomach 1 hour before or 2 hours after meals with orange juice, away from milk and antacids; dark stools are expected and constipation prevention is needed
Take at bedtime only with tea to enhance absorption

Rationale

Answer: 3. Oral iron best absorbed empty stomach with vitamin C OJ ↑ absorption, away from milk/calcium/antacids/tea/coffee which ↓ absorption. Dark green-black stools expected, not red. Constipation common need fluids/fiber/activity. Milk (1) and antacids (2) reduce absorption, red stools not expected. Tea (4) ↓ absorption and bedtime only insufficient. Need continue 2-3 months beyond Hgb normal to refill stores, don't stop early (2).

2. A client with pernicious anemia has B12 85 pg/mL, MCV 115, paresthesias in feet, and ataxic gait. Which is the priority nursing action?

Give folic acid 1mg PO immediately without checking B12
Give cyanocobalamin 1000mcg IM per order, monitor K+ early, implement fall precautions, and teach lifelong monthly injections
Encourage vegan diet with more leafy greens only
Give iron sucrose IV with test dose

Rationale

Answer: 2. Pernicious low B12 + macrocytic + neuro symptoms ataxia/paresthesias → risk irreversible nerve damage. Need IM B12 (pernicious cannot absorb PO) loading then monthly lifelong, monitor K+ early hypokalemia as marrow produces RBCs K shifts into cells, fall precautions safety, teach lifelong. Folate alone (1) without B12 can correct anemia but worsen neuro damage. Vegan diet leafy greens (3) provides folate not B12 and diet insufficient for pernicious intrinsic factor lack. Iron sucrose (4) for iron deficiency not B12.

3. A client with aplastic anemia has WBC 1.8k, ANC 400, Hgb 7.2, platelets 18k, temp 101.2°F. Which intervention is priority?

Encourage fresh fruits and vegetables
Take rectal temperature every 2 hours to monitor fever
Obtain cultures blood/urine/sputum/wounds before antibiotics per protocol, notify provider STAT, and initiate neutropenic and bleeding precautions
Give IM injection of vitamin B12

Rationale

Answer: 3. Aplastic pancytopenia ANC 400 <500 + fever ≥100.4°F once = febrile neutropenia emergency + platelets 18k <20k spontaneous bleeding risk. Need STAT cultures before antibiotics per protocol, notify provider, broad-spectrum antibiotics within 60 min, neutropenic precautions hand hygiene private room no fresh flowers/raw foods per facility no live vaccines no rectal temps/suppositories, bleeding precautions soft toothbrush electric razor no NSAIDs no IM pressure 10 min. Fresh fruits (1) may be restricted per facility, rectal temps (2) contraindicated infection/bleeding risk, B12 IM (4) not for aplastic and IM contraindicated platelets low.

4. A 22-year-old with sickle cell disease reports severe back and leg pain 9/10 after cold exposure and dehydration, HR 110, BP 96/60, SpO2 90% RA, chest tightness, fever 100.8°F. Which action should the nurse take first?

Apply cold packs to painful areas and encourage rest
Give oral iron to increase Hgb quickly
Administer O2 to keep SpO2 ≥95%, start IV hydration per order, assess pain, and notify provider STAT for possible acute chest syndrome
Encourage strenuous exercise to improve circulation

Rationale

Answer: 3. Vaso-occlusive crisis triggered cold/dehydration + chest tightness + fever + SpO2 90% low + tachy/hypotension → acute chest syndrome emergency. Need O2 to keep ≥95% to prevent sickling, IV hydration per order to ↓ viscosity, pain assessment and opioids per order, cultures, antibiotics, incentive spirometry q2h, type & cross, prepare transfusion. Cold packs (1) cause vasoconstriction worsen sickling — use heat not cold. Iron (2) not for sickle hemolytic anemia and won't fix acute. Strenuous exercise (4) worsens sickling.

5. A client receiving a second unit of packed RBCs develops fever 101.5°F, chills, back pain, dyspnea, and hypotension 15 minutes into transfusion. What is the nurse's first action?

Slow the transfusion and give acetaminophen
Continue transfusion and monitor vitals in 1 hour
Stop the transfusion immediately, keep IV open with normal saline using new tubing, notify provider and blood bank, and recheck identification
Give iron dextran test dose

Rationale

Answer: 3. Signs fever/chills/back pain/dyspnea/hypotension 15 min into transfusion = acute hemolytic transfusion reaction emergency. First stop transfusion immediately, keep IV open with NS new tubing (not LR), notify provider and blood bank, recheck labels/IDs, vitals, I&O, send blood back, monitor renal function. Slowing (1) or continuing (2) would worsen reaction. Iron dextran (4) unrelated.

6. SATA. Which findings support iron deficiency anemia? Select all that apply.

Microcytic MCV 72, MCH low hypochromic, RDW high, ferritin 10 low, TIBC high
Beefy red smooth tongue and paresthesias of feet with ataxic gait
Spoon nails koilonychia, pica craving ice, angular cheilitis, fatigue, tachycardia
High reticulocyte count 8% with jaundice and indirect bilirubin high
History of heavy menstrual bleeding and GI bleed from NSAID use

Rationale

Answers: 1, 3, 5. Iron deficiency microcytic <80 hypochromic low ferritin <15 low iron high TIBC low transferrin sat, spoon nails, pica ice, angular cheilitis, fatigue/tachy, history heavy menses/GI bleed NSAIDs. Beefy tongue/paresthesias/ataxia (2) = B12 pernicious. High retic 8% + jaundice + indirect bilirubin high (4) = hemolysis sickle, not iron deficiency (retic low before treatment).

7. SATA. Which interventions are appropriate for a child with sickle cell disease? Select all that apply.

Hydration 2-3L/day if not contraindicated, O2 to keep SpO2 ≥95% during crisis, heat not cold for pain, incentive spirometry q2h
Hydroxyurea adherence with CBC monitoring, folic acid daily, penicillin prophylaxis per provider in children <5, vaccines pneumococcal/meningococcal/Hib/flu
Trigger avoidance: cold, dehydration, infection, high altitude, stress, smoking, alcohol
Give iron supplements routinely to prevent anemia
Apply cold packs to painful joints and restrict fluids

Rationale

Answers: 1, 2, 3. Sickle: hydration ↓ viscosity, O2 ≥95% prevents sickling, heat not cold vasodilation, incentive spirometry prevents acute chest, hydroxyurea ↑ HgbF with myelosuppression monitor CBC black box, folic acid supports turnover, penicillin prophylaxis children <5 autosplenectomy encapsulated bacteria risk, vaccines critical, avoid triggers cold/dehydration/infection/high altitude/stress/smoking/alcohol. Iron routinely (4) not given — anemia from hemolysis not iron deficiency, iron overload risk with transfusions. Cold packs and fluid restriction (5) worsen sickling — need heat and hydration.

8. Priority. The nurse has four clients. Who should be seen first?

Client with iron deficiency anemia Hgb 10.2, mild fatigue, stable vitals
Client with pernicious anemia B12 150, mild paresthesias, stable, awaiting B12 injection
Client with aplastic anemia ANC 350, temp 101.4°F, HR 118, BP 90/60, platelets 22k with petechiae
Client with sickle cell disease pain 4/10 controlled with oral meds, SpO2 96%, afebrile

Rationale

Answer: 3. Aplastic pancytopenia ANC 350 <500 + fever 101.4°F + tachy 118 + hypotension 90/60 + platelets 22k petechiae = febrile neutropenia + bleeding risk sepsis emergency — needs STAT cultures before antibiotics within 60 min, neutropenic and bleeding precautions, rapid response. Others stable mild anemia fatigue, pernicious mild paresthesias awaiting B12, sickle pain controlled SpO2 96% afebrile routine.

9. Delegation. Which task can the RN delegate to LPN/VN for a stable client with iron deficiency anemia on oral iron?

Interpret ferritin and TIBC and adjust iron dose
Teach initial cause of anemia and need for bone marrow biopsy
Assess for high-output heart failure and manage transfusion reaction
Check vital signs, orthostatics, daily weight, I&O, and reinforce teaching about iron administration with OJ away from milk/antacids and constipation prevention per plan

Rationale

Answer: 4. LPN/VN can check vitals including orthostatics, daily weight, I&O, give PO iron per order, reinforce teaching about iron with OJ away from milk/antacids and constipation prevention per plan, report changes. Interpreting ferritin/TIBC and adjusting dose (1), initial teaching about cause/biopsy (2), assessing high-output failure and managing transfusion reaction (3) require RN.

10. NGN Case Study. A 20-year-old with sickle cell SS disease, baseline Hgb 8.5, presents after playing football in heat with little water, reports severe bilateral leg and back pain 10/10, HR 112, BP 94/62, RR 24, Temp 100.9°F, SpO2 90% RA, appears in distress, sclera icteric, chest tightness, cough, crackles left base, Hgb 6.9, retic 9% high, indirect bilirubin high, LDH high, haptoglobin low.

a) What condition and cues support it?
b) What are 3 priority actions and why?
c) What indicates improvement and what teaching to prevent recurrence?

Model answer

a) Vaso-occlusive pain crisis with acute chest syndrome triggered by dehydration, exertion, heat: Sickle SS disease, dehydration/heat/exertion triggers sickling, severe leg/back pain 10/10 vaso-occlusive, fever 100.9°F infection trigger, HR 112 hypotension 94/62 tachypnea 24 SpO2 90% low chest tightness cough crackles left base → acute chest syndrome (new pulmonary infiltrate with chest symptoms), Hgb drop 8.5→6.9 hemolysis, retic high 9%, indirect bilirubin high LDH high haptoglobin low hemolysis, icteric sclera jaundice.

b) Priorities: 1) ABCs — O2 to keep SpO2 ≥95% to prevent sickling, IV hydration NS per order 1.5x maintenance if not overloaded to ↓ viscosity, monitor for overload crackles/I&O/weight. 2) Pain control — around-the-clock opioids per order PCA, assess pain q15-30min, heat not cold, nonpharm, hydration, monitor sedation/RR/bowel regimen. 3) Infection and acute chest — blood/sputum cultures before antibiotics per protocol, broad-spectrum antibiotics within 60 min per order, incentive spirometry q2h, type & crossmatch, prepare for simple or exchange transfusion per order, notify hematology/ICU, vitals q15min-1h, neuro checks for stroke, sequestration watch.

c) Improvement: Pain 10→4/10, SpO2 90%→96%, RR 24→18, HR 112→88, BP 94/62→108/68, crackles decreasing, no new infiltrate, Hgb stable 7.4, retic decreasing, bilirubin/LDH down, afebrile, no stroke/sequestration signs. Teaching: avoid triggers dehydration, cold, high altitude, infection, stress, alcohol, smoking, overexertion; hydrate 2-3L/day if not contraindicated, dress warmly, rest, hand hygiene, vaccines pneumococcal/meningococcal/Hib/flu/COVID, penicillin prophylaxis children, folic acid daily, hydroxyurea adherence with CBC monitoring, pain action plan early meds at home, when to seek emergency fever ≥101°F, chest pain/dyspnea/SpO2 <94%, severe headache/weakness/speech change stroke, LUQ pain + pallor + hypotension sequestration, priapism >4hr, jaundice worsening, genetic counseling for trait/disease.

Key Takeaways

Iron deficiency = microcytic <80 hypochromic low ferritin low iron high TIBC low sat + spoon nails + pica — treat find bleed source, oral iron empty stomach + OJ away from milk/antacids, dark stools expected, constipation prevention, continue 2-3 months beyond Hgb normal.
Pernicious = macrocytic >100 + beefy tongue + paresthesias/ataxia/proprioception loss irreversible if delayed — B12 low MMA high intrinsic factor antibody + → lifelong IM B12 monthly after loading, monitor K+ early, never folate alone before B12.
Aplastic = pancytopenia + very low retic + empty hypocellular marrow — emergency fever + ANC <500 and platelets <20k bleeding — neutropenic + bleeding precautions, cultures before antibiotics within 60 min, transfusions, growth factors, HSCT definitive.
Sickle = genetic HgbS → hemolysis high retic high bilirubin high LDH low haptoglobin + vaso-occlusion pain — triggers COLD SHIP (cold, overexertion, low O2, dehydration, stress, high altitude, infection, pain). Treatment HOPIS: Hydrate, Oxygen ≥95%, Pain opioids + heat not cold, Incentive spirometry q2h, Sequestration/stroke watch. Complications acute chest, stroke, splenic sequestration, priapism.
Transfusion safety: verify consent/type/screen, vitals baseline q15min first 15 min, stop if reaction fever/chills/back pain/dyspnea/hypotension/chest pain, keep NS open new tubing, notify provider/blood bank.

References

Hinkle, J. L., Cheever, K. H., & Overbaugh, K. J. (2022). Brunner & Suddarth's textbook of medical-surgical nursing (15th ed.). Wolters Kluwer.
McCance, K. L., & Huether, S. E. (2019). Pathophysiology: The biologic basis for disease in adults and children (8th ed.). Elsevier.
Schrier, S. L. (2023). Approach to the adult patient with anemia. UpToDate. Wolters Kluwer.
National Heart, Lung, and Blood Institute. (2022). Sickle cell disease — clinical practice guidelines. National Institutes of Health.
Silvestri, L. A., & Silvestri, A. E. (2023). Saunders comprehensive review for the NCLEX-RN examination (9th ed.). Elsevier.
Assessment Technologies Institute. (2023). ATI RN adult medical-surgical nursing review module (12th ed.). ATI Nursing Education.
Centers for Disease Control and Prevention. (2023). Anemia and sickle cell disease. https://www.cdc.gov/ncbddd/sicklecell/

Anemias

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Welcome & Getting Started

Launch RN Simulator

Wellness Center

Nursing Foundations

Fundamentals & Safety

Pharmacology

Dosage Calculations

Leadership, Management & Delegation

Medical-Surgical Body Systems

Neurological System

Sensory System

Endocrine System

Respiratory System

Cardiovascular System

Hematologic/Immune/Lymphatic System

Gastrointestinal (GI) System

Renal & Genitourinary

Reproductive System

Musculoskeletal System

Integumentary System

Specialty Areas

Maternity

Infectious Diseases

Pediatrics

Mental Health

NCLEX Success Center

Clinical Judgment Practice

Prioritization Practice

Delegation Practice

Lab Values

Final Review