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Anemias

NCLEX hematology chapter: iron B12 and folate deficiency cues, anemia activity tolerance, sickle-cell crisis priorities, and when bleeding precautions apply.

Clesial Editorial TeamReviewed by Clesial Editorial Team, Clinical Content Review

4 minUpdated Aug 6, 2026
Contents7 sections

Anemia items ask why the client is short of breath on one flight of stairs and which vitamin or hemoglobinopathy is behind it. Clotting failure, DIC, and transfusion reactions live in Bleeding and transfusion — this chapter owns deficiency anemias and sickle-cell crisis care.

What anemia does at the bedside

Hemoglobin carries oxygen. When it is low — from blood loss, underproduction, or destruction — tissues extract what they can and the heart works harder. Clients look pale, tire easily, get tachycardic, and may be dyspneic on exertion. Nursing basics are rest with clustered care, oxygen as ordered, fall precautions if dizzy, and diet/med teaching matched to the cause. Treating “fatigue” with forced ambulation contests fails the stem when saturation and pulse say the reserve is gone.

  • Assess activity tolerance and pace care.
  • Report chest pain or syncope — anemia can unmask cardiac ischemia.
  • Find the driver: bleed, diet, malabsorption, marrow, hemolysis, or inherited hemoglobin.

Iron, B12, and folate

Iron deficiency is the exam’s workhorse: blood loss (GI, menstrual) or poor intake. Teach oral iron on an empty stomach when tolerated, with vitamin C-containing juice, expecting dark stools and possible constipation — not a GI bleed by color alone. Liquid iron stains teeth; use a straw. Do not stack the dose onto milk, calcium, or antacids at the same moment.

DeficiencyExtra cueTeaching / action
IronPallor, fatigue, sometimes picaIron + C; dark stools expected; separate from Ca
B12 / perniciousNeuro: paresthesia, ataxia, glossitisLifelong B12 if intrinsic factor lost
FolateMegaloblastic; poor diet / alcoholFolate replacement; fix intake

Pernicious anemia is B12 deficiency from lack of intrinsic factor — oral absorption fails, so parenteral or high-dose pathways appear as ordered. Neurologic damage can become permanent; numbness and gait change are not “just aging.” Folate looks hematologically similar without that same neuro package — still treat, and remember folate in pregnancy prevention stems belongs with prenatal care.

Sickle cell disease

Sickle hemoglobin polymerizes under stress, sickled cells occlude microvasculature, and ischemic pain crises follow. Triggers include infection, dehydration, cold, high altitude, and acidosis. Bedside priorities are hydration, oxygenation as ordered, aggressive pain control (believe the pain), and warmth. Ice causes vasoconstriction and is a classic wrong answer on a vaso-occlusive limb.

  1. Pain crisis: fluids, O₂ as ordered, analgesia, warmth, treat infection.
  2. Fever in sickle cell: emergency evaluation — asplenic infection risk.
  3. Acute chest (chest pain, tachypnea, new infiltrate pattern): escalate now.

Safety

Neurologic change or acute chest in sickle cell is not “wait for the pain med to work” — think stroke / acute chest pathway.

Teaching includes hydration, infection prevention, vaccination as ordered, and avoiding known triggers. Hydroxyurea and transfusion programs appear as ordered disease-modifying pathways — nursing focus is adherence and toxicity watch per protocol. Splenic sequestration and aplastic crisis patterns show as sudden anemia and hypovolemia — volume and escalate.

Priority map

SituationFirst move
Exertional dyspnea + low HgbRest, O₂ as ordered, find cause
Iron dose with antacidSeparate timing; teach C vs calcium
B12 deficiency + numbnessReplacement now; neuro is time-sensitive
Sickle pain crisisHydration, O₂ as ordered, pain meds, warmth
Sickle + fever or chest symptomsEmergency escalation

Revision

Must know

  1. 1Anemia means less oxygen-carrying capacity — prioritize activity tolerance, oxygenation, and the cause.
  2. 2Iron deficiency: microcytic picture, fatigue, pallor; teach iron with vitamin C, expect dark stools, avoid taking with milk/antacids at the same moment.
  3. 3B12 deficiency (including pernicious): neuro changes (paresthesias, balance) plus megaloblastic anemia — IM/oral B12 as ordered; neuro injury can persist if delayed.
  4. 4Folate deficiency: megaloblastic without the same classic neuro map — alcohol use and poor intake are common stems.
  5. 5Sickle cell vaso-occlusive crisis: hydration, oxygen as ordered, pain control, warmth — do not use ice on painful areas as a default.
  6. 6Sickle cell: avoid high altitude / severe dehydration triggers as taught; infection is an emergency (fever).
  7. 7Acute chest syndrome and stroke symptoms in sickle cell are emergencies — escalate, do not treat as “just pain.”
  8. 8Transfusion reactions and thrombocytopenia precautions live in Bleeding and transfusion.

Memory hooks

  • Iron with C, not with tea/milk

    Vitamin C helps absorption; calcium and many antacids block it at the same sitting.

  • Sickle: HOP to help

    Hydration, Oxygen as ordered, Pain control — plus find the trigger.

How it's tested

Stems ask iron teaching, why B12 deficiency has numbness, first actions in sickle pain crisis, or which anemia needs neuro checks. Distractors ice a sickle crisis limb, give iron with a calcium antacid at once, or treat acute chest as anxiety.

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