exam 1

The nurse who is about to begin a blood transfusion knows that blood cells start to deteriorate after a certain period of time. The nurse takes which actions in order to prevent a complication of the blood transfusion as it relates to deterioration of blood cells? Select all that apply.

Check expiration date Hang blood within time frame

The nurse is assessing a dark-skinned client for signs of anemia. The nurse should focus the assessment on which structures? Select all that apply.

Lips conjunctiva mucous membranes

The nurse has discontinued a unit of blood that was infusing into a client because the client experienced a transfusion reaction. After documenting the incident appropriately, the nurse sends the blood bag and tubing to which department?

blood bank

A client is diagnosed with iron deficiency anemia, and ferrous sulfate is prescribed. The nurse should tell the client that it would be best to take the medication with which food?

tomato juice

During a routine prenatal visit, a client complains of gums that bleed easily with brushing. The nurse performs an assessment and teaches the client about proper nutrition to minimize this problem. Which client statement indicates an understanding of the proper nutrition to minimize this problem?

"I will eat fresh fruits and vegetables for snacks and for dessert each day."

The nurse has provided instructions to the mother of a child with sickle cell disease regarding measures that will prevent a sickle cell crisis. Which client statement indicates an understanding of these measures?

"My child needs to avoid situations that may lead to an infection."

The nurse is monitoring the laboratory results of a client receiving an antineoplastic medication by the intravenous route. The nurse plans to initiate bleeding precautions if which laboratory result is noted?

A platelet count of 50,000 mm3 (50 × 109/L)

The nurse is told by a primary health care provider that a client in hypovolemic shock will require plasma expansion. The nurse should prepare which supplies for transfusion?

Bottle of albumin with vented tubing

The nurse is preparing to care for a client with chronic kidney disease and anemia. Which describes the relationship between chronic kidney disease and anemia?

Decreased erytrhopoeitein causes anemia

As part of chemotherapy education, the nurse teaches a female client about the risk for bleeding and self-care during the period of greatest bone marrow suppression (the nadir). The nurse understands that further teaching is needed if the client makes which statement?

I am going to take aspirin when I get home

The nurse has provided medication instructions to a client with an iron deficiency anemia who will be taking iron supplements. Which statement made by the client indicates an understanding of this medication?

I need to increase my fluid intake

The nurse is preparing a plan of care for a child with sickle cell crisis who will be admitted to the nursing unit. The nurse should include which intervention as a priority in the plan of care for the child?

Initiate an intravenous (IV) line for the administration of fluids

The nurse is teaching a client who has iron deficiency anemia about foods she should include in the diet. The nurse determines that the client understands the dietary modifications if which items are selected from the menu?

Oranges and dark leafy veggies

The nurse is reviewing the laboratory test results for a client who takes 325 mg of acetylsalicylic acid, or aspirin, daily and has been having frequent nosebleed episodes. What blood level should the nurse review?

PT

After undergoing Billroth I gastric surgery, the client experiences fatigue and complains of numbness and tingling in the feet and difficulties with balance. On the basis of these symptoms, the nurse suspects which postoperative complication?

Pernicious anemia

The nurse is reviewing the laboratory test results for a client and notes that the differential white blood cell (WBC) count indicates a shift to the right. The nurse suspects that the client's diagnosis is most likely to be which one?

Pernicious anemia

Following infusion of a unit of packed red blood cells, the client has developed new onset of tachycardia, bounding pulses, crackles, and wheezes. Which action should the nurse implement first?

Place the client in high fowlers

The nurse is instructing a client with iron deficiency anemia regarding the administration of a liquid oral iron supplement. Which instruction should the nurse tell the client?

administer through a straw

The nurse is caring for a client who is receiving a blood transfusion and is complaining of a cough. The nurse checks the client's vital signs, which include a temperature of 97.2º F (36.2º C), pulse of 108 beats per minute, blood pressure of 152/76 mm Hg, respiratory rate of 24 breaths per minute, and an oxygen saturation level of 95% on room air. The client denies pain at this time. Based on this information, what initial action should the nurse take?

compare to baseline

A client is at risk for developing disseminated intravascular coagulopathy (DIC). The nurse determines that which fibrinogen level is normal?

400

A unit of platelets was just received from the blood bank for transfusion to an assigned client. The nurse should select tubing with which feature for the transfusion?

An a line filter

A client requiring surgery is anxious about the possible need for a blood transfusion during or after the procedure. The nurse suggests to the client to take which actions to reduce the risk of possible transfusion complications? Select all that apply.

Ask a family member to donate blood ahead of time. Give an autologous blood donation before the surgery

A prescription reads heparin sodium, 1300 units/hr by continuous intravenous (IV) infusion. The pharmacy prepares the medication and delivers an IV bag labeled heparin sodium 20,000 units/250 mL D5W. An infusion pump must be used to administer the medication. The nurse sets the infusion pump at how many milliliters (mL) per hour to deliver 1300 units/hour? Fill in the blank. Record your answer to the nearest whole number.

16

A client is prescribed a liquid iron preparation that has the potential to stain the teeth. The nurse should instruct the client to take which action to prevent staining of the teeth?

Dilute the iron in juice, drink it through a straw, and rinse the mouth afterward.

One unit of packed red blood cells has been prescribed for a client with severe anemia. The client has received multiple transfusions in the past, and it is documented that the client has experienced urticaria-type reactions from the transfusions. The nurse anticipates that which medication will be prescribed before administration of the red blood cells to prevent this type of reaction?

Diphenhydramine

The nurse is performing an assessment on a client with a diagnosis of anemia that developed as a result of blood loss after a traumatic injury. The nurse should expect to find which sign or symptom in the client as a result of the anemia?

SOB with activity

A client receiving a transfusion of packed red blood cells (PRBCs) begins to vomit. The client's blood pressure is 90/50 mm Hg from a baseline of 125/78 mm Hg. The client's temperature is 100.8º F (38.2º C) orally from a baseline of 99.2º F (37.3º C) orally. The nurse determines that the client may be experiencing which complication of a blood transfusion?

Septicemia

The nurse, listening to the morning report, learns that an assigned client received a unit of granulocytes the previous evening. The nurse makes a note to assess the results of which daily serum laboratory studies to assess the effectiveness of the transfusion?

WBC

The nurse is reviewing the laboratory test results for a client with a diagnosis of thrombocytopenia purpura. The nurse should expect the results for platelet aggregation to be at which level? **

decreased

The nurse has obtained a unit of blood from the blood bank and has checked the blood bag properly with another nurse. Just before beginning the transfusion, the nurse should assess which priority item?

vital signs

A client with iron deficiency anemia complains of feeling fatigued almost all of the time. The nurse should respond with which statement?

"Adequate amounts of hemoglobin are needed to carry oxygen for tissue metabolism."

The registered nurse is precepting a new nurse who is caring for a client with pernicious anemia as a result of a gastrectomy. Which statement made by the new nurse indicates understanding of this diagnosis?

"Decreased production of intrinsic factor by the stomach affects absorption of vitamin B12 in the small intestine."

A client has a prescription to receive a unit of packed red blood cells. The nurse should obtain which intravenous (IV) solution from the IV storage area to hang with the blood product at the client's bedside?

0.9 sodium chloride

The nurse is picking up a unit of packed red blood cells at the hospital blood bank. After putting the pen down, the nurse glances at the clock, which reads 1300. The nurse calculates that the transfusion must be started by which time?

1330 (should be administered within 30 min)

The nurse has a prescription to administer packed red blood cells (PRBCs) to a client who does not currently have an intravenous (IV) line inserted. When obtaining supplies to start the blood infusion, the nurse should select an angiocatheter of at least which size?

19 gauge

A client with severe blood loss resulting from multiple trauma requires rapid transfusion of several units of blood. The nurse asks another health team member to obtain which device for use during the transfusion procedure to help reduce the risk of cardiac dysrhythmias?

Blood warming device

Which interventions are the most appropriate for a client who is experiencing thrombocytopenia? Select all that apply.

Check secretions occult test oral sponge soft toothbrush fluid intake to avoid constipation

The nurse has just received a prescription to transfuse a unit of packed red blood cells for an assigned client. What action should the nurse take next?

Check to be sure that consent for transfusion is signed

The nurse is assisting in monitoring a client who is receiving a transfusion of packed red blood cells (PRBCs). Before leaving the room, the nurse tells the client to immediately report which symptoms of a transfusion reaction? Select all that apply.

Chills Chest pain Difficulty breathing Lower Back pain

A client who was diagnosed with toxic shock syndrome (TSS) now exhibits petechiae, oozing from puncture sites, and coolness of the digits of the hands and feet. Clotting times determined for this client are prolonged. The nurse interprets these clinical signs as being most compatible with which condition?

DIC

A client has received a transfusion of platelets. The nurse evaluates that the client is benefiting most from this therapy if the client exhibits which finding?

Decreased oozing of blood from puncture sites and gums

Packed red blood cells have been prescribed for a female client with anemia who has a hemoglobin level of 7.6 g/dL (76 mmol/L) and a hematocrit level of 30% (0.30). The nurse takes the client's temperature before hanging the blood transfu¬sion and records 100.6° F (38.1° C) orally. Which action should the nurse take?

Delay hanging the blood and notify the primary health care (PHCP).

When obtaining assessment data from a client with a microcytic normochromic anemia, which should the nurse question the client about?

Dietary intake of iron

A client is brought to the emergency department having experienced blood loss related to an arterial laceration. Which blood component should the nurse expect the primary health care provider to prescribe?

Fresh frozen plasma

A client who has undergone preadmission testing has had blood drawn for serum laboratory studies, including a complete blood count, coagulation studies, and electrolytes and creatinine levels. Which laboratory result should be reported to the surgeon's office by the nurse, knowing that it could cause surgery to be postponed?

Hemoglobin 8.0

The nurse is caring for a client in the early stages of disseminated intravascular coagulation (DIC). At this stage, what medication would the nurse expect to be prescribed?

Heparin

The nurse is preparing a client with thrombocytopenia for discharge. Which statement by the client about measures minimizing injury indicates that discharge teaching was effective? Select all that apply?

I will continue using an electric razor I will not blow my nose when I am sick I will use a soft toothbrush

A client's laboratory test results reveal an increased transferrin level and a decreased iron-binding capacity. The nurse interprets that these laboratory results are compatible with anemia because of which problem?

Iron deficiency

An adult female client has a hemoglobin level of 10.8 g/dL (108 mmol/L). The nurse interprets that this result is most likely caused by which condition noted in the client's history?

Iron deficiency anemia

The nurse is reviewing the laboratory test results for a client seen in the health care clinic and notes that the hematocrit value is 30% (0.30). The nurse determines that this hematocrit value is most likely to be associated with which condition?

Iron deficiency anemia

The nurse is providing dietary teaching for a client with a diagnosis of chronic gastritis. The nurse instructs the client to include which foods rich in vitamin B12 in the diet? Select all that apply.

Nuts Corn Liver

The ambulatory care nurse is reviewing an adult client's laboratory test results and notes that the hematocrit level is 60% (0.60). The nurse recognizes that this level is most likely to be found in clients with which diagnosis?

Pernicious anemia

Laboratory studies are performed for a client suspected to have iron deficiency anemia. The nurse reviews the laboratory results, knowing that which result indicates this type of anemia?

Red blood cells that are microcytic and hypochromic

The nurse is performing an assessment on a client with a diagnosis of pernicious anemia. Which finding would the nurse expect to note in this client?

Red tongue smooth and sore

The nurse determines that a client is having a transfusion reaction. After the nurse stops the transfusion, which action should be taken next?

Run normal saline and keep vein rate open

Client enters the hospital emergency department with a nosebleed. On assessment, the client tells the nurse that the nosebleed just suddenly began. The nurse notes no obvious facial injury. Which is the initial nursing action?

Sit the client down, ask the client to lean forward slightly, and apply pressure to the nose for 5 to 10 minutes.

The nurse monitors the client for which condition as a complication of polycythemia vera?

Thrombosis

The nurse is reviewing the prescriptions for a client admitted to the hospital with a diagnosis of idiopathic autoimmune hemolytic anemia. The nurse prepares the client for treatment of this disorder, understanding that which may be recommended? Select all that apply

Transfusion splenectomy corticosteroids immunosuppresents

A unit of packed red blood cells has been prescribed for a client with low hemoglobin and hematocrit typing and crossmatching. The nurse receives a telephone call from the blood bank and is informed that the unit of blood is ready for administration. In order of priority, how should the nurse plan the actions to take? Arrange the actions in the order that they should be performed. All options must be used.

Verify order, ensure consent is signed, insert gauge catheter, obtain unit of blood, have nurse confirm vitals and compatibility, hang the bag transfusion

A home care nurse is visiting a client with a diagnosis of pernicious anemia that developed as a result of gastric surgery. The nurse instructs the client that in this disorder, because the stomach lining produces a decreased amount of a substance known as the intrinsic factor, the client will need which medication?

Vit b12 injections

The nurse should anticipate that the primary health care provider (PHCP) will prescribe which treatment for a client with pernicious anemia?

Vitamin b 12 injections

The nurse enters the room of a client who began receiving a blood transfusion 45 minutes earlier to check on the client. The client is complaining of "itching all over" and has a generalized rash. The client's temperature has not changed from baseline and the lungs are clear to auscultation. Which complication of blood transfusion therapy should the nurse determine that this client is most likely experiencing?

allergic transfusion reaction

The nurse enters a client's room to assess the client, who began receiving a blood transfusion 45 minutes earlier, and notes that the client is flushed and dyspneic. On assessment, the nurse auscultates the presence of crackles in the lung bases. The nurse determines that this client most likely is experiencing which complication of blood transfusion therapy?

circulatory overload

The nurse overhears a primary health care provider (PHCP) stating that a client diagnosed with disseminated intravascular coagulation (DIC) requires a transfusion. Which blood product should the nurse anticipate that the PHCP will write a prescription for?

cryoprecipitate

A client has experienced high blood pressure and crackles in the lungs during previous blood transfusions. The client asks the nurse whether it is safe to receive another transfusion. The nurse explains that which medication most likely will be prescribed before the transfusion is begun?

furesomide

A clinic nurse is reviewing the record of a client with a suspected diagnosis of pernicious anemia. The nurse anticipates that which diagnostic test will be prescribed by the client's primary health care provider?

schilling test