Heme Nclex questions

Which of the following blood components is decreased in anemia? A. Erythrocytes B. Granulocytes C. Leukocytes D. Platelets

A Anemia is defined as a decreased number of erythrocytes (red blood cells). Leukopenia is a decreased number of leukocytes (white blood cells). Thrombocytopenia is a decreased number of platelets. Lastly, granulocytopenia is a decreased number of granulocytes (a type of white blood cells)

A client is to receive epoetin (Epogen) injections. What laboratory value should the nurse assess before giving the injection? A. Hematocrit B. Partial thromboplastin time C. Hemoglobin concentration D. Prothrombin time

A Epogen is a recombinant DNA form of erythropoietin, which stimulates the production of RBCs and therefore causes the hematocrit to rise. The elevation in hematocrit causes an elevation in blood pressure; therefore, the blood pressure is a vital sign that should be checked. The PTT, hemoglobin level, and PT are not monitored for this drug.

A client receiving a transfusion of packed red blood cells begins to vomit. The client's blood pressure is 90/50 from a baseline of 125/78. Temp is 100.8 from baseline 99.2 orally. The nurse determines patient is experiencing which complication with blood transfusion? a. septicemia B. hyperkalemia. c. circulatory overload. D. Delayed tranfusion reaction.

A, septicemia occurs with transfusion of blood contaminated with microorganisms. Signs include chills, fever, vomiting, diarrhea, hypotension, and development of shock. Hyerkalemia causes weakness, paresthesia, abdominal cramps, diarrhea, and dysrythmias. Circulatory overload causes cough, dyspnea, chest pain, wheezing, tachycardia, and hypertension. Delayed transfusion reaction can occer days or weeks after transfuison. Signs include fever, mild jaundice, and a decrease hematocrit level.

The nurse implements which of the following for the client who is starting a Schilling test? A. Administering methylcellulose (Citrucel) B. Starting a 24- to 48 hour urine specimen collection C. Maintaining NPO status D. Starting a 72 hour stool specimen collection

B Urinary vitamin B12 levels are measured after the ingestion of radioactive vitamin B12. A 24-to 48- hour urine specimen is collected after administration of an oral dose of radioactively tagged vitamin B12 and an injection of non-radioactive vitamin B12. In a healthy state of absorption, excess vitamin B12 is excreted in the urine; in a malabsorption state or when the intrinsic factor is missing, vitamin B12 is excreted in the feces. Citrucel is a bulk-forming agent. Laxatives interfere with the absorption of vitamin B12. The client is NPO 8 to 12 hours before the test but is not NPO during the test. A stool collection is not part of the Schilling test. If stool contaminates the urine collection, the results will be altered.

A client is brought to the emergency department having experienced blood loss related to an arterial laceration. Fresh-frozen plasma is prescribed and transfused to replace fluid and blood loss. The nurse understands that which is the rationale for transfusing fresh-frozen plasma to this client? a) To treat the loss of platelets b) To promote rapid volume expansion c) Because a transfusion must be done slowly d) Because it will increase the hemoglobin and hematocrit levels

B - Rationale: Fresh-frozen plasma is often used for volume expansion as a result of fluid and blood loss. It does not contain platelets, so it is not used to treat any type of low platelet count disorder. It is rich in clotting factors and can be thawed quickly and transfused quickly. It will not specifically increase the hemoglobin and hematocrit level

During a blood transfusion a client develops chills and a headache, what is the priority nursing action A) cover the client B) stop the transfusion at once C) notify the physician immediately D) decrease the rate of blood infusion

B) stop the transfusion because chills, headache, and nausea are all signs of transfusion reaction

Which of the following laboratory values is expected for a client just diagnosed with chronic lymphocytic leukemia? A. Elevated sedimentation rate B. Uncontrolled proliferation of granulocytes C. Thrombocytopenia and increased lymphocytes D. Elevated aspartate aminotransferase and alanine aminotransferase levels.

C Chronic lymphocytic leukemia shows a proliferation of small abnormal mature B lymphocytes and decreased antibody response. Thrombocytopenia also is often present. Uncontrolled proliferation of granulocytes occurs in myelogenous leukemia.

Which statement is the scientific rationale for infusing a unit of blood in less than four (4) hours? "1. The blood will coagulate if left out of the refrigerator for >four (4) hours. 2. The blood has the potential for bacterial growth if allowed to infuse longer. 3. The blood components begin to break down after four (4) hours. 4. The blood will not be affected; this is a laboratory procedure."

Correct 2 "1. Blood will coagulate if left out for an extended period of, but blood is stored with a preservative that prevents this and prolongs the life of the blood. 2. (CORRECT). Blood is a medium for bacterial growth, and any bacteria contaminating the unit will begin to grow if left outside of a controlled refrigerated temperature for longer than four (4) hours, placing the client at risk for septicemia. 3. Blood components are stable and do not break down after four (4) hours. 4. These are standard nursing and laboratory procedures to prevent the complication of septicemia."

Halfway through the administration of blood, the female client complains of lumbar pain. After stopping the infusion Nurse Hazel should: a. Increase the flow of normal saline b. Assess the pain further c. Notify the blood bank d. Obtain vital signs."

Correct A The blood must be stopped at once, and then normal saline should be infused to keep the line patent and maintain blood volume.

A month after receiving a blood transfusion an immunocompromised male patient develops fever, liver abnormalities, a rash, and diarrhea. The nurse would suspect this patient has: a. Nothing related to the blood transfusion b. Graft-versus-host disease (GVHD) c. Myelosuppression d. An allergic response to a recent medication"

Correct: B GVHD occurs when white blood cells in donor blood attack the tissues of an immunocompromised recipient. This process can occur within a month of the transfusion. Options 1 and 4 may be a thought, but the nurse must remember that immunocompromised transfusion recipients are at risk for GVHD

Laboratory studies are performed for a child suspected of having iron deficiency anemia. The nurse reviews the laboratory results, knowing that which of the following results would indicate this type of anemia? A. An elevated hemoglobin level B. A decreased reticulocyte count C. An elevated RBC count D. Red blood cells that are microcytic and hypochromic

D The results of a CBC in children with iron deficiency anemia will show decreased hemoglobin levels and microcytic and hypochromic red blood cells. The red blood cell count is decreased. The reticulocyte count is usually normal or slightly elevated.

Laboratory studies are performed for a child suspected of having iron deficiency anemia. The nurse reviews the laboratory results, knowing that which of the following results would indicate this type of anemia? An elevated hemoglobin level A decreased reticulocyte count An elevated RBC count Red blood cells that are microcytic and hypochromic

39. 4. The results of a CBC in children with iron deficiency anemia will show decreased hemoglobin levels and microcytic and hypochromic red blood cells. The red blood cell count is decreased. The reticulocyte count is usually normal or slightly elevated.

Characterized by: Pancytopenia, Hemmorhagic Findings, Easy Fatigue and weakness, Gingival hyperplasia. Fever in the presence of infection only, and/or Luekemic cutis (skin involvement) A. AML (Acute Myelogenous Leukemia) B. ALL (Acute Lymphocytic Leukemia) C. CLL (Chronic Lymphocytic Leukemia) D. CML (Chronic Myelogenous Leukemia

A

Characterized by easy fatigability, malaise, anorexia, early satiety, excessive sweating, weight loss, and upon PE, splenomegaly, pallor, and sternal tenderness A. AML (Acute Myelogenous Leukemia) B. ALL (Acute Lymphocytic Leukemia) C. CLL (Chronic Lymphocytic Leukemia) D. CML (Chronic Myelogenous Leukemia

D

A client comes into the health clinic 3 years after undergoing a resection of the terminal ileum complaining of weakness, shortness of breath, and a sore tongue. Which client statement indicates a need for intervention and client teaching? A. "I have been drinking plenty of fluids." B. "I have been gargling with warm salt water for my sore tongue." C. "I have 3 to 4 loose stools per day." D. "I take a vitamin B12 tablet every day."

D Vitamin B12 combines with intrinsic factor in the stomach and is then carried to the ileum, where it is absorbed in the bloodstream. In this situation, vitamin B12 cannot be absorbed regardless of the amount of oral intake of sources of vitamin B12 such as animal protein or vitamin B12 tablets. Vitamin B12 needs to be injected every month, because the ileum has been surgically removed. Replacement of fluids and electrolytes is important when the client has continuous multiple loose stools on a daily basis. Warm salt water is used to soothe sore mucous membranes. Crohn's disease and small bowel resection may cause several loose stools a day.

Which of the following symptoms is expected with hemoglobin of 10 g/dl? A. None B. Pallor C. Palpitations D. Shortness of breath

A Mild anemia usually has no clinical signs. Palpitations, SOB, and pallor are all associated with severe anemia.

A 16 year old girl presents to the Charlottesville free clinic complaining of generalized weakness. She tells you she has run away from home and has been living on the streets for the last year. Physical examination reveals multiple purpura over her body and gingival swelling with bleeding gums. Laboratory tests reveal that she has anemia. The anemia is most likely due to: A. an iron deficiency due to a lack of absorption. B. a vitamin B12 deficiency due to a lack of intrinsic factor. C. a folic acid deficiency due to a lack of vitamin B12. D. a lack of niacin due to a problem with tryptophan uptake. E. vitamin A toxicity.

A Vitamin C has antioxidant properties and facilitates iron absorption in the intestine by keeping iron in a reduced state (Fe2+), which is more amenable to absorption.

A client with anemia may be tired due to a tissue deficiency of which of the following substances? A. Carbon dioxide B. Factor VIII C. Oxygen D. T-cell antibodies

C Anemia stems from a decreased number of red blood cells and the resulting deficiency in oxygen and body tissues. Clotting factors, such as factor VIII, relate to the body's ability to form blood clots and aren't related to anemia, not is carbon dioxide of T antibodies.

The nurse is caring for a 70-year-old client with hypovolemia who is receiving a blood transfusion. Assessment findings reveal crackles on chest auscultation and distended neck veins. What is the nurse's initial action? A. Slow the transfusion. B. Document the finding as the only action. C. Stop the blood transfusion and turn on the normal saline. D. Assess the client's pupils."

Answer A is correct. The client is exhibiting symptoms of fluid volume excess; slowing the rate is the proper action. The nurse would not stop the infusion of blood, as in answer C, and answers B and D would not help.

"The physician orders 2 units of packed RBCs to be administered to the client. At 0600 the night shift nurse initiates the first unit's transfusion before going off shift. At 1000 the day shift nurse notes the IV line has clotted off and the transfusion has not been completed. The nursing assessment revealed the transfusion was only approximately 75% complete. Which of the actions by the nurse is most appropriate? A. Advise the blood bank about the delay for the next unit. B. Restart another peripheral line with 0.9% NS and restart the blood transfusion with the remaining blood unit. C. Discontinue the transfusion. D. Document the amount infused thus far and continue the transfusion."

Answer C Rationale: A unit of blood should be administered within a 4 hour period of time. The nurse should discontinue the transfusion, document the findings and notify the blood bank. The agency policy will need to be followed concerning the documentation process and notification of appropriate personnel. Continuing the transfusion with the "open" unit will expose the client to an increase risk of injury."

The nurse is preparing to initiate a blood transfusion. The client has a peripheral intravenous infusion in their left arm that the physician has ordered not be slowed or rate reduced. The nurse prepares to start another line in the right arm. The client asks the nurse to use the existing site to avoid the trauma of having another line started. Which of the following statements by the nurse is correct? A. ""That will be fine"" B. "I will need to infuse the blood through a separate IV line." C. "I will let the physician know about your preferences." D. "We will need to assess the line before I can make a determination about your request.""

Answer: B "Rationale: A blood infusion must be administered via a separate IV line. The other responses indicate to the client their request is being considered"

Which ONE of the following is required for proper absorption of vitamin B12? A. Vitamin C. B. Intrinsic factor. C. Iron. D. Triacylglycerol. E. Vitamin D.

B

Which of the following complications are three main consequences of leukemia? A. Bone deformities, spherocytosis, and infection. B. Anemia, infection, and bleeding tendencies C. Lymphocytopoiesis, growth delays, and hirsutism D. Polycythemia, decreased clotting time, and infection

B The three main consequences of leukemia are anemia, caused by decreased erythrocyte production; infection secondary to neutropenia; and bleeding tendencies, from decreased platelet production. Bone deformities don't occur with leukemia although bones may become painful because of the proliferation of cells in the bone marrow. Spherocytosis refers to erythrocytes taking on a spheroid shape and isn't a feature in leukemia. Mature cells aren't produced in adequate numbers. Hirsutism and growth delay can be a result of large doses of steroids but isn't common in leukemia. Anemia, not polycythemia, occurs. Clotting times would be prolonged.

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? 1. Lactated Ringer's 2. 0.9% sodium chloride 3. 5% dextrose in 0.9% sodium chloride 4. 5% dextrose in 0.45% sodium chloride

B - Rationale: Sodium chloride 0.9% (normal saline) is a standard isotonic solution used to precede and follow infusion of blood products. Dextrose is not used because it could result in clumping and subsequent hemolysis of red blood cells. Lactated Ringer's is not the solution of choice with this procedure.

Which of the following conditions is not a complication of Hodgkin's disease? A. Anemia B. Infection C. Myocardial Infarction D. Nausea

C Complications of Hodgkin's are pancytopenia, nausea, and infection. Cardiac involvement usually doesn't occur.

When comparing the hematocrit levels of a post-op client, the nurse notes that the hematocrit decreased from 36% to 34% on the third day even though the RBC and hemoglobin values remained stable at 4.5 million and 11.9 g/dL, respectively. Which nursing intervention is most appropriate? A. Check the dressing and drains for frank bleeding B. Call the physician C. Continue to monitor vital signs D. Start oxygen at 2L/min per NC

C The nurse should continue to monitor the client, because this value reflects a normal physiologic response. The physician does not need to be called, and oxygen does not need to be started based on these laboratory findings. Immediately after surgery, the client's hematocrit reflects a falsely high value related to the body's compensatory response to the stress of sudden loss of fluids and blood. Activation of the intrinsic pathway and the renin-angiotensin cycle via antidiuretic hormone produces vasoconstriction and retention of fluid for the first 1 to 2 day post-op. By the second to third day, this response decreases and the client's hematocrit level is more reflective of the amount of RBCs in the plasma. Fresh bleeding is a less likely occurrence on the third post-op day but is not impossible; however, the nurse would have expected to see a decrease in the RBC and hemoglobin values accompanying the hematocrit.

A client brought to the emergency department states that he has accidentally been taking two times his prescribed dose of warfarin (Coumadin) for the past week. After noting that the client has no evidence of obvious bleeding, the nurse plans to do which of the following? 1. Prepare to administer an antidote. 2. Draw a sample for type and crossmatch and transfuse the client. 3. Draw a sample for an activated partial thromboplastin time (aPTT) level. 4. Draw a sample for prothrombin time (PT) and international normalized ratio (INR)."

Correct - 4 - no rationale

A new RN is preparing to administer packed red blood cells (PRBCs) to a client whose anemia was caused by blood loss after surgery. Which action by the new RN requires that you, as charge nurse, intervene immediately? "a. The new RN waits 20 minutes after obtaining the PRBCs before starting the infusion. b. The new RN starts an intravenous line for the transfusion using a 22-gauge catheter. c. The new RN primes the transfusion set using 5% dextrose in lactated Ringer's solution. d. The new RN tells the client that the PRBCs may cause a serious transfusion reaction."

Correct: C ANSWER C - Normal saline, an isotonic solution, should be used when priming the IV line to avoid causing hemolysis of RBCs. Ideally, blood products should be infused as soon as possible after they are obtained; however, a 20-minute delay would not be unsafe. Large-gauge IV catheters are preferable for blood administration; if a smaller catheter must be used, normal saline may be used to dilute the RBCs. Although it is appropriate to instruct clients to notify the nurse if symptoms of a transfusion reaction such as shortness of breath or chest pain occur, it will cause unnecessary anxiety to indicate that a serious reaction is likely to occur. Focus: Prioritization

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? a) Infusion pump b) Pulse oximeter c) Cardiac monitor d) Blood-warming device

D - Rationale: If several units of blood are to be administered, a blood warmer should be used. Rapid transfusion of cool blood places the client at risk for cardiac dysrhythmias. To prevent this, the nurse warms the blood with a blood-warming device. Pulse oximetry and cardiac monitoring equipment are useful for the early assessment of complications but do not reduce the occurrence of cardiac dysrhythmias. Electronic infusion devices are not helpful in this case because the infusion must be rapid, and infusion devices generally are used to control the flow rate. In addition, not all infusion devices are made to handle blood or blood products.

About ten minutes after the nurse begins an infusion of packed RBCs, the patient complains of chills, chest and back pain, and nausea. His face is flushed, and he's anxious. Which is the priority nursing action? 1. Administering antihistamines STAT for an allergic reaction. 2. Notifying the physician of a possible transfusion reaction. 3. Obtaining a urine and serum specimen to send to the lab immediately. 4. Stopping hte transfusion and maintaining a patent IV catheter."

The correct answer is 4. The patietn is experiencing a transfusion reaction. The immediate nursing action is to stop the transfusion and maintain a patent IV line. The other options may be indicated but aren't the priority in this case.

The nurse has just admitted a 35-year-old female client who has a serum B12 concentration of 800 pg/ml. Which of the following laboratory findings would cue the nurse to focus the client history on specific drug or alcohol abuse? Total bilirubin, 0.3 mg/dL Serum creatinine, 0.5 mg/dL Hemoglobin, 16 g/dL Folate, 1.5 ng/mL

The normal range of folic acid is 1.8 to 9 ng/mL, and the normal range of vitamin B12 is 200 to 900 pg/mL. A low folic acid level in the presence of a normal vitamin B12 level is indicative of a primary folic acid-deficiency anemia. Factors that affect the absorption of folic acid are drugs such as methotrexate, oral contraceptives, antiseizure drugs, and alcohol. The total bilirubin, serum creatinine, and hemoglobin values are within normal limits.

The nurse is preparing to teach a client with microcytic hypochromic anemia about the diet to follow after discharge. Which of the following foods should be included in the diet? A. Eggs B. Lettuce C. Citrus fruits D. Cheese

a One of the microcytic, hypochromic anemias is iron-deficiency anemia. A rich source of iron is needed in the diet, and eggs are high in iron. Other foods high in iron include organ and muscle (dark) meats; shellfish, shrimp, and tuna; enriched, whole-grain, and fortified cereals and breads; legumes, nuts, dried fruits, and beans; oatmeal; and sweet potatoes. Dark green leafy vegetables and citrus fruits are good sources of vitamin C. Cheese is a good source of calcium.

A patient with macrocytic-megaloblastic anemia was diagnosed with a folate deficiency. Treatment with folate supplements resolved the patient's signs of anemia but the patient continued to complain of other symptoms including poor memory and numbness/tingling in the extremities. You suspect that the patient was originally misdiagnosed and instead is suffering from which ONE of the following deficiencies? A. A vitamin B12 deficiency. B. An iron deficiency. C. A vitamin C deficiency. D. A biotin deficiency. E. A vitamin B6 deficiency.

A

The nurse is reviewing the laboratory results of a client receiving chemotherapy. The platelet count is 10,000 cells/mm. Based on this laboratory value, the priority nursing assessment is which of the following? A. Assess level of consciousness B. Assess temperature C. Assess bowel sounds D. Assess skin turgor

A A high risk of hemorrhage exists when the platelet count is fewer than 20,000. Fatal central nervous system hemorrhage or massive gastrointestinal hemorrhage can occur when the platelet count is fewer than 10,000. The client should be assessed for changes in levels of consciousness, which may be an early indication of an intracranial hemorrhage. Option 2 is a priority nursing assessment when the white blood cell count is low and the client is at risk for an infection.

Nausea and vomiting are common adverse effects of radiation and chemotherapy. When should a nurse administer antiemetics? A. 30 minutes before the initiation of therapy. B. With the administration of therapy. C. Immediately after nausea begins. D. When therapy is completed

A Antiemetics are most beneficial when given before the onset of nausea and vomiting. To calculate the optimum time for administration, the first dose is given 30 minutes to 1 hour before nausea is expected, and then every 2, 4, or 6 hours for approximately 24 hours after chemotherapy. If the antiemetic was given with the medication or after the medication, it could lose its maximum effectiveness when needed.

When a client is diagnosed with aplastic anemia, the nurse monitors for changes in which of the following physiological functions? A. Bleeding tendencies B. Intake and output C. Peripheral sensation D. Bowel function

A Aplastic anemia decreases the bone marrow production of RBCs, WBCs, and platelets. The client is at risk for bruising and bleeding tendencies. A change in the intake and output is important, but assessment for the potential for bleeding takes priority. Change in the peripheral nervous system is a priority problem specific to clients with vitamin B12 deficiency. Change in bowel function is not associated with aplastic anemia.

Because of the risks associated with administration of factor VIII concentrate, the nurse would teach the client's family to recognize and report which of the following? A. Yellowing of the skin B. Constipation C. Abdominal distention D. Puffiness around the eyes

A Because factor VIII concentrate is derived from large pools of human plasma, the risk of hepatitis is always present. Clinical manifestations of hepatitis include yellowing of the skin, mucous membranes, and sclera. Use of factor VIII concentrate is not associated with constipation, abdominal distention, or puffiness around the eyes.

The nurse is teaching a 17-year old client and the client's family about what to expect with high-dose chemotherapy and the effects of neutropenia. What should the nurse teach as the most reliable early indicator of infection in a neutropenic client? A. Fever B. Chills C. Tachycardia D. Dyspnea

A Fever is an early sign requiring clinical intervention to identify potential causes. Chills and dyspnea may or may not be observed. Tachycardia can be an indicator in a variety of clinical situations when associated with infection; it usually occurs in response to an elevated temperature or change in cardiac function.

In which of the following diseases would bone marrow transplantation not be indicated in a newly diagnosed client? A. Acute lymphocytic leukemia B. Chronic myeloid leukemia C. Severe aplastic anemia D. Severe combined immunodeficiency

A For the first episode of acute lymphocytic anemia, conventional therapy is superior to bone marrow transplantation. In severe combined immunodeficiency and in severe aplastic anemia, bone marrow transplantation has been employed to replace abnormal stem cells with healthy cells from the donor's marrow. In myeloid leukemia, bone marrow transplantation is done after chemotherapy to infuse healthy marrow and to replace marrow stem cells ablated during chemotherapy.

A client was admitted with iron deficiency anemia and blood-streaked emesis. Which question is most appropriate for the nurse to ask in determining the extent of the client's activity intolerance? A. "What activities were you able to do 6 months ago compared with the present?" B. "How long have you had this problem?" C. "Have you been able to keep up with all your usual activities?" D. "Are you more tired now than you used to be?

A It is difficult to determine activity intolerance without objectively comparing activities from one time frame to another. Because iron deficiency anemia can occur gradually and individual endurance varies, the nurse can best assess the client's activity tolerance by asking the client to compare activities 6 months ago and at the present. Asking a client how long a problem has existed is a very open-ended question that allows for too much subjectivity for any definition of the client's activity tolerance. Also, the client may not even identify that a "problem" exists. Asking the client whether he is staying abreast of usual activities addresses whether the tasks were completed, not the tolerance of the client while the tasks were being completed or the resulting condition of the client after the tasks were completed. Asking the client if he is more tired now than usual does not address his activity tolerance. Tiredness is a subjective evaluation and again can be distorted by factors such as the gradual onset of the anemia or the endurance of the individual.

Which of the following medications usually is given to a client with leukemia as prophylaxis against P. carinii pneumonia? A. Bactrim B. Oral nystatin suspension C. Prednisone D. Vincristine (Oncovin)

A The most frequent cause of death from leukemia is overwhelming infection. P. carinii infection is lethal to a child with leukemia. As prophylaxis against P. carinii pneumonia, continuous low doses of co-trimoxazole (Bactrim) are frequently prescribed. Oral nystatin suspension would be indicated for the treatment of thrush. Prednisone isn't an antibiotic and increases susceptibility to infection. Vincristine is an antineoplastic agent.

Which of the following assessment findings in a client with leukemia would indicate that the cancer has invaded the brain? A. Headache and vomiting. B. Restlessness and tachycardia C. Hypervigilant and anxious behavior D. Increased heart rate and decreased blood pressure

A The usual effect of leukemic infiltration of the brain is increased intracranial pressure. The proliferation of cells interferes with the flow of cerebrospinal fluid in the subarachnoid space and at the base of the brain. The increased fluid pressure causes dilation of the ventricles, which creates symptoms of severe headache, vomiting, irritability, lethargy, increased blood pressure, decreased heart rate, and eventually, coma. Often children with a variety of illnesses are hypervigilant and anxious when hospitalized.

The nurse has received a prescription to transfuse a client with a unit of packed red blood cells. Before explaining the procedure to the client, the nurse should ask which initial question? a) "Have you ever had a transfusion before?" b) "Why do you think that you need the trans-fusion?" c) "Have you ever gone into shock for any reason in the past?" d) "Do you know the complications and risks of a transfusion?"

A - Rationale: Asking the client about personal experience with transfusion therapy provides a good starting point for client teaching about this procedure. Questioning about previous history of shock and knowledge of complications and risks of transfusion are not helpful because they may elicit a fearful response from the client. Although determining whether the client knows the reason for the transfusion is important, it is not an appropriate statement in terms of eliciting information from the client regarding an understanding of the need for the transfusion.

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 100.8 ° F orally from a baseline of 99.2 ° F orally. The nurse determines that the client may be experiencing which complication of a blood transfusion? a) Septicemia b) Hyperkalemia c) Circulatory overload d) Delayed transfusion reaction

A - Rationale: Septicemia occurs with the transfusion of blood contaminated with microorganisms. Signs include chills, fever, vomiting, diarrhea, hypotension, and the development of shock. Hyperkalemia causes weakness, paresthesias, abdominal cramps, diarrhea, and dysrhythmias. Circulatory overload causes cough, dyspnea, chest pain, wheezing, tachycardia, and hypertension. A delayed transfusion reaction can occur days to years after a transfusion. Signs include fever, mild jaundice, and a decreased hematocrit level.

82. The nurse who is about to begin a blood transfusion knows that blood cells start to deteriorate after a certain period of time. Which item is important to check regarding the age of blood cells before the transfusion is begun? a) Expiration date b) Presence of clots c) Blood group and type d) Blood identification number

A - Rationale: The nurse notes the expiration date on the unit of blood to ensure that the blood is fresh. Blood cells begin to deteriorate over time, so safe storage usually is limited to 35 days. Careful notation of the expiration date by the nurse is an essential part of the verification process before hanging a unit of blood. The nurse also notes the blood identification (unit) number, blood group and type, and client's name. The nurse also inspects the unit of blood for leaks, abnormal color, clots, and bubbles and returns the unit to the blood bank if clots are noted.

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 action(s) to reduce the risk of possible transfusion complications? Select all that apply. a) Ask a family member to donate blood ahead of time. b) Give an autologous blood donation before the surgery. c) Take iron supplements before surgery to boost hemoglobin levels. d) Request that any donated blood be screened twice by the blood bank. e) Take adequate amounts of vitamin C several days prior to the surgery date.

A, B - Rationale: A donation of the client's own blood before a scheduled procedure is autologous. Donating autologous blood to be reinfused as needed during or after surgery reduces the risk of disease transmission and potential transfusion complications. The next most effective way is to ask a family member to donate blood before surgery. Blood banks do not provide extra screening on request. Preoperative iron supplements are helpful for iron deficiency anemia but are not helpful in replacing blood lost during the surgery. Vitamin C enhances iron absorption, but also is not helpful in replacing blood lost during surgery.

The physician has ordered several laboratory tests to help diagnose an infant's bleeding disorder. Which of the following tests, if abnormal, would the nurse interpret as most likely to indicate hemophilia? A. Bleeding time B. Tourniquet test C. Clot retraction test D. Partial thromboplastin time (PTT)

D PTT measures the activity of thromboplastin, which is dependent on intrinsic clotting factors. In hemophilia, the intrinsic clotting factor VIII (antihemophilic factor) is deficient, resulting in a prolonged PTT. Bleeding time reflects platelet function; the tourniquet test measures vasoconstriction and platelet function; and the clot retraction test measures capillary fragility. All of these are unaffected in people with hemophilia.

Which of the following foods would the nurse encourage the mother to offer to her child with iron deficiency anemia? A. Rice cereal, whole milk, and yellow vegetables B. Potato, peas, and chicken C. Macaroni, cheese, and ham D. Pudding, green vegetables, and rice

B Potato, peas, chicken, green vegetables, and rice cereal contain significant amounts of iron and therefore would be recommended. Milk and yellow vegetables are not good iron sources. Rice by itself also is not a good source of iron.

A client with microcytic anemia is having trouble selecting food items from the hospital menu. Which food is best for the nurse to suggest for satisfying the client's nutritional needs and personal preferences? A. Egg yolks B. Brown rice C. Vegetables D. Tea

B Brown rice is a source of iron from plant sources (nonheme iron). Other sources of non heme iron are whole-grain cereals and breads, dark green vegetables, legumes, nuts, dried fruits (apricots, raisins, dates), oatmeal, and sweet potatoes. Egg yolks have iron but it is not as well absorbed as iron from other sources. Vegetables are a good source of vitamins that may facilitate iron absorption. Tea contains tannin, which combines with nonheme iron, preventing its absorption.

The nurse devises a teaching plan for the patient with aplastic anemia. Which of the following is the most important concept to teach for health maintenance? A. Eat animal protein and dark leafy vegetables each day B. Avoid exposure to others with acute infection C. Practice yoga and meditation to decrease stress and anxiety D. Get 8 hours of sleep at night and take naps during the day

B Clients with aplastic anemia are severely immunocompromised and at risk for infection and possible death related to bone marrow suppression and pancytopenia. Strict aseptic technique and reverse isolation are important measures to prevent infection. Although diet, reduced stress, and rest are valued in supporting health, the potentially fatal consequence of an acute infection places it as a priority for teaching the client about health maintenance. Animal meat and dark green leafy vegetables, good sources of vitamin B12 and folic acid, should be included in the daily diet. Yoga and meditation are good complimentary therapies to reduce stress. Eight hours of rest and naps are good for spacing and pacing activity and rest.

Which of the following diagnostic findings are most likely for a client with aplastic anemia? A. Decreased production of T-helper cells B. Decreased levels of white blood cells, red blood cells, and platelets C. Increased levels of WBCs, RBCs, and platelets D. Reed-Sternberg cells and lymph node enlargement

B In aplastic anemia, the most likely diagnostic findings are decreased levels of all the cellular elements of the blood (pancytopenia). T-helper cell production doesn't decrease in aplastic anemia. Reed-Sternberg cells and lymph node enlargement occur with Hodgkin's disease.

Which of the following tests in performed on a client with leukemia before initiation of therapy to evaluate the child's ability to metabolize chemotherapeutic agents? A. Lumbar puncture B. Liver function studies C. Complete blood count (CBC) D. Peripheral blood smear

B Liver and kidney function studies are done before initiation of chemotherapy to evaluate the child's ability to metabolize the chemotherapeutic agents. A CBC is performed to assess for anemia and white blood cell count. A peripheral blood smear is done to assess the maturity and morphology of red blood cells. A lumbar puncture is performed to assess for central nervous system infiltration.

A client with macrocytic anemia has a burn on her foot and states that she had been watching television while lying on a heating pad. What is the nurse's first response? A. Assess for potential abuse B. Check for diminished sensations C. Document the findings D. Clean and dress the area

B Macrocytic anemias can result from deficiencies in vitamin B12 or ascorbic acid. Only vitamin B12 deficiency causes diminished sensations of peripheral nerve endings. The nurse should assess for peripheral neuropathy and instruct the client in self-care activities for her diminished sensation to heat and pain. The burn could be related to abuse, but this conclusion would require more supporting data. The findings should be documented, but the nurse would want to address the client's sensations first. The decision of how to treat the burn should be determined by the physician.

A client with pernicious anemia asks why she must take vitamin B12 injections for the rest of her life. What is the nurse's best response? A. "The reason for your vitamin deficiency is an inability to absorb the vitamin because the stomach is not producing sufficient acid." B. "The reason for your vitamin deficiency is an inability to absorb the vitamin because the stomach is not producing sufficient intrinsic factor." C. "The reason for your vitamin deficiency is an excessive excretion of the vitamin because of kidney dysfunction." D. "The reason for your vitamin deficiency is an increased requirement for the vitamin because of rapid red blood cell production."

B Most clients with pernicious anemia have deficient production of intrinsic factor in the stomach. Intrinsic factor attaches to the vitamin in the stomach and forms a complex that allows the vitamin to be absorbed in the small intestine. The stomach is producing enough acid, there is not an excessive excretion of the vitamin, and there is not a rapid production of RBCs in this condition.

The nurse understands that the client with pernicious anemia will have which distinguishing laboratory findings? A. Schilling's test, elevated B. Intrinsic factor, absent C. Sedimentation rate, 16 mm/hour D. RBCs 5.0 million

B The defining characteristic of pernicious anemia, a megaloblastic anemia, is lack of the intrinsic factor, which results from atrophy of the stomach wall. Without the intrinsic factor, vitamin B12 cannot be absorbed in the small intestines, and folic acid needs vitamin B12 for DNA synthesis of RBCs. The gastric analysis was done to determine the primary cause of the anemia. An elevated excretion of the injected radioactive vitamin B12, which is protocol for the first and second stage of the Schilling test, indicates that the client has the intrinsic factor and can absorb vitamin B12 into the intestinal tract. A sedimentation rate of 16 mm/hour is normal for both men and women and is a nonspecific test to detect the presence of inflammation. It is not specific to anemias. An RBC value of 5.0 million is a normal value for both men and women and does not indicate anemia.

The nurse is assessing a client's activity intolerance by having the client walk on a treadmill for 5 minutes. Which of the following indicates an abnormal response? A. Pulse rate increased by 20 bpm immediately after the activity B. Respiratory rate decreased by 5 breaths/minute C. Diastolic blood pressure increased by 7 mm Hg D. Pulse rate within 6 bpm of resting phase after 3 minutes of rest

B The normal physiologic response to activity is an increased metabolic rate over the resting basal rate. The decrease in respiratory rate indicates that the client is not strong enough to complete the mechanical cycle of respiration needed for gas exchange. The post activity pulse is expected to increase immediately after activity but by no more than 50 bpm if it is strenuous activity. The diastolic blood pressure is expected to rise but by no more than 15 mm Hg. The pulse returns to within 6 bpm of the resting pulse after 3 minutes of rest.

The nurse is teaching a client with polycythemia vera about potential complications from this disease. Which manifestations would the nurse include in the client's teaching plan? Select all that apply. A. Hearing loss B. Visual disturbance C. Headache D. Orthopnea E. Gout F. Weight loss

B,C,D,E Polycythemia vera, a condition in which too many RBCs are produced in the blood serum, can lead to an increase in the hematocrit and hypervolemia, hyperviscosity, and hypertension. Subsequently, the client can experience dizziness, tinnitus, visual disturbances, headaches, or a feeling of fullness in the head. The client may also experience cardiovascular symptoms such as heart failure (shortness of breath and orthopnea) and increased clotting time or symptoms of an increased uric acid level such as painful swollen joints (usually the big toe). Hearing loss and weight loss are not manifestations associated with polycythemia vera.

A client with leukemia has neutropenia. Which of the following functions must be frequently assessed? A. Blood pressure B. Bowel sounds C. Heart sounds D. Breath sounds

D Pneumonia, both viral and fungal, is a common cause of death in clients with neutropenia, so frequent assessment of respiratory rate and breath sounds is required. Although assessing blood pressure, bowel sounds, and heart sounds is important, it won't help detect pneumonia.

A client with iron deficiency anemia is scheduled for discharge. Which instruction about prescribed ferrous gluconate therapy should the nurse include in the teaching plan? A. "Take the medication with an antacid." B. "Take the medication with a glass of milk." C. "Take the medication with cereal." D. "Take the medication on an empty stomach

D Preferably, ferrous gluconate should be taken on an empty stomach. Ferrous gluconate should not be taken with antacids, milk, or whole-grain cereals because these foods reduce iron absorption.

What are the three most important prognostic factors in determining long-term survival for children with acute leukemia? A. Histologic type of disease, initial platelet count, and type of treatment B. Type of treatment and client's sex C. Histologic type of disease, initial WBC count, and client's age at diagnosis D. Progression of illness, WBC at the time of diagnosis, and client's age at the time of diagnosis.

C The factor whose prognostic value is considered to be of greatest significance in determining the long-range outcome is the histologic type of leukemia. Children with a normal or low WBC count appear to have a much better prognosis than those with a high WBC count. Children diagnosed between ages 2 and 10 have consistently demonstrated a better prognosis because age 2 or after 10.

Which of the following cells is the precursor to the red blood cell (RBC)? A. B cell B. Macrophage C. Stem cell D. T celL

C The precursor to the RBC is the stem cell. B cells, macrophages, and T cells and lymphocytes, not RBC precursors

The client with cancer is receiving chemotherapy and develops thrombocytopenia. The nurse identifies which intervention as the highest priority in the nursing plan of care? A. Ambulation three times a day B. Monitoring temperature C. Monitoring the platelet count D. Monitoring for pathological factors

C Thrombocytopenia indicates a decrease in the number of platelets in the circulating blood. A major concern is monitoring for and preventing bleeding. Option 2 relates to monitoring for infection particularly if leukopenia is present. Options 1 and 4, although important in the plan of care are not related directly to thrombocytopenia.

Packed red blood cells have been prescribed for a client with low hemoglobin and hematocrit levels. The nurse takes the client's temperature before hanging the blood transfusion and records 100.6 ° F orally. Which action should the nurse take? a) Begin the transfusion as prescribed. b) Administer an antihistamine and begin the transfusion. c) Delay hanging the blood and notify the health care provider (HCP). d) Administer two tablets of acetaminophen (Tylenol) and begin the transfusion.

C - Rationale: If the client has a temperature higher than 100 ° F, the unit of blood should not be hung until the HCP is notified and has the opportunity to give further prescriptions. The HCP likely will prescribe that the blood be administered regardless of the temperature, but the decision is not within the nurse's scope of practice to make. The nurse needs an HCP's prescription to administer medications to the client.

According to a standard staging classification of Hodgkin's disease, which of the following criteria reflects stage II? A. Involvement of extralymphatic organs or tissues B. Involvement of single lymph node region or structure C. Involvement of two or more lymph node regions or structures. D. Involvement of lymph node regions or structures on both sides of the diaphragm.

C Stage II involves two or more lymph node regions. Stage I only involves one lymph node region; stage III involves nodes on both sides of the diaphragm; and stage IV involves extralymphatic organs or tissues.

A child suspected of having sickle cell disease is seen in a clinic, and laboratory studies are performed. A nurse checks the lab results, knowing that which of the following would be increased in this disease? A. Platelet count B. Hematocrit level C. Reticulocyte count D. Hemoglobin level

C A diagnosis is established based on a complete blood count, examination for sickled red blood cells in the peripheral smear, and hemoglobin electrophoresis. Laboratory studies will show decreased hemoglobin and hematocrit levels and a decreased platelet count, and increased reticulocyte count, and the presence of nucleated red blood cells. Increased reticulocyte counts occur in children with sickle cell disease because the life span of their sickled red blood cells is shortened.

The nurse explains to the parents of a 1-year-old child admitted to the hospital in a sickle cell crisis that the local tissue damage the child has on admission is caused by which of the following? A. Autoimmune reaction complicated by hypoxia B. Lack of oxygen in the red blood cells C. Obstruction to circulation D. Elevated serum bilirubin concentration

C Characteristic sickle cells tend to cause "log jams" in capillaries. This results in poor circulation to local tissues, leading to ischemia and necrosis. The basic defect in sickle cell disease is an abnormality in the structure of RBCs. The erythrocytes are sickle-shaped, rough in texture, and rigid. Sickle cell disease is an inherited disease, not an autoimmune reaction. Elevated serum bilirubin concentrations are associated with jaundice, not sickle cell disease.

A vegetarian client was referred to a dietitian for nutritional counseling for anemia. Which client outcome indicates that the client does not understand nutritional counseling? The client: A. Adds dried fruit to cereal and baked goods B. Cooks tomato-based foods in iron pots C. Drinks coffee or tea with meals D. Adds vitamin C to all meals

C Coffee and tea increase gastrointestinal motility and inhibit the absorption of nonheme iron. Clients are instructed to add dried fruits to dishes at every meal because dried fruits are a nonheme or nonanimal iron source. Cooking in iron cookware, especially acid-based foods such as tomatoes, adds iron to the diet. Clients are instructed to add a rich supply of vitamin C to every meal because the absorption of iron is increased when food with vitamin C or ascorbic acid is consumed.

The nurse would instruct the client to eat which of the following foods to obtain the best supply of vitamin B12? A. Whole grains B. Green leafy vegetables C. Meats and dairy products D. Broccoli and Brussels sprouts

C Good sources of vitamin B12 include meats and dairy products. Whole grains are a good source of thiamine. Green leafy vegetables are good sources of niacin, folate, and carotenoids (precursors of vitamin A). Broccoli and Brussels sprouts are good sources of ascorbic acid (vitamin C).

The oncology nurse specialist provides an educational session to nursing staff regarding the characteristics of Hodgkin's disease. The nurse determines that further education is needed if a nursing staff member states that which of the following is characteristic of the disease? A. Presence of Reed-Sternberg cells B. Involvement of lymph nodes, spleen, and liver C. Occurs most often in the older client D. Prognosis depends on the stage of the disease

C Hodgkin's disease is a disorder of young adults. Options 1, 2, and 4 are characteristics of this disease.

A clinic nurse instructs the mother of a child with sickle cell disease about the precipitating factors related to pain crisis. Which of the following, if identified by the mother as a precipitating factor, indicates the need for further instructions? A. Infection B. Trauma C. Fluid overload D. Stress

C Pain crisis may be precipitated by infection, dehydration, hypoxia, trauma, or physical or emotional stress. The mother of a child with sickle cell disease should encourage fluid intake of 1 ½ to 2 times the daily requirement to prevent dehydration.

The primary purpose of the Schilling test is to measure the client's ability to: A. Store vitamin B12 B. Digest vitamin B12 C. Absorb vitamin B12 D. Produce vitamin B12

C Pernicious anemia is caused by the body's inability to absorb vitamin B12. This results in a lack of intrinsic factor in the gastric juices. Schilling's test helps diagnose pernicious anemia by determining the client's ability to absorb vitamin B12.

Which of the following nursing assessments is a late symptom of polycythemia vera? A. Headache B. Dizziness C. Pruritus D. Shortness of breath

C Pruritus is a late symptom that results from abnormal histamine metabolism. Headache and dizziness are early symptoms from engorged veins. Shortness of breath is an early symptom from congested mucous membrane and ineffective gas exchange.

The nurse determines that a client is having a transfusion reaction. After the nurse stops the transfusion, which action should be taken next? a) Remove the intravenous (IV) line. b) Run a solution of 5% dextrose in water. c) Run normal saline at a keep-vein-open rate. d) Obtain a culture of the tip of the catheter device removed from the client

C - Rationale: If the nurse suspects a transfusion reaction, the nurse stops the transfusion and infuses normal saline at a keep-vein-open rate pending further health care provider prescriptions. This maintains a patent IV access line and aids in maintaining the client's intravascular volume. The nurse would not remove the IV line because then there would be no IV access route. Obtaining a culture of the tip of the catheter device removed from the client is incorrect. First, the catheter should not be removed. Second, cultures are performed when infection, not transfusion reaction, is suspected. Normal saline is the solution of choice over solutions containing dextrose because saline does not cause red blood cells to clump.

The nurse has just received a unit of packed red blood cells from the blood bank for transfusion to an assigned client. The nurse is careful to select tubing especially made for blood products, knowing that this tubing is manufactured with which item? a) An air vent b) Tinted tubing c) An in-line filter d) A microdrip chamber

C - Rationale: The tubing used for blood administration has an in-line filter. The filter helps ensure that any particles larger than the size of the filter are caught in the filter and are not infused into the client. Tinted tubing is incorrect because blood does not need to be protected from light. The tubing should be macrodrip, not microdrip, to allow blood to flow freely through the drip chamber. An air vent is unnecessary because the blood bag is not made of glass.

The nurse is working in a blood bank facility procuring units of blood from donors. Which client would not be a candidate to donate blood? 1.The client who had wisdom teeth removed a week ago. 2.The nursing student who received a measles immunization 2 months ago. 3. The mother with a six (6)-week-old newborn. 4.The client who developed an allergy to aspirin in childhood

Correct 3 "1. Oral surgeries are associated with transientbacteremia, and the client cannot donate for 72hours after an oral surgery.2.The client cannot donate blood following ubella immunizations for one (1) month. 3. CORRECT The client cannot donate blood for 6months after a pregnancy because of thenutritional demands on the mother. 4.Recent allergic reactions prevent donationbecause passive transference of hypersensitiv-ity can occur. This client has an allergy thatdeveloped during childhood"

Which of the following is the reason to perform a spinal tap on a client newly diagnosed with leukemia? A. To rule out meningitis B. To decrease intracranial pressure C. To aid in classification of the leukemia D. To assess for central nervous system infiltration

D A spinal tap is performed to assess for central nervous system infiltration. It wouldn't be done to decrease ICP nor does it aid in the classification of the leukemia. Spinal taps can result in brain stem herniation in cases of ICP. A spinal tap can be done to rule out meningitis but this isn't the indication for the test on a leukemic client.

The nurse determines that a client is having a transfusion reaction. After the nurse stops the transfusion, which action should immediately be taken next? 1. remove the intravenous line 2. run a solution of 5% dextrose in water 3.run normal saline at a keep-vein-open rate 4. obtain a culture of the tip of the catheter device removed from the client"

Correct 3 If the nurse suspects a transfusion reaction, the nurse stops the transfusion and infuses normal saline at a keep-vein-open rate pending further physician prescriptions. This maintains a patent IV access line and aids in maintaining the client's intravascular volume. The nurse would not remove the IV line because then there would be no IV access route. Obtaining a culture of the tip of the catheter device removed from the client is incorrect. First the catheter should not be removed. Second, cultures are performed when infection, not transfusion reaction, is suspected. Normal saline is the solution of choice over solutions containing dextrose because saline does not cause red blood cells to clump.

The nurse receives a physician's order to transfuse fresh frozen plasma to a patient suffering from an acute blood loss. Which of the following procedures is most appropriate for infusing this blood product? A. Infuse the fresh frozen plasma as rapidly as the patient will tolerate. B. Hang the fresh frozen plasma as a piggyback to the primary IV solution. C. Infuse the fresh frozen plasma as a piggyback to a primary solution of normal saline. D. Hand the fresh frozen plasma as a piggyback to a new bag of primary IV solution without KCl."

Correct A "The fresh frozen plasma should be administered as rapidly as possible and should be used within 2 hours of thawing. Fresh frozen plasma is infused using any straight-line infusion set. Any existing IV should be interrupted while the fresh frozen plasma is infused, unless a second IV line has been started for the transfusion."

Following surgery, the client requires a blood transfusion. The main reason the nurse wants to complete the unit transfusion within a four-hour period that blood: "A. Hanging for a longer four hours creates an increased risk of sepsis B. May clot in the bag C. May evaporate D. May not clot in the recipient after this time period

Correct A Hanging for a longer four hours creates an increased risk of sepsis, which is why the nurse wants to complete the unit transfusion in less than four hours. The remaining items are not likely to happen.

The nurse who is about to give a blood transfusion knows that blood cells start to deteriorate after a certain period of time. Which of the following itens is important to check regarding the age of blood cells before the transfusion is begun? A. Expiration date B. Presence of clots C. Blood group and type D. Blood identification number

Correct A - no rationale

Before starting a transfusion of packed red blood cells for an anemic patient, the nurse would arrange for a peer to monitor his or her other assigned patients for how many minutes when the nurse begins the transfusion? A. 5 minutes B. 15 minutes C. 60 minutes D. 30 minutes"

Correct B Patients who are likely to have a transfusion reaction will more often exhibit signs within the first 15 minutes that the blood is infusing

The client has a hematocrit of 22.3% and a hemoglobin of 7.7 mg/dL. The HCP hasordered two (2) units of packed red blood cells to be transfused. Which interventionsshould the nurse implement? Select all that apply 1. Obtain a signed consent. 2.Initiate a 22-gauge IV. 3.Assess the client's lungs. 4.Check for allergies. 5.Hang a keep-open IV of D5W

Correct: 1, 3, 4

Which statement is the scientific rationale for infusing a unit of blood in less than four (4) hours? 1. The blood will coagulate if left out of the refrigerator for longer than four(4)hours. 2. The blood has the potential for bacterial growth if allowed to infuse longer. 3. The blood components begin to break down after four (4) hours. 4. The blood will not be affected; this is a laboratory procedure. "

Correct: 2 "1,-Blood will coagulate if left out for an extended period, but blood is stored with a preservative that prevents this and prolongs the life of the blood. 2.-Blood is a medium for bacterial growth, and any bacteria contaminating the unit will begin to grow if left outside of a con- trolled refrigerated temperature for longer than four (4) hours, placing the client at risk for septicemia. . 3)Blood components are stable and do not break down at four 4.)These are standard nursing and laboratory procedures to prevent the complication of septicemia."

A 28-year old client with cancer is afraid of experiencing a febrile reaction associated with blood transfusions. He asks the nurse if this will happen to him. The nurse's best response is which of the following? 1) Febrile reactions are caused when antibodies on the surface of blood cells in the transfusion are directed against antigens of the recipient. 2) Febrile reactions can usually be prevented by administering antipyretics and antihistamines before the start of the transfusion. 3) Febrile reactions are rarely immune-mediated reactions and can be a sign of hemolytic transfusion. 4) Febrile reactions primarily occur within 15 minutes after initiation of the transfusion and occur during the blood transfusion.

Correct: 2 The administration of antipyretics and antihistamines before initiation of the transfusion in the frequently transfused client can decrease the incidence of febrile reactions. Febrile reactions are immune-mediated and are caused by antibodies in the recipient that are directed against antigens present on the granulocytes, platelets, and lymphocytes in the transfused component. They are the most common transfusion reaction and may occur with onset, during transfusion, or hours after transfusion is completed.

One of the most serious blood coagulation complications for individuals with cancer and for those undergoing cancer treatments is disseminated intravascular coagulation (DIC). The most common cause of this bleeding disorder is: A. Underlying liver disease B. Brain metastasis C. Intravenous heparin therapy D. Sepsis

D Bacterial endotoxins released from gram-negative bacteria activate the Hageman factor or coagulation factor XII. This factor inhibits coagulation via the intrinsic pathway of homeostasis, as well as stimulating fibrinolysis. Liver disease can cause multiple bleeding abnormalities resulting in chronic, subclinical DIC; however, sepsis is the most common cause.

A 52-year-old woman is admitted with a new diagnosis of gastrointestinal (GI) bleed. The physician has ordered the client to receive 2 units of packed red blood cells (PRBCs) for a hemoglobin (Hgb) of 6.8g/dL. The nurse begins the infusion of the first unit at 100mL/hr. Firfteen minutes after the start of the infusion, the client complains that she is feeling chilled, is short of breath, and is experiencing lumbar pain rated 8 on a 1-10 scale. Whic of the following should be the nurse's FIRST action. "1. Obtain vital signs and notify the physician of potential reaction 2. Slow the infusion to 75mL/hr and reassess in 15 minutes 3. Stop the infusion and run normal saline (NS) to keep the vein open (KVO) 4. Administer PRN pain medication as ordered, apply oxygen at 2 L/min, and provide an additional blanket"

Correct: 3 "1. ""Obtain vital signs..."" - vital sings should be obtained, and the physician notified after treatment is discontinue. The unit in quesiton should not be restarted, and any other units that were issued should not be implemented. 2. ""Slow the infusion..."" - just slowing the infusino will not resolve the issue of an allergic reaction to the treatment 3. ""Stop the infusion..."" - (CORRECT): The symptoms of feeling chilllded, being short of breath, and having back pain coudl indicate an acute hemolytic reaction. This medical emergency requires swift action on the part of the nurse, including immediately discontinuing the infusion, flushing the IV site, and saving the unit of blood in question for testing. 4. ""Administer PRN pain medication..."" - Treating the symptoms of the reaction will not resolve the issue of an allergic reactio to the treatment"

The nurse and unlicensed nursing assistant are caring for clients on an oncology floor. Which nursing task would be delegated to the unlicensed nursing assistant? "1. Assess the urine output on a client who has had a blood transfusion reaction. 2. Take the first 15 minutes of vital signs on a client receiving a unit of PRBCs. 3. Auscultate the lung sounds of a client prior to a transfusion. 4. Assist a client who received ten (10) units of platelets in brushing teeth.

Correct: 4 "1. Unlicensed nursing assistants cannot assess. The nurse cannot delegate assessment. 2. The likelihood of a reaction is the greatest during the first 15 minutes of a transfusion.The nurse should never leave the client until after this time. The nurse should take and assess the vital signs during this time. 3. Auscultation of the lung sounds and administering blood based on this information are the nurse's responsibility. Any action requiring nursing judgment cannot be delegated. 4. The unlicensed nursing assistant can assist a client to brush the teeth. Instructions about using soft-bristle toothbrushes and the need to report to the nurse any pink or bleeding should be given prior to delegating the procedure. (CORRECT) TEST-TAKING HINT: The test taker must be aware of delegation guidelines. The nurse cannot delegate assessment or any intervention requiring nursing judgment. Options "1," "2," and "3" require judgment and cannot be delegated to an unlicensed assistant."

The nurse is administering packed red blood cells (PRBCs) to a client. The nurse should first: "1. Discontinue the I.V. catheter if a blood transfusion reaction occurs. 2. Administer the PRBCs through a percutaneously inserted central catheter line with a 20-gauge needle. 3. Flush PRBCs with 5% dextrose and 0.45% normal saline solution. 4. Stay with the client during the first 15 minutes of infusion.

Correct: 4 The most likely time for a blood transfusion reaction to occur is during the first 15 minutes or first 50 mL of the infusion. If a blood transfusion reaction does occur, it is imperative to keep an established I.V. line so that medication can be administered to prevent or treat cardiovascular collapse in case of anaphylaxis. PRBCs should be administered through a 19-gauge or larger needle; a peripherally inserted central catheter line is not recommended, in order to avoid a slow flow. RBCs will hemolyze in dextrose or lactated Ringer's solution and should be infused with only normal saline solution.

Cris asks the nurse whether all donor blood products are cross-matched with the recipient to prevent a transfusion reaction. Which of the following always require cross-matching? a. packed red blood cells b. platelets c. plasma d. granulocytes"

Correct: A Red blood cells contain antigens and antibodies that must be matched between donor and recipient. The blood products in options 2-4 do not contain red cells. Thus, they require no cross-match.

A nurse check a unit of blood received from the blood bank and notes the presence of gas bubbles in the bag. Which should the nurse implement? A. Return the bag to the blood bank. B. Infuse the blood using the filter tubing. C. Add 10ml of NS to the bag. D. Agitate the bag to mix contents gently

Correct: A The nurse should return the blood to the blood bank because the gas bubbles in the bag indicate possible contamination. If the nurse were going to administer the blood, the nurse would use filter tubing to trap the particulate matter. Although normal saline can be infused concurrently with the blood, NS or any other substance should never be added to the blood in a blood bag. The blood should not be agitated this can harm the RBCs.

The nurse understands that the client with pernicious anemia will have which distinguishing laboratory findings? "a. Schilling's test, elevated b. Intrinsic factor, absent. c. Sedimentation rate, 16 mm/hour d. RBCs 5.0 million

Correct: B ANSWER B. The defining characteristic of pernicious anemia, a megaloblastic anemia, is lack of the intrinsic factor, which results from atrophy of the stomach wall. Without the intrinsic factor, vitamin B12 cannot be absorbed in the small intestines, and folic acid needs vitamin B12 for DNA synthesis of RBCs. The gastric analysis was done to determine the primary cause of the anemia. An elevated excretion of the injected radioactive vitamin B12, which is protocol for the first and second stage of the Schilling test, indicates that the client has the intrinsic factor and can absorb vitamin B12 into the intestinal tract. A sedimentation rate of 16 mm/hour is normal for both men and women and is a nonspecific test to detect the presence of inflammation. It is not specific to anemias. An RBC value of 5.0 million is a normal value for both men and women and does not indicate anemia.

Clinical presentation of painless, swelling of lymph nodes, lymphocytosis upon CBC, Splenomegaly, Hepatomegaly, AI Thrombocytopenia, hemolytic anemia, and/or Hypogammaglobulinemia A. AML (Acute Myelogenous Leukemia) B. ALL (Acute Lymphocytic Leukemia) C. CML (Chronic Myelogenous Leukemia) D. CLL (Chronic Lymphocytic Leukemia

D

The nurse has just admitted a 35-year-old female client who has a serum B12 concentration of 800 pg/ml. Which of the following laboratory findings would cue the nurse to focus the client history on specific drug or alcohol abuse? A. Total bilirubin, 0.3 mg/dL B. Serum creatinine, 0.5 mg/dL C. Hemoglobin, 16 g/dL D. Folate, 1.5 ng/mL

D The normal range of folic acid is 1.8 to 9 ng/mL, and the normal range of vitamin B12 is 200 to 900 pg/mL. A low folic acid level in the presence of a normal vitamin B12 level is indicative of a primary folic acid-deficiency anemia. Factors that affect the absorption of folic acid are drugs such as methotrexate, oral contraceptives, antiseizure drugs, and alcohol. The total bilirubin, serum creatinine, and hemoglobin values are within normal limits.

A client states that she is afraid of receiving vitamin B12 injections because of the potential toxic reactions. What is the nurse's best response to relieve these fears? A. "Vitamin B12 will cause ringing in the eats before a toxic level is reached." B. "Vitamin B12 may cause a very mild skin rash initially." C. "Vitamin B12 may cause mild nausea but nothing toxic." D. "Vitamin B12 is generally free of toxicity because it is water soluble.

D Vitamin B12 is a water-soluble vitamin. When water-soluble vitamins are taken in excess of the body's needs, they are filtered through the kidneys and excreted. Vitamin B12 is considered to be nontoxic. Adverse reactions that have occurred are believed to be related to impurities or to the preservative in B12 preparations. Ringing in the ears, skin rash, and nausea are not considered to be related to vitamin B12 administration.

A unit of packed red blood cells has been prescribed for a client with low hemoglobin and hematocrit levels. The nurse notifies the blood bank of the order, and a blood specimen is drawn from the client for typing and cross-matching. The nurse receives a telephone call from the blood bank and is informed that he unit of blood is ready for administration. Arrange the actions in order of priority that the nurse should take to administer the blood. (Letter A is the first and letter F is the last action.) a) hang the bag of blood b) obtain the unit of blood from the bank c) ensure that an informed consent has been signed d) verify the physician's order for the blood transfusion e) insert an 18 or 19-gauge IV catheter into the client f) ask a licensed nurse to assist in confirming blood compatibility and verifying client identity."

F, D, B, A, C, E - The nurse would first verify the physician's order for the blood transfusion and ensure that the client has been informed about the procedure and has signed an informed consent. Once this has been done, the nurse would ensure that at least an 18- or 19-gauge intravenous needle is inserted into the client. Blood has a thicker and stickier consistency than intravenous solutions and using an 18- or 19-gauge catheter ensures that the bore of the catheter is large enough to prevent damage to the blood cells. Next, the blood is obtained from the blood bank, once the nurse is sure that the client has been informed and has an adequate access for administering the blood. Once the blood has been obtained, two registered nurses, or one registered and a licensed practical nurse (depending on agency policy), must together check the label on the blood product against the client's identification number, blood group, and complete name. This minimizes the risk of error in checking information on the blood bag and thereby minimizes the risk of harm or injury to the client. The nurse should measure vital signs and assess lung sounds and then hang the transfusion."`