NCLEX Review: CH 19

Place the following procedural steps in order for transfusing a unit of packed red blood cells (PRBCs):

1) Start an intravenous line. 2) Obtain the unit of PRBCs from the blood bank. 3) Double check the labels with another nurse to ensure correct ABO group and Rh type. 4) Initiate the blood transfusion within 30 minutes of receipt. 5) Monitor closely for signs of a transfusion reaction.

Which of the following signs and symptoms would the nurse expect to assess in a patient with a low H&H? Select all that apply 1) dyspnea 2) palpitations 3) headaches 4) bradycardia 5) tinnitus

1, 2, 3, 5 4: Tachycardia would be seen.

A nursing student studying hematology understands that which of the following stimulates platelet production? 1) Erythropoietin 2) Thrombopoietin 3) Eosinophils 4) Megakaryocytes

2)

Following a bone marrow biopsy and/or aspiration, what are the two priority nursing diagnoses that are applicable? 1) Acute Pain and Risk for Infection 2) Risk for Infection and Risk for Bleeding 3) Risk for Bleeding and Readiness for Enhanced Learning 4) Acute Pain and Readiness for Enhanced Learning

2)

A nursing student understands that at WHAT platelet count would we begin to worry about the risk for spontaneous bleeding? 1) 10,000 2) 20,000 3) 25,000 4) 50,000

2) 20,000

While providing teaching to a patient admitted to the hospital with severe thrombocytopenia, which of the following statements, if made by the nurse, is incorrect? 1) "You will need to avoid contact sports to make sure you don't bleed." 2) "If you develop a bad headache, you may take Acetaminophen, but you need to avoid Aspirin and Motrin." 3) "If you start to feel dizzy or have trouble breathing, please press your callbell." 4) "We will need you to avoid sexual intercourse at this time. You may resume when your platelet count exceeds 50,000."

2) Incorrect Patients with severe thrombocytopenia are at increased risk for intracranial bleeding and should report even mild headaches immediately.

A nurse is teaching about bone marrow biopsy. Which statement, if made by the nurse, is an incorrect statement? 1) "You will likely receive this AFTER an aspiration, if you are receiving both." 2) "You will experience a sharp, stabbing pain upon removal of the sample." 3) "You may have aching at the site for 2 or 3 days. You can take a Tylenol to help with this, but please avoid Motrin." 4) "Please avoid being submerged in a bathtub for approximately 24 hours until your site heals."

2) Incorrect; This may cause pressure should not cause actual pain. Pain needs to be reported.

To prevent infection in a patient diagnosed with agranulocytosis, what is the nurse's most important action? 1) Reverse isolation procedures, including mask, gown, and gloves 2) Advising the patient to stay away from sick people 3) Use of stringent hand-washing 4) Helping the patient make a follow-up appointment for bi-weekly lab draws.

3)

Karen is a 35 year-old patient who admits to the E.D. with bleeding gums after her gums began bleeding excessively after brushing her teeth. Her lab results are as follows: Hgb 10, Hct 36%, WBC 9,400, RBC 3.9, platelets 47,000. What is the nurse's priority action at this time? 1) Obtain a urine sample to test for pregnancy 2) Administer an IM injection of vitamin K 3) Initiate bleeding precautions 4) Obtain a hemoccult test kit

3) Bleeding precautions should be initiated at this time due to a platelet count below 50,000.

A client has an increased number of eosinophils. Which of the following disorders would the nurse expect the client to have? a) Allergy b) Pediculosis pubis c) Liver failure d) Hemophilia

a)

The nurse begins a routine blood transfusion of packed red blood cells (PRBCs) at 1100. To ensure client safety, the unit of blood should be completely transfused by what time? a) 1500 b) 1600 c) 1530 d) 1115

a) Administration time for PRBCs should not exceed 4 hours because of the increased risk of bacterial proliferation. For the first 15 minutes, the transfusion should be run slowly- no faster than 5 mL/min.

An instructor asks students approximately how long platelets last? What would the students correctly identify? a) 72 hours b) Lifetime c) 7.5 days d) 75 days

c)

A client in acute renal failure has been prescribed 2 units of packed red blood cells (PRBCs). The nurse explains to the client that the blood transfusion is most likely needed for which of the following reasons? a) Preparation for likely nephrectomy b) Increases the effectiveness of dialysis c) Hypervolemia d) Lack of erythropoietin

d)

While discussing bleeding precautions with a student, which statement, if made by the instructor, is an incorrect statement? 1) "The patient should not be given IM injections at this time." 2) "There should be no catheters inserted into the patient at this time." 3) "Pressure should be applied to a venipuncture site for at least 2 minutes, and the smallest needle possible should be used." 4) "Stool softeners and laxatives are encouraged."

3) Incorrect. Pressure should be applied for at least 5 minutes, not 2.

When providing teaching to a patient undergoing bone marrow aspiration, which of the following statements is incorrect? 1) "We will need your signed informed consent before beginning this procedure. The physician will obtain this." 2) "If you are incredibly anxious about this procedure, we can provide you with an antianxiety agent." 3) "You may feel a sensation of sudden and sharp but brief pain when the fluid is aspirated." 4) "We would discourage you from taking deep breaths during the procedure."

4) Deep breathing and relaxation techniques should be encouraged during aspiration, because this can cause a sharp pain.

The nurse is administering a blood transfusion to a patient over 4 hours. After 2 hours, the patient complaints of chills and has a fever of 101°F, an increase from a previous temperature of 99.2°F. What does the nurse recognize is occurring with this patient? a) The patient is having a febrile nonhemolytic reaction. b) The patient is experiencing vascular collapse. c) The patient is having an allergic reaction to the blood. d) The patient is having decrease in tissue perfusion from a shock state.

a) The signs and symptoms of a febrile nonhemolytic transfusion reaction are chills (minimal to severe) followed by fever (more than 1°C elevation). The fever typically begins within 2 hours after the transfusion is begun. Although the reaction is not life threatening, the fever, and particularly the chills and muscle stiffness, can be frightening to the patient

The client is to receive a unit of packed red blood cells. The first intervention of the nurse is to a) Check the label on the unit of blood with another registered nurse. b) Observe for gas bubbles in the unit of packed red blood cells. c) Verify that the client has signed a written consent form. d) Ensure that the intravenous site has a 20-gauge or larger needle.

c) All the options are interventions the nurse will do to ensure the blood transfusion is safe. The question asks about the first action of the nurse. The first action would be verifying that the client has signed a written consent form. Then, the nurse would ensure the intravenous site has a 20-gauge or larger needle. The nurse would proceed to obtain the unit of blood, check the blood with another registered nurse, and observe for gas bubbles in the unit of blood.

A patient will need a blood transfusion for the replacement of blood loss from the gastrointestinal tract. The patient states, "That stuff isn't safe!" What is the best response from the nurse? a) "I agree that you should be concerned with the safety of the blood, but it is important that you have this transfusion." b) "I understand your concern. The blood is carefully screened but is not completely risk free." c) "The blood is carefully screened, so there is no possibility of you contracting any illness or disease from the blood." d) "You will have to decide if refusing the blood transfusion is worth the risk to your health."

b)

The nurse is working at a blood donation clinic. What teaching should the nurse provide to the donor immediately after blood donation? a) Remove the band-aid after 5 minutes. b) Remain for observation after eating and drinking. c) Hold the involved arm below the heart. d) Sit up promptly after the needle is removed.

b)

A client with a history of sickle cell anemia has developed iron overload from repeated blood transfusions. What treatment does the nurse anticipate will be prescribed? a) White blood cell filter b) Red blood cell phenotyping c) Chelation therapy d) Hepatitis B immunization

c)

An adult client reports that it is taking longer than usual for minor cuts and injuries to clot. Which of the following questions would the nurse most likely ask the client? a) "Are you eating sugary foods lately?" b) "Do you have a history of allergy or asthma?" c) "Have you been tested for hemophilia?" d) "Are you regularly taking aspirin?"

d) Aspirin and anticoagulants can contribute to bleeding and interfere with clot formation. Sugary foods, allergy, and asthma would not influence the client's clotting capacity. Hemophilia is a disorder of clotting, but it manifests from early in childhood as a genetic problem and would not suddenly appear in adulthood

The nurse should be alert to which adverse assessment finding when transfusing a unit of packed red blood cells (PRBCs) too rapidly? a) Respiratory rate of 10 breaths/minute b) Pain and tenderness in calf area c) Oral temperature of 97°F d) Crackles auscultated bilaterally

d) Increasing the flow rate of a blood transfusion too rapidly can result in circulatory overload. Fluid overload can be manifested by crackles in the lungs. A decreased respiratory rate and decreased temperature are not manifestations of fluid overload. Pain and tenderness in the calf area may indicate a thrombosis which is not as common a manifestation as fluid overload.

The charge nurse should intervene when observing a new nurse perform which action after a client has suffered a possible hemolytic blood transfusion reaction? a) Notifying the blood bank of the reaction. b) Informing the client to leave a urine sample after the client's next void. c) Documenting the reaction in the client's medical record. d) Disposing of the blood container and tubing in biohazard waste.

d) The blood container and tubing should be returned to the blood bank for repeat typing and culture, and the blood bank should be notified of the reaction. A urine sample is collected as soon as possible to detect hemoglobin in the urine. Documenting the client's reaction in the medical record is an appropriate action.

A client tells the nurse that he would like to donate blood before his abdominal surgery next week. What should be the nurse's first action? a) Provide the client with a list of the nearest donation centers. b) Remind the client to take supplemental iron before donation. c) Explain the time frame needed for autologous donation. d) Tell the client that 2 units of blood will be needed.

c) Preoperative autologous donations are ideally collected 4 to 6 weeks before surgery. The nurse should first explain that time frame to this client. Surgery is scheduled in one week which means that autologous blood donation may not be an option for this client. A list of donation centers can be provided to the client; and even though iron is recommended and 2 units of blood may be suggested, the first action is to tell the client about the needed time frame for donation.

You are caring for a client who is undergoing bone marrow aspiration to determine their blood cell formation status. What nursing intervention should you provide to your client after the test? a) Collect urine for 24 to 48 hours after the client receives the nonradioactive B12. b) Support the client during a bone marrow aspiration and monitor the status. c) Administer a nonradioactive B12 injection. d) Administer oral radioactive vitamin B12 to the client.

b) When a client undergoes a bone marrow aspiration, the nurse assists the physician, supports the client during the procedure, and monitors his or her condition afterward. The client needs to be administered oral radioactive vitamin B12 or a nonradioactive B12 injection in case of the Schilling test, which helps in determining pernicious anemia and macrocytic anemia. Collecting urine for 24 to 48 hours after administering nonradioactive B12 is also applicable to the Schilling test.

The nurse obtains a unit of blood for the client, Donald D. Smith. The name on the label on the unit of blood reads Donald A. Smith. All the other identifiers are correct. The nurse a) Checks with Blood Bank first and then administers the blood with their permission b) Asks the client if he was ever known as Donald A. Smith c) Refuses to administer the blood d) Administers the unit of blood

c)

Which of the following nursing interventions should be implemented for a patient who is on bleeding precautions? Select all that apply 1) Overinflation of blood pressure cuffs should be avoided 2) Biking and roller-blading are sports that might be good alternatives to contact sports 3) Sexual intercourse should be avoided until the platelet count is above 20,000. 4) Side rails should be padded as needed. 5) Vigorous coughing and blowing of the nose should be avoided.

1, 4, 5 2: Incorrect; these sports should be avoided as well 3: Incorrect; platelet count must be above 50,000 to resume sexual intercourse

A client in end-stage renal disease is prescribed epoetin alfa (Epogen) and oral iron supplements. Before administering the next dose of epoetin alfa and oral iron supplement, the nurse a) Holds the epoetin alfa if the BUN is elevated b) Assesses the hemoglobin level c) Ensures the client has completed dialysis treatment d) Questions the administration of both medications

b) Erythropoietin with oral iron supplements can raise hematocrit levels in the client with end-stage renal disease. The nurse should check the hemoglobin prior to administration of erythropoietin, because too high a hemoglobin level can put the client at risk for heart failure, myocardial infarction, and cerebrovascular accident. Erythropoietin may be administered during dialysis treatments. The BUN will be elevated in the client with end-stage renal disease.

Which client is not a candidate for blood donation according to the American Heart Association? a) 50 year old female with pulse 95 beats/minute b) 86 year old male with blood pressure 110/70 mmHg c) 26 year old female with hemoglobin 11.0 g/dL d) 18 year old male weighing 52 kg.

c) Clients must meet the following criteria to be eligible as blood donors: body weight at least 50 kg; pulse rate regular between 50 and 100 bpm; systolic BP 90 to 180 mmHg and diastolic 50 to 100 mmHg; hemoglobin level at least 12.5 g/dL for women. There is no upper age limit to donation.

A client receiving a blood transfusion complains of shortness of breath, appears anxious, and has a pulse of 125 beats/minute. What is the best action for the nurse to take after stopping the transfusion and awaiting further instruction from the healthcare provider? a) Remove the intravenous line. b) Place the client in a recumbent position with legs elevated. c) Ensure there is an oxygen delivery device at the bedside. d) Administer prescribed PRN anti-anxiety agent.

c) The client is exhibiting signs of circulatory overload. After stopping the transfusion and notifying the healthcare provider, the nurse should place the client in a more upright position with the legs dependent to decrease workload on the heart. The IV line is kept patent in case emergency medications are needed. Oxygen and morphine may be needed to treat severe dyspnea. Administering an anti-anxiety agent is not a priority action over ensuring oxygen is available.