ATI Hematology
A nurse is assessing a client who is postoperative and has anemia due to excess blood loss following surgery. Which of the following findings should the nurse expect? a. Fatigue b. Hypertension c. Bradycardia d. Diarrhea
a. Fatigue Fatigue The nurse should identify that the client who has anemia due to blood loss following surgery will experience fatigue. This is due to the body's decreased ability carry oxygen to vital tissues and organs. Constipation is a manifestation of anemia due to blood loss following surgery. Tachycardia is manifestation of anemia due to blood loss following surgery. Hypotension is manifestation of anemia due to blood loss following surgery.
A nurse is preparing an in-service about the various supplements clients might use. Which of the ff. herbal supplements should the nurse include as potentially increasing the anticoagulant effects of aspirin and other oral anticoagulants? a. Valerian b. Feverfew c. Milk Thistle d. Saw Palmetto
b. Feverfew Feverfew can increase the risk of bleeding due to the suppression of platelet aggregation. Clients can use valerian to promote sleep and decrease restlessness from anxiety. Milk thistle reduces the effectiveness of oral contraceptives. Clients may use saw palmetto to relieve urinary and prostate symptoms, such as frequent urination and nocturia.
A nurse us preparing to administer 2units of packed RBCs to an older adult client. Which of the ff. actions should the nurse take? a. Administer each unit over 3 hr. b. Use an 18-gauge needle to obtain venous access. c. Use blood that is less than a month old. d. Obtain the client's vital signs every 30min throughout the transfusion.
A. The nurse should administer blood to an older adult client at a slower rate. Therefore, each unit should be administered over 2 to 4 hr. The nurse should use no larger than a 19-gauge needle to obtain venous access on an older adult client. The nurse should use blood that is less than a week old for older adult clients. Older blood cell membranes are more fragile and can break, releasing potassium into circulation. The nurse should obtain an older adult client's vital signs every 15 min throughout the transfusion.
A nurse is monitoring a client who is receiving a blood transfusion. Which of the ff finding indicates an allergic transfusion reactions? a. generalized urticaria b. Blood pressure 184/92 mm Hg c. Distended jugular veins d. Bilateral flank pain.
A. The nurse should recognize urticaria as an indicator of an allergic transfusion reaction. Other clinical manifestations include itching and signs of anaphylaxis with bronchospasm. Hypertension may be an indication of circulatory overload rather than an allergic reaction. Distended jugular veins may be an indication of circulatory overload rather than an allergic reaction. Bilateral flank pain may be an indication of a hemolytic transfusion reaction rather than an allergic reaction.
A nurse is creating a dietary plan for an adult female client who has a hemoglobin level of 9.8 g/dL. Which of the ff. foods should the nurse recommend? a. Carrots b. Raisins c. Maple Syrup d. Orange Juice
B. Foods high in iron are recommended to improve a low hemoglobin level. Raisins are a high source of iron. Foods high in iron are recommended to improve a low hemoglobin level. Carrots are not high in iron. Foods high in iron are recommended to improve a low hemoglobin level. Molasses, rather than maple syrup, is high in iron. Foods high in iron are recommended to improve a low hemoglobin level. Although orange juice is not high in iron, it does enhance the absorption of iron.
A nurse is assessing a client who is receiving a blood transfusion. Which of the ff. finding is a manifestation of hemolytic transfusion reaction? a. HTN b. Report of low-back pain c. Pallor d. Report of metallic taste
B. Low-back pain, fever, and chills are manifestations of a hemolytic transfusion reaction. The nurse should discontinue the transfusion and administer 0.9% sodium chloride through new IV tubing. Hypotension is a manifestation of a hemolytic transfusion reaction. Flushing and tachycardia are manifestations of a hemolytic transfusion reaction. Tachypnea and hemoglobinuria are manifestations of a hemolytic transfusion reaction.
A nurse is caring for who has esophageal varices and is hypotensive after vomiting 500mL of blood. Which of the following actions is the nurse's priority? a. Elevate the client's feet b. Increase the client's IV fluid rate c. Initiate a dopamine IV infusion for the client d. Administer a unit of packed RBCs.
B. When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority action is to increase the client's IV fluid rate. Providing fluid to the client will restore circulating volume and increase blood pressure. The nurse should elevate the client's feet to increase perfusion to the brain during the hypotensive episode, but this action is not the priority. The nurse might need to initiate a dopamine IV infusion to treat the client's hypotension, but this action is not the priority. The nurse should plan to administer a unit of packed RBCs to treat the hypotension and the blood loss, but this action is not the priority.
A nurse is caring for a client who has a prescription for one unit of packed RBCs. The nurse should plan to remain in the room with the client at which of the ff. times during the infusion to observe for a transfusion reaction? a. first 2min b. final 2min c. first 15min d. final 15min
C. The nurse should remain in the room during the first 15 min of the infusion, which is the most critical time period for monitoring a client for a transfusion reaction. Severe reactions usually occur during the infusion of the first 50 mL of blood.
A nurse is caring for a young female adult client who reports weakness, fatigue, and heavy menstrual periods. The client has a Hgb of 8 g/dL and a Hct of 28 g/dL. The nurse suspect which of the ff. types of anemia? a. Folic acid deficiency anemia b. Pernicious anemia c. Iron-deficiency anemia d. Sickle cell anemia
C. Iron-deficiency anemia results from poor gastrointestinal absorption of iron, a diet that is deficient in iron, or blood loss. The nurse should expect a client who has iron-deficiency anemia to have weakness, pallor, fatigue, reduced tolerance for activity, and cheilosis (ulcerations of the corners of the mouth). The nurse should expect a client who has folic acid deficiency to have pallor and jaundice; a smooth, beefy-red tongue (glossitis); fatigue; and weight loss. This type of anemia is caused by nutritional deficiencies, malabsorption syndromes (Crohn's disease), and medications (e.g., anticonvulsants, oral contraceptives). A client who has pernicious anemia is unable to absorb vitamin B12 due to a lack of intrinsic factors in the stomach. The nurse should expect this client to have pallor and jaundice; a smooth, beefy-red tongue (glossitis); fatigue; weight loss; and paresthesias to the hands and feet. Sickle cell anemia is an autosomal recessive disorder in which the RBCs develop a sickle shape following conditions in which decreased oxygen is available. These sickled cells then clump together and become fragile, causing tissue ischemia leading to eventual organ damage. Manifestations of sickle cel anemia include pain, pallor, cyanosis, dyspnea, fatigue, and weakness.
A nurse is planning care for a client who is to receive packed RBCs. The nurse should plan for the total infusion time to not exceed which of the ff? a. 2hr b. 6hr c. 8hr d. 4hr
D. The nurse should infuse the packed RBCs for no longer than 4 hr due to temperature inconsistencies that develop over time and the possibility of bacterial contamination.
A nurse is teaching a client who has a new dx. of aplastic anemia. Which of the ff. information should the nurse include in the teaching? a. Aplastic anemia is associated with a decreased intake of iron. b. Aplastic anemia is associated with a decreased intake of iron. c. Aplastic anemia results in an inability to absorb vitamin B12. d. Aplastic anemia results from decreased bone marrow production of RBCs.
D. Aplastic anemia is a hypoproliferative anemia resulting from decreased production of RBC within the bone marrow. An inadequate intake of iron can result in iron deficiency anemia rather than aplastic anemia. Autoimmune hemolytic anemia, rather than aplastic anemia, is associated with an increased rate of RBC destruction. Pernicious anemia is seen in clients who lack the intrinsic factor responsible for vitamin B12 absorption.
A nurse at a blood donation center is screening clients for blood donation. The nurse should identify that which of the ff. clients must reschedule donation? a. a client who weighs 50kg (110 lbs) and plans to donate 450mL of blood. b. A client who is 14yrs. of age c. A client who is Rh-positive d. A client who has an oral temperature of 37.8 or (100 F)
D. A client who has an oral temperature that exceeds 37.5° C (99.6° F) defers eligibility to donate blood. The client should weigh at least 50 kg (110 lb) to donate 450 mL of blood. The client who is 14 years of age is not eligible to donate blood: however, a client who is 16 or 17 years of age with a parental consent is eligible to donate blood. Blood type does not affect eligibility to donate blood.
A nurse received a unit of packed RBCs from a blood bank and notes that the time is 1130. The nurse should begin the infusion at which of the ff. times? a. when the client has finished eating lunch b. when the client states he is ready to start the infusion c. 2 hr after obtaining blood from the blood bank d. As soon as the nurse can prepare the client and the administration set.
D. The nurse should infuse the blood as soon as possible and complete the procedure within 4 hr. The nurse should begin the infusion as soon as possible after obtaining the packed RBCs from the blood bank. This delay is unnecessary and can complicate the requirement to complete the infusion within 4 hr. This delay is unnecessary and increases the risk of bacterial contamination since the blood is out of the refrigerator. The nurse should infuse the blood as soon as possible after obtaining the packed RBCs from the blood bank.
A nurse is caring for a client who is recievig a unit of packed red blood cells. Fifteen minutes following the start of the transfusion, the nurse notes that the client is febrile, with chills and red-tinged urine. Which of the following transfusion reactions should the nurse suspect? a. Febrile b. Allergic c. Acute Pain d. Hemolytic
d. Hemolytic A hemolytic transfusion reaction occurs when antibodies in the recipient's blood react to foreign blood cells introduced by the transfusion. The antibodies bind to the foreign cells and destroy them in a process known as hemolysis. The destroyed cells are excreted by the kidneys (hemoglobinuria), causing the red-tinged urine. Hemolytic transfusion reactions can result in acute renal injury, disseminated intravascular coagulation, and circulatory collapse. A febrile transfusion reaction can occur in clients who have received multiple blood product transfusions. It is a response in which anti-white blood cell (WBC) antibodies react with the WBCs remaining in the blood product. This results in chills, fever, hypotension, tachycardia and tachypnea. Clients who have a history of multiple blood product transfusions may receive leukocyte reduced blood or single-donor HLA matched platelets along with a WBC filter to prevent febrile reactions. Allergic (anaphylactic) transfusion reactions occur most often in clients who have pre-existing allergies. It is thought to be the result of a reaction to the plasma protein contained in the blood product. Manifestations include urticaria, itching, and flushing. In extreme cases, bronchospasm and laryngeal edema, and shock may occur. Onset may occur as late as 24 hr following the transfusion. Clients who have a history of allergies may receive blood products in which the WBCs, plasma, and immunoglobulin A has been removed or the client may be pre-treated with antihistamines and corticosteroids. An acute pain transfusion reaction can occur during or following transfusion with blood products. It manifests as severe chest, joint, and back pain, along with hypertension and flushing of the face and neck. The client is often anxious. Acute pain transfusion reactions are treated symptomatically with medications for pain and rigors.
