Hematology

Alteplase, a thrombolytic agent, is indicated for the treatment of acute pulmonary emboli, acute ischemic stroke, acute myocardial infarction, and occluded venous access devices. Adverse effects of alteplase: - Hematological. Risk of bleeding or hemorrhage - Central Nervous System. Intracranial hemorrhage - Gastrointestinal (GI). GI bleeding - Genitourinary (GU). GU bleeding - Local. Hemorrhage at injection sites - Allergic reactions. Fever and anaphylaxis

- Assess for contraindications. Active internal bleeding, Recent trauma, Severe uncontrolled hypertension, Known bleeding tendencies - Observe for manifestations of bleeding. Monitor the client every 15 minutes during the first hour of therapy and 15 to 30 minutes for the duration of therapy. - Assess neurological status. Changes can indicate intracranial bleeding. - Monitor pulse, BP, and respiratory status. Changes can indicate signs of bleeding

Which of the following should a nurse include when preparing a discharge teaching plan for a client who was just diagnosed with polycythemia vera? Correct Answers: - Elevate the legs and feet when sitting - Report any swelling in the lower extremities - Wear support stockings - Be aware of swelling and tenderness in the lower extremities. Report these to PCP. - Maintain adequate fluid intake, particularly when active and in hot weather - Periodically undergo phlebotomy to remove excess blood.

- Avoid use of iron supplements or increased intake of food that contains iron. Iron excess increases the production of hemoglobin. - To reduce itching: Use of starch in the bath, reduce water temperature, pat instead of rubbing the skin when towel drying.

A client who had received 25 mL of packed red blood cells (PRBCs) has low back pain and pruritus. After stopping the infusion, which of the following is the most appropriate action for the nurse to take? Correct Answer: Collect blood and urine samples to send to the lab. At the first indication of any sign or symptom of a reaction, the blood transfusion is stopped. Blood and urine samples are obtained from the client and sent to the lab, along with the remaining untransfused blood and tubing to the blood bank. Stop the blood transfusion. Flush the intravenous catheter with normal saline. replaced all IV tubing. Keep the I.V. line open with normal saline solution.

ABO- and Rh- incompatible blood causes an antigen-antibody reaction that produces hemolysis or agglutination of red blood cells. Hemoglobin in the urine and blood samples taken at the time of the reaction provide evidence of a hemolytic blood transfusion reaction. Signs and symptoms of a reaction include fever or chills, flank pain, vital sign changes, nausea, headache, urticaria, dyspnea, and bronchospasm

A nurse is caring for a client who has undergone cardiac catheterization. Which of the following signs of potential complication of a femoral artery catheter should a nurse report immediately to the healthcare provider? (Select all that apply. Correct Answers: Bleeding at the catheter site Coolness in the foot on the side of the catheter Other abnormalities that can indicate a potential complication include swelling, redness, and pain. Hypotension and bradycardia may also occur with significant retroperitoneal bleeding.

After femoral artery catheterization, the client is usually instructed to lie flat for several hours to avoid dislodging the clot. Clients should be reminded to drink adequately to flush dyes out of circulation and to prevent dehydration Formation of a hematoma can indicate internal bleeding into the pelvis or thigh. Retroperitoneal hematomas can cause pain in the abdomen, groin, and back.

A nurse is caring for a client scheduled for an elective surgical procedure. The client is concerned about the risk of HIV transmission if blood transfusion is required. The nurse advises the client that the risk of a disease transmission and transfusion reaction is reduced by: Correct Answer: Autologous blood donation prior to surgery Donations can be made every 3 days if the client's hemoglobin level remains within the target range. Blood can be frozen and stored for as long as ten years.

Autologous blood transfusion refers to aseptic collection, filtering, and return of the client's own blood during surgical procedures. Autologous transfusion is contraindicated in clients with bacteremia or leukemia. Autologous blood transfusion reduces the risk of allergic reaction, blood type incompatibility, and transmission of infectious disease.

Which best describes the purpose of a bone marrow biopsy? Correct Answer: To determine the cause of severe anemia A bone marrow biopsy is performed to investigate the cause of anemia, cancers, immune and other blood related disorders. A bone marrow biopsy involves taking a small sample of the tissue found inside the bone. Tests used to detect blood clots include ultrasound and angiography.

Bone marrow is the soft tissue contained in the medullary canals of long bone and the interstices of cancellous bone. Yellow marrow is composed of fat cells and connective tissue. Red marrow produces blood cell progenitors (stem cells), including red blood cells (erythrocytes), white blood cells (leukocytes), and platelets.

The spleen plays an important role in the breakdown and removal of deformed or senescent (old) erythrocytes. Splenic enlargement occurs in individuals with hemolytic anemia, hematologic malignancies, portal hypertension, and splenic sequestration crisis of sickle cell anemia. In hemolytic anemia, the spleen may become enlarged as a result of sequestration of red blood cells.

Clients who have undergone splenectomy are at risk of serious infection and sepsis. They should receive vaccines against encapsulated bacteria, including Streptococcus pneumoniae (pneumococcus), Neisseria meningitidis (meningococcus), and Haemophilus influenzae type B.

Components of the CBC. The complete blood count (CBC) is a measure of blood cells and their sizes and concentrations. The main components of the CBC include red blood cells (RBCs), white blood cells (WBCs), hemoglobin (Hgb), hematocrit (Hct), and red blood cell indices, including MCV, MCH, and MCHC.

Complete Blood Count, or CBC is done many times prior to surgery or when fever is present to check for infection. When low hemoglobin and hematocrit can be an indicator of anemia and low blood volume.

A nurse is caring for a client who has gone into disseminated intravascular coagulation (DIC) following a surgical procedure. Which of the following nursing interventions is most appropriate when caring for a client in DIC? (Select all that apply.) Correct Answers: - Monitor dressings and output for signs of bleeding - Measure abdominal girth and increased output on dressing at least each shift Avoid suctioning the patient at higher-than-normal pressures, avoid Non-steroidal anti-inflammatory drugs, avoid administering medications via the rectal or IM route; all due to increase risk of bleeding

DIC (disseminated intravascular coagulation) is a disease process that stimulates coagulation with resultant thrombosis, as well as depletion of clotting factors, leading to clotting and hemorrhage. The patient ends up bleeding uncontrollably.

Disseminated intravascular coagulation (DIC). - Hemorrhage and thrombosis occur at the same time - Bleeding is the primary clinical manifestation - Platelet count will be decreased (less then 150,000/ mm3) and the PTT will be increased. - The client will typically have a normal temperature. - Supportive measures include administration of oxygen, heparin, platelets and/or plasma, antibiotics, and fluid replacement. - The underlying cause of DIC must be identified and treated.

DIC is caused by abnormal activation of the clotting cascade in infection, childbirth, and surgical procedures. A client with DIC will have signs of excessive bleeding or bruising (petechiae) Hypercoagulation causes diffuse thrombosis in small and large vessels, leading to depletion of clotting factors, fibrinogen, and platelets. This results in hemorrhage.

A nurse is caring for a client after repair of a tib-fib fracture. Which of the following clinical signs is associated with a deep vein thrombosis? Correct Answer: Positive Homans sign A Homans sign is positive when dorsiflexion of the foot causes calf pain. This assessment technique could dislodge the DVT and it is no longer recommended. Clinical manifestation of DVT include asymmetrical swelling in one leg and warmth, redness (erythema), and pain in the affected extremity.

DVT refers to formation of a blood clot in the deep veins of the legs or pelvis, usually causing leg pain or swelling. It is a serious condition since the clot can embolize and travel through the bloodstream to obstruct blood flow to the lungs (pulmonary embolism) Treatment includes anticoagulation, thrombolytic therapy in some cases, and endovascular intervention when a pulmonary embolism is likely.

What is the most appropriate nursing action when administering a unit of packed red blood cells to a client with a bleeding peptic ulcer and anemia who currently has D5W infusing through a 20-gauge catheter? Correct Answer: Discontinue D5W and flush the catheter with normal saline before starting transfusion A dedicated IV line must be used to infuse blood products. The only fluid that can be administered with a blood transfusion is normal saline. After the transfusion is complete, the nurse should clear the catheter with a flush of NS before administering any fluids or medications.

Discontinue tubing that is currently in place, and flushed with normal saline before connecting the tubing for administration of blood. After the transfusion is complete, clear the catheter with a flush of NS before administering any fluids or medications. A Y tubing set with microaggregate filter is used for transfusion. Use a needle that is 20-gauge or larger. An 18-gauge or 16-gauge is recommended for rapid transfusion.

A nurse is providing discharge teaching for a client who has hepatitis B. Which of the following instructions should the nurse include in the teaching? (Select all that apply.) Correct Answers: - Limit physical activity - Take frequent rest breaks - Avoid alcohol. - Eat small, frequent meals. Foods should be high in calories and protein. Selecting food options the client likes and adding gravies or sauces to foods can enhance nutritional intake. - Limit fat intake if steatorrhea develops. - Donation of blood or blood products, organs, or other body tissues are no longer permitted.

Do not share needles for injection, tattoos, or body piercing, use a condom during sexual activity or abstain from sex, and cover cuts or sores with bandages. Hepatitis B is transmitted primarily through the blood. Hepatitis is a viral infection that results in inflammation of the liver due to the liver becoming congested with lymphocytes, fluid, and inflammatory cells. Manifestations of hepatitis B develop within 25 to 180 days of infection and include anorexia, fever, fatigue, and pain in the joints and in the upper right quadrant.

A nurse is planning to administer IV alteplase (Activase) to a client who is demonstrating manifestations of an acute pulmonary embolism. Which of the following actions should the nurse plan to take? Correct Answer: B. Hold direct pressure on puncture sites for up to 30 min. The nurse should plan to hold direct pressure on puncture sites for 30 min or until the oozing of blood stops. The recommended dosage for alteplase is 100 mg infused over 1 hr.

Enoxaparin can increase the risk of intracranial bleeding when administered with anticoagulant therapy and is only available in a subcutaneous form. When a client receives alteplase, subcutaneous and IM injections, as well as other administration methods that cause punctures, should be avoided due to an increased risk for bleeding. Aminocaproic acid is an antifibrinolytic agent, which is the antidote for alteplase.

A nurse at a hemodialysis center is caring for a client who has a new order for erythropoietin (Epogen) to be administered subcutaneously. Which of the following side effects should the nurse advise the client to report to the healthcare provider? Correct Answer: Severe headache Hypertension and related headaches occur in 15% of individuals with the administration of erythropoietin. A headache may progress to seizures or encephalopathy. Increased blood pressure occurs less frequently with subcutaneous administration compared to intravenous administration of EPO.

Erythropoietin (EPO) is a hormone made in the kidney and is necessary for maturation of red blood cells. It is used to treat anemia associated with chronic renal failure and due to cancer and treatment with toxic chemotherapeutic drugs. Hypertension can be relieved with dialysis or, in individuals who are not on dialysis, with a diuretic. Check for increased RBCs. Monitor for increased hemoglobin and hematocrit.

What is the rationale for administration of fresh frozen plasma for a client who has a rapidly bleeding arterial laceration? Correct Answer: Rapid volume expansion Fresh frozen plasma (FFP) is used when volume expansion and/or clotting factors are needed. It should be infused over 15 to 30 minutes, since clotting factors deteriorate rapidly after thawing. FFP can be frozen for a year or more, but it must be used within 24 hours of thawing. If only volume expansion is necessary, other colloid solutions are preferable.

Fresh frozen plasma does not contain erythrocytes or platelets. It does not increase hemoglobin or hematocrit. ABO and Rh compatibility is required, and assessment includes monitoring resolution of hypovolemia and/or coagulation studies, including activated partial thromboplastin time (aPTT) and prothrombin time (PT)

A nurse is caring for a client who has a new prescription for heparin therapy. The nurse should identify that which of the following statements by the clieerythemant is the priority to report? Correct Answer: "I take antacids several times a day." Antacids are used to treat hyperacidity caused by GERD or a peptic ulcer. A client who has peptic ulcer has an increased risk for gastrointestinal bleeding. An anticoagulant, such as heparin, increases this risk and can lead to severe hemorrhage.

Heparin therapy is used to prevent thrombus formation. The nurse should check the client's aPTT to monitor heparin therapy. Therapeutic anticoagulation is 1.5 to 2 times the baseline value. Heparin overdose is treated with protamine. Manifestations of bleeding can include hypotension, tachycardia, ecchymosis, petechiae, discolored urine, and black, tarry stools.

Polycythemia vera refers to a disorder of the bone marrow that results in increased production of blood cells, including red cells, white cells, and platelets. This is associated with an increased risk of developing a blood clot since blood viscosity and volume are increased. PCV results in blood hemoglobin levels to 18 g/dL, hematocrit of 55% or greater. Clinically, it is characterized by dark, purple, or flushed appearance of the face, known as facial plethora, with distended veins and intense pruritus.

Hyperviscosity can result in vascular stasis and thrombosis in small blood vessels. The red blood cells produced in excess have impaired oxygen-carrying capacity, causing poor gas exchange that results in severe hypoxia. Although platelets are produced in excess, their function is impaired and bleeding problems are common.

A nurse is caring for a client with a new prescription for warfarin (Coumadin.) Which of the following should the nurse include when teaching the client about this medication? Correct Answer: International Normalized Ratio (INR) is used to assess effectiveness

INR is the value used to assess effectiveness of warfarin sodium therapy. INR reflects the prothrombin time. It is the ratio of the actual PT to the PT that would be obtained if the thromboplastin reagent from the World Health Organization was used for the plasma test. It is now the recommended method for monitoring the effectiveness of warfarin sodium.

A nurse in the oncology unit is caring for a client who has developed disseminated intravascular coagulation (DIC) and is bleeding from her mucous membranes and venipuncture sites. Which of the following laboratory values indicates that the client's clotting factors are depleted? (Select all :that apply.) Correct Answers: Platelets 100,000 per cubic millimeter (mm3) Fibrinogen levels 57 milligrams per deciliter (mg/dL) The client's platelet count is less than the expected reference range of 150,000 to 400,000/mm³. Fibrinogen level is less than the expected reference range of 60 to 100 mg/dL, meaning clotting factors have become depleted.

In DIC: - Platelet levels are decreased - Fibrinogen levels are decreased, - Fibrin degradation product level increased than the reference range of 0 to 5 micrograms per milliliter (mcg/mL). - D-dimer level increased than the expected reference range of < 0.4 micrograms per milliliter (mcg/mL). - Clotting times of PT, aPTT, and thrombin time (TT) are all increased, which raises the risk of fatal hemorrhage

A nurse is receiving a report on a client who received a unit of granulocytes the previous evening. Which of the following daily laboratory studies will the nurse assess to determine the effectiveness of the client's transfusion? Correct Answer: White blood cell count A granulocyte infusion refers to the infusion of white blood cells, including neutrophils, eosinophils, and basophils. Granulocyte concentrate transfusion is typically reserved for clients with severe neutropenia who have serious infections and have not responded to other treatments.

In addition to monitoring the white blood cell count, a nurse must monitor a neutropenic client for signs of infection. A nurse caring for a client receiving a granulocyte transfusion should monitor the client for non-hemolytic febrile transfusion reaction. Granulocytes are stored at room temperature and should be used within six hours of collection when possible.

A nurse is caring for a client who develops urticaria after a blood transfusion is initiated. Which of the following is the most appropriate initial action by the nurse? Correct Answer: Stop the transfusion The most critical action is to stop the blood transfusion. Do not throw the blood bag or tubing away. Monitor the client's vital signs and notify the healthcare provider about the reaction. Depending on the reaction, the healthcare provider may give orders for medication to counteract the reaction. Finally, let the blood bank know about the reaction and complete any forms as required by the facility.

In any transfusion reaction, the nurse should stop the transfusion and keep the intravenous line open with normal saline ( 0.9% sodium chloride). The nurse should check information on the blood unit label and the client's identification to ensure that the "right" blood unit was administered to the "right" client. The remaining contents of the blood product container should be returned the blood bank, together with a freshly collected blood sample from the client, for investigation of the transfusion reaction.

A client with iron deficiency anemia asked the nurse about possible food sources of iron. Which of the following foods contain iron? (Select all that apply) Correct Answers: Dried beans Brown rice Egg yolks Heme iron can be found in egg yolks, beef, chicken, turkey, pork loin, clams, and oysters. Nonheme iron sources include oatmeal, dried beans, bran flakes, brown rice, and whole grain bread.

Iron deficient anemia is characterized as microcytic, hypochromic anemia. Small size of erythrocytes and the decreased iron content Common causes include heavy menstrual bleeding, GI bleeding, inadequate dietary iron or inadequate absorption. Symptoms such as pallor, weakness, dyspnea, and gastrointestinal disturbances are typical manifestations. Treatment with iron from either food or medication.

A nurse is providing teaching for a client who is scheduled for elective surgery. Which of the following herbal supplements should the nurse instruct the client to discontinue due to increased risk of bleeding? (Select all that apply)? Correct Answers: Ginseng Ginkgo biloba Herbal supplements that can increase the risk of bleeding during surgery include garlic, ginkgo biloba, ginseng, ginger, and feverfew.

It is important to remind the client to discuss all prescribed and over the counter medications and supplements with the healthcare provider prior to undergoing a surgical procedure. Supplements have many medicinal effects and often interact with medications

A nurse is caring for a client who is diagnosed with deep vein thrombosis. When the client complains of pain and swelling in the legs, the first intervention of the nurse should be which of the following?: Correct Answer: Elevate the foot of the bed Other interventions: elevate the affected extremity, use of graduated compression stockings; application of warm compresses; and encouraging ambulation; elevate the feet and lower legs periodically above the level of the heart. Active and passive leg exercises should be performed to increase venous flow.

Massaging the client's calves is contraindicated since this may cause a clot to break off and cause pulmonary embolism. Placing a pillow under the client's knees is contraindicated since the lower legs will be lower than the upper legs.

A nurse is caring for a client who takes large doses of ibuprofen daily for joint pain. The nurse knows that it is important to monitor for which of the following adverse effects? (Select all that apply.) Correct Answers: Black tarry stools Bruising Ibuprofen is a commonly used nonsteroidal anti-inflammatory drug (NSAID). This class of medication decreases the production of prostaglandins, which protect the stomach and intestinal lining from damage caused by digestive acids. Lack of protective prostaglandins may result in gastrointestinal bleeding. Clinical signs of gastrointestinal bleeding include black tarry stools known as melena and/or "coffee-ground" emesis

NSAIDs also decrease platelet aggregation, although aspirin is the NSAID most likely to cause significantly decreased platelet aggregation. This results in easy bruising and prolonged bleeding times. Significant effects that require monitoring include GI bleeding and renal toxicity (associated with large doses or long duration of treatment.) Hemoglobin and hematocrit levels are monitored for clients who have bleeding or anemia

A nurse is reviewing laboratory results of a client who has a WBC count of 20,000/mm3. The nurse should identify that the client has which of the following conditions? Correct Answer: Leukocytosis Leukocytosis is a WBC count of greater than 10,000/mm3, which can indicate inflammation or infection, the presence of leukemia, or cancer of the blood. Monitor the client for shortness of breath, mental status changes, malaise, anorexia, and weight loss.

Neutropenia is a neutrophil count of less than 2,000/mm3. C. Thrombocytosis is an increase in platelets. D. Leukopenia is a total WBC count of less than 4,000/mm3, which can indicate overwhelming infection or medication toxicity.

A nurse is caring for a client who requires rapid transfusion of multiple units of blood. Which of the following will the nurse obtain for use during the transfusion to reduce the risk of cardiac arrhythmia? Correct Answer: Blood warmer Transfusion of massive amounts of cold blood can result in hypothermia and cardiac arrhythmia, so a blood warmer is indicated. Other complications of massive transfusion include citrate toxicity and hypocalcemia; and hyperkalemia.

Only devices specially designed and approved to warm blood products should be utilized.

The nurse is caring for a client with anemia who has a prescription for infusion of one unit of packed red blood cells (PRBCs) . Within which period of time must the blood administration be initiated after it is obtained from the blood bank? Correct Answer: 30 minutes Starting the blood within 15 minutes would be ideal, but the nurse has a 30-minute window in which to start the process. The transfusion should be initiated as soon as the blood product arrives on the unit. Blood products should be transfused within four hours after they are obtained from the blood bank.

Packed red blood cells are red blood cells from which most of the plasma has been removed. The hemoglobin concentration of PRBCs is approximately 20 g/100 mL. To prevent growth of pathogenic microorganisms, blood products must be stored at a temperature between +2°C and +6°C in an approved blood bank refrigerator that is equipped with a temperature monitor and alarm. Blood must be returned to the blood bank if the transfusion is not initiated within 30 minutes.

Types of reactions to blood products; - A hemolytic reaction is characterized by low back pain, hypotension, and dark urine - A febrile reaction will demonstrate signs of fever (a rise in temperature of 2° F), chills, headache and infection - A mild allergic reaction will show itching, urticaria and flushing. - An anaphylactic reaction will show dyspnea, wheezing and chest tightness If a transfusion reaction is suspected; stop the transfusion, remove the blood bag and tubing from the IV catheter., keep the I.V. line open with normal saline solution, obtain a urine specimen, notify the healthcare provider, save the blood container, blood tubing, and attached labels and send to the blood bank.

Parameters for when to transfuse blood products: - When the client's hemoglobin level drops to 6 g/dL or less - Hemorrhage that causes 30 percent total volume blood loss - Sickle cell disease that causes severe anemia - When platelets are less than 10,000 micrograms per liter

A nurse is reviewing the laboratory results of a client who has thrombocytopenia. Which of the following actions should the nurse expect to take? Correct Answer: Apply prolonged pressure to puncture sites when obtaining blood. The nurse should implement bleeding precautions for a client who has thrombocytopenia, such as holding prolonged pressure after punctures and implementing methods to reduce risk of injury or falls.

Platelets are essential for blood clotting. Thrombocytopenia is a decrease in the amount of platelets circulating in the bloodstream, and this condition is often identified in clients who are being treated for cancer. Normal platelet range is 150,000 to 450,000/mm3. The nurse should know that clients are at an increased risk for bleeding once platelets drop below 100,000/mm3.

A nurse is providing care to a client after delivery of a healthy baby. While assessing the client's extremities, the nurse notes tenderness, warmth, and redness of the lower extremity. Which of the following does this finding most likely represent? Correct Answer: Thrombophlebitis Tenderness, warmth, and redness of the leg are the symptoms of thrombophlebitis. Thrombophlebitis is vein inflammation related to a blood clot. It occurs more commonly in pregnancy and the postpartum period.

Postpartum deep vein thrombosis (DVT) and superficial thrombophlebitis in the postpartum period may occur as a result of trauma to the pelvic veins from pressure exerted by the presenting fetal part. Other pregnancy related changes that increase the risk of thrombophlebitis or DVT include impaired circulation and hypercoagulability related to the increased production of estrogens during pregnancy.

A client diagnosed with pulmonary embolism is receiving a heparin infusion. The nurse knows to administer which of the following drugs immediately in case of a serious bleeding reaction? Correct Answer: Protamine sulfate Protamine sulfate is the reversal agent for heparin. Immediate reversal can be achieved by administration of 1.0-1.5 mg per 100 units of heparin. Given alone, protamine sulfate is a weak anticoagulant. However, in the presence of heparin, it forms a stable salt that stops the anticoagulant activity of both.

Protamine sulfate is an agent that can rapidly reverse the anticoagulant activity of heparin.

A nurse is admitting a client at 12 weeks' gestation for treatment of a deep vein thrombosis. Which of the following medications is contraindicated in pregnancy? Correct Answer: Warfarin Warfarin is associated with fetal malformations and is contraindicated in early pregnancy through the first trimester for most indications. It is considered category D for women with high-risk mechanical heart valves. Pregnancy increases the risk of venous thromboembolism four to five fold. DVT occurs three times as often as PE.

Prothrombin time (PT) and International Normalized Ratio (INR) are used to monitor the therapeutic effects of the drug. Enoxaparin (Lovenox) is a low molecular weight heparin. It is pregnancy risk category B and is preferred over unfractionated heparin for treatment of deep vein thrombosis. It does not cross the placenta.

A nurse is caring for a client with deep vein thrombosis (DVT) who has sudden onset of anxiety and shortness of breath. The client has a heart rate of 160, and a respiratory rate of 36 breaths per minute. Which of the following is most appropriate initial nursing intervention? Correct Answer: Call the healthcare provider. Tachycardia, tachypnea, and anxiety following diagnosis of deep venous thrombosis (DVT) are all signs of possible pulmonary embolus. This life-threatening complication must be treated immediately. Anticoagulant medications are used to treat suspected pulmonary embolism.

Pulmonary embolism (PE) occurs when a pulmonary artery is occluded, usually by a blood clot that has broken free from its site of origin and embolized to the lungs. PE can be fatal if misdiagnosed, unrecognized, or untreated. Symptoms of PE include shortness of breath, dry cough, hemoptysis, diaphoresis or sudden chest pain that worsens with deep inspiration. Severe clinical findings suggestive of a massive PE (50 %) include hypotension, hypoxemia, and loss of consciousness

A nurse is caring for a 4-year-old child with sickle cell anemia who has new prescriptions cycrimine (Pagitane), folic acid, hydroxyurea, and penicillin. When reviewing the medications with the parents, which of the following is the appropriate nursing intervention? Correct Answer: Notify the doctor and ask to cancel cycrimine (Pagitane) Cycrimine (Pagitane) is an anticholinergic used in Parkinson's disease and is not used to treat this condition. The nurse must notify the doctor about the prescription error.

Sickle cell anemia is a condition where there is abnormal sickling of red blood cells. The sickling of the RBCs causes sickle cell crisis such as vaso-occlusion that obstruct capillaries and impedes blood flow. Sickle cell anemia is believed to be caused by genetic mutation of sickle cell genes. The treatment involves administration of folic acid and penicillin. Analgesics are prescribed to resolve painful episodes.

A nurse is caring for a client with a GI bleed who has been diagnosed with liver failure due to hepatitis B. Which of the following blood products will most likely be prescribed to achieve hemostasis? Correct Answer: Cryoprecipitate In individuals with hemorrhage and liver failure, cryoprecipitate or fresh frozen plasma is administered to provide clotting factors. Cryoprecipitate provides VIII, XIII, and fibrinogen. It is infused through a sterile infusion set with a filter. ABO compatibility testing is recommended, but Rh factor testing is unnecessary. Cryoprecipitate is stored frozen and thawed in a water bath for 15 minutes.

Side effects can include allergic reactions and febrile reactions. Liver failure results in decreased synthesis of clotting factors and increased risk of hemorrhage. Platelet counts may be normal in some individuals with chronic liver disease. Cirrhosis also results in esophageal varices. clotting factors can be replaced by administration of cryoprecipitate or fresh frozen plasma.

A client is undergoing a massive blood transfusion and complains of muscle cramps. The nurse knows to assess Chvostek's sign because of which of the following possible effects of a large-volume blood transfusion? Correct Answer: Hypocalcemia Hypocalcemia can occur when citrate in transfused blood binds with calcium and is subsequently excreted, so serum calcium should be assessed before and after transfusion. For each liter of transfused citrated blood, 10 mL of 10% calcium gluconate should be infused. Cardiac arrhythmias and ECG changes may occur.

Signs of hypocalcemia include Chvostek's sign, Trousseau's sign, tetany, muscle weakness, muscle tremor, paresthesias, and hyperactive reflexes. - Chvostek's sign refers to contraction of the facial muscles on the same side of the face when the facial nerve is stimulated by tapping in front of the ear. - Trousseau's sign is a spasm of the muscles of the hand and forearm with inflation of a blood pressure cuff on the arm and occlusion of the brachial artery.

A nurse is providing teaching to the parent of a school-age child who has iron-deficiency anemia and a new prescription for a liquid iron supplement. Which of the following parent statements indicates an understanding of the teaching? Correct Answer: "I will administer this medication to my child using a straw." The nurse should identify that liquid iron supplements can temporarily stain the child's teeth. Therefore, the nurse should instruct the parent to administer this medication using a straw, needleless syringe, or medicine dropper placed toward the back of the child's mouth.

The child should take a missed dose within 12 hr of the missed dose. Consuming milk with this medication can decrease iron absorption. The medication will turn the child's stools dark green or black. Adverse effects of oral iron therapy include: • Gastric irritation • Nausea • Vomiting • Diarrhea or constipation • Anorexia

A nurse is preparing to initiate hemodialysis through an Arteriovenous (AV) fistula for a client who has end stage kidney disease. The nurse should take the following actions: - Review the client's current laboratory results and medications. - Assess the AV fistula for a bruit. - Measure the client's weight. - Monitor the client's vital signs before and the level of consciousness for several hours after dialysis due to orthostatic hypotension. - Heparin, or another anticoagulant, is administered using an IV pump. - Venipuncture should never be performed on the arm that has the AV fistula. - Blood pressures should never be taken in the arm with the fistula.

The client's fluid allowance is based upon the amount of urine the client voids daily added to a volume of 500 to 700 mL. Dialysis can result in thrombus formation. Anticoagulation is administered to prevent this from occurring. Heparin, remains in the body for up to 6 hr following dialysis. Monitor the AV site for complications such as bleeding or air embolism; regulates the flow of the dialysate; and monitors the client.

A nurse is preparing to initiate peritoneal dialysis for a client who has chronic kidney disease. The nurse should take the following actions: - Maintain surgical asepsis when accessing the catheter insertion site. - Monitor the client's glucose levels. - Report cloudy dialysate return. - Assess the client for the presence of shortness of breath. - Position the drainage bag lower than the client's abdomen. - Ensure that the client is in proper body alignment and reposition the client to promote flow. - Weigh the client before and after dialysis - Warm the dialysate using a warming chamber or by wrapping a heating pad around the dialysate bag

The dialysate solution contains glucose to manage tonicity of the solution, the client can develop hyperglycemia. The dialysate return should appear clear and light yellow in color. Cloudy effluent is an indication of peritonitis. Fever, tenderness or pain in the abdomen, nausea, vomiting, or general malaise, are also manifestations of peritonitis. Measure the quantity of effluent and compare that to the amount of dialysate infused.

A nurse is admitting a school-age child who has leukemia and has a platelet count of 40,000/mm3. Which of the following precautions should the nurse initiate? Correct Answer: Bleeding Bleeding precautions involve specific measures to reduce the risk for bleeding, such as using soft-bristled toothbrushes, avoiding IM injections, and preventing constipation.

The nurse should initiate bleeding precautions for a child who has a low platelet count. The expected reference range for platelets in children is 150,000 to 400,000/mm³. Platelet counts less than 100,000/mm³ are an indication of thrombocytopenia and an increased risk for bleeding.

A nurse is caring for a client who has been undergoing anticoagulation with heparin for 3 days. Which of the following should the nurse monitor carefully? Correct Answer: Platelet count Heparin is an anticoagulant agent given as an infusion or by subcutaneous injection for treatment of venous thrombosis or pulmonary embolism. After several days, the client may develop heparin-induced thrombocytopenia, which is characterized by a platelet count of <150,000 cells/mm^3.

The nurse should monitor the client for bleeding by assessing the gums, the stool for dark tarry stools, or for an increased pulse or drop in blood pressure. The activated partial thromboplastin time (aPTT) is used to monitor the efficacy of the drug. The therapeutic level is 1.5 to 2.5 times the normal value )control 12). A normal aPTT is 30 to 40 seconds. Protamine sulfate is the antidote to heparin in cases requiring rapid reversal of anticoagulation.

A nurse is caring for a client with pulmonary embolism. The client is hypotensive and dyspneic. Which of the following client outcomes is the priority in this client? Correct Answer: The client will have increased cardiac output The nurse must first ensure that the client's heart continues beating. In a hypotensive client, restoration of adequate cardiac output is the goal of treatment. Anticoagulants and/or thrombolytic medications are prescribed to break up clots and to prevent additional clots from forming. insure that the client will also be free of hemorrhage and abnormal bleeding.

The priorities are: airway, breathing, and then circulation (which includes cardiac output). Other expected outcomes for clients affected with pulmonary emboli are the maintenance of urinary output of 30 mL or more per hour, and the absence of cor pulmonale, or right-sided heart failure.

A nurse is preparing to transfuse a unit of packed RBCs for a client who has severe anemia. The nurse should identify that which of the following interventions will help prevent an acute hemolytic reaction? Correct Answer: Verifies with another nurse that the client and blood product match the client's ID band for blood components as well as the blood ID information in their chart Check the label on the blood product against the medical record, the client's identification number, blood group, and full name. If any discrepancies exist, the nurse should not transfuse the blood.

Verified with another nurse to ensure client safety. Ensuring that the client has a patent IV line before obtaining the blood product. Stay with the client for the first 15 to 30 min of the transfusion. Take vital signs before and during the transfusion. Acute hemolytic reaction is caused by ABO or Rh incompatibility.

A client is receiving warfarin for deep vein thrombosis. His INR is 5.0. Which of the following orders from the healthcare provider can the nurse anticipate? Correct Answer: Administer oral vitamin K An INR level >5.0 is associated with a high risk of bleeding from any trauma, so the warfarin dose should be withheld for 1-2 doses with or without administration of low-dose vitamin K, depending on the individual risk factors for bleeding. Fresh frozen plasma or prothrombin complex concentrate can be used when a client has an INR >2 with serious hemorrhage.

Warfarin is an anticoagulant medication that is monitored by prothrombin time (PT) or INR (international normalized ratio). An INR of 1.1 or below is normal, but a target range of 2.0 to 3.0 is indicated for preventing clotting in clients with deep vein thrombosis, atrial fibrillation, or pulmonary embolism. Clients with a high risk of a blood clot may have a target range of 2.5-3.5.

A nurse is providing discharge instructions to a client who has a new prescription for warfarin therapy initiated after undergoing placement of a prosthetic heart valve. Which of the following should the nurse include in the discharge education? Correct Answer: The client should not make any significant change in consumption of foods rich in vitamin K. Clients are monitored to achieve the appropriate international normalized ratio (INR) and prothrombin time (PT); when that is achieved, they should not make any significant changes in consumption of foods rich in vitamin K.

Warfarin is an oral anticoagulant used as long-term therapy for treatment and prevention of deep vein thrombosis, pulmonary embolism, and embolic complications of atrial fibrillation and mechanical prosthetic heart valves. Assess the client for signs of bleeding and hemorrhage, including bleeding gums; nosebleed; unusual bruising; tarry, black stools; hematuria; fall in hematocrit or BP; and guaiac-positive stools, urine, or nasogastric aspirate.

A nurse is caring for a 56-year-old client who is taking warfarin (Coumadin). Which of the following laboratory parameters should be monitored? (Select all that Correct Answers: PT INR In a client taking warfarin, PT should be 1.5-2.5 times the normal (9.5-12) and INR should be between 2.0-3.5, depending upon the client's underlying condition and indication for warfarin.

Warfarin produces an anticoagulant effect by interfering with the vitamin K dependent clotting factors synthesized in the liver. The activity of these clotting factors is reflected by the prothrombin time (PT) and International Normalized Ration (INR.)

Warfarin is an oral anticoagulant medication that interferes with the liver's synthesis of vitamin K-dependent clotting factors (II, VII, IX, and X). It is used for prophylaxis and treatment of: venous thrombosis, pulmonary embolism, and thromboembolism in clients with atrial fibrillation. It is also used for prevention of thrombus formation and embolization after prosthetic valve placement. Therapeutic levels can be monitored using the prothrombin time or INR.

Warfarin sodium will help to prevent blood clots. Fresh frozen plasma or vitamin K is used to reverse warfarin sodium's anticoagulant effect

Which solution should be hung at the bedside of a client receiving a unit of packed red blood cells? Correct Answer: Normal saline Isotonic (0.9%) saline (i.e. normal saline) is the crystalloid solution of choice to hang at the bedside for use before and after transfusion of blood product. Dextrose-containing IV solutions can cause clumping of red blood cells, and lactated Ringer's solution is not a first-line choice when normal saline is available.

When transfusing blood products, a needle that is at least 19 gauge is indicated, although larger (16 or 18 gauge) needles should be used for rapid transfusion. Tubing for administration of blood products is usually Y-type with a microaggregate filter. One arm of the Y tubing is used for the isotonic saline solution, with the other arm reserved for blood product.

Transfusion of red blood cells should improve the hemoglobin level. One unit of packed red blood cells increases the hemoglobin level by 1 gram/dL but it will take 4-6 hours after the transfusion before the laboratory values reflect this. The hematocrit is a measurement associated with erythrocyte count. After red blood cell transfusion, the hematocrit should reflect an improvement 4-6 hours after transfusion with a 2-3% increase in hematocrit.

Whole blood is not used when components are available. Whole blood transfusion is associated with a higher rate of complications, including volume overload. Platelets are blood cells involved in clotting. Severe thrombocytopenia, low platelets with active bleeding, and platelet dysfunction are indications for platelet transfusion

A nurse is assessing a client who has a premeal blood glucose level of 42 mg/dL. Which finding should the nurse expect? Correct Answer: Diaphoresis Hypoglycemia can occur if the blood glucose level drops below the expected reference range for a fasting blood glucose level of 70 to 100 mg/dL. A client who has hypoglycemia can have diaphoresis and cool, clammy skin; Trembling, Dizziness, Headache, Confusion, Hunger, Shaking Manifestations usually occur with blood glucose levels less than 50 mg/dL.

manifestation of hyperglycemia Fruity breath odor, Ketones, Vomiting Hypoglycemia can occur from taking too much insulin, not eating meals at regular intervals, or increased exercise.