Medsurge chapter 31
A 73-year-old patient who underwent left total knee arthroplasty has a prescription written at 1000 for two units of packed red blood cells. If the transfusion is picked up at 1015, the nurse should plan to hang the unit no later than:
1045 The nurse must hang the unit of packed red blood cells within 30 minutes of signing them out from the blood bank, which would be at 1045. 1030, 1100, and 1115 are not consistent with this policy.
The nurse notes a health care provider's prescription written at 10:00 am for two units of packed red blood cells to be administered to a patient who is anemic as a result of chronic blood loss. If the transfusion is picked up at 11:30 am, the nurse should plan to hang the unit no later than what time?
12 noon The nurse must hang the unit of packed red blood cells within 30 minutes of signing them out from the blood bank. Because the blood was picked up at 11:30 AM, 12:00 PM is the latest it can be hung. It is okay to hang the blood at 11:45 AM. It is too late to hang the blood at 12:30 PM or 3:30 PM.
A patient has been admitted to the emergency department after an automobile accident. The patient had been bleeding from a leg laceration, but the bleeding has stopped. While checking the patient's vital signs, the nurse notes that the patient has normal blood pressure and pulse while at rest, but when getting up to use the bathroom, the patient almost passed out. The nurse rechecked the patient's vital signs and found that the patient's blood pressure had dropped by 20 mm Hg and the pulse had become tachycardic. Based on these findings, the nurse suspects that the patient may have lost what percentage of blood volume?
30% Manifestations of loss of 30% of blood volume include normal supine blood pressure and pulse at rest, but postural hypotension and tachycardia with exercise.
Which patient is most likely to experience anemia related to an increased destruction of red blood cells?
A 23-year-old African-American man who has a diagnosis of sickle cell disease
After receiving chemotherapy treatments for leukemia, a patient is declared to be in partial remission. Which statement does the nurse identify as being true about partial remission?
A lack of symptoms and a normal peripheral blood smear, but evidence of the disease is still present in bone marrow. In complete remission there is no evidence of overt disease on physical examination, and the bone marrow and peripheral blood appear normal. A lesser state of control is known as partial remission. Minimal residual disease is defined as tumor cells that cannot be detected by morphologic examination, but can be identified by molecular testing. Partial remission is characterized by a lack of symptoms and a normal peripheral blood smear, but still evidence of disease in the bone marrow. Molecular remission indicates that all molecular studies are negative for residual leukemia.
A nurse is caring for a neutropenic patient admitted to the health care facility with a febrile episode. Which priority intervention would the nurse perform first?
Administer a broad spectrum IV antibiotic The first nursing intervention for a febrile neutropenic patient is to administer a broad spectrum antibiotic by IV route within one hour. Because of the rapid lethal effects of infection, this should be done even before obtaining cultures to determine a specific causative organism. Administration of a broad spectrum antibiotic by the IV route is preferred to oral antibiotic for initial management because it is the faster administration method.
What will caring for a patient with a diagnosis of polycythemia vera likely require the nurse to do?
Assist with or perform phlebotomy at the bedside Primary polycythemia vera often requires phlebotomy to reduce blood volume. The increased risk of thrombus formation that accompanies the disease requires regular exercises and ambulation. Deep breathing and coughing exercises do not address directly the etiology or common sequelae of polycythemia, and neurologic manifestations are not typical.
A 57-year-old patient has been diagnosed with acute myelogenous leukemia (AML). The nurse explains to the patient that collaborative care will focus on what?
Attaining remission Attaining remission is the initial goal of collaborative care for leukemia. The methods to do this are decided based on age and cytogenetic analysis. The treatments include leukapheresis or hydroxyurea to reduce the white blood cell (WBC) count and risk of leukemia-cell induced thrombosis. A combination of chemotherapy agents will be used for aggressive treatment to destroy leukemic cells in tissues, peripheral blood, and bone marrow and minimize drug toxicity. In nonsymptomatic patients with chronic lymphocytic leukemia (CLL), waiting may be done to attain remission, but not with AML.
A patient is scheduled for a Schilling test. The nurse explains that the purpose of the test is to measure:
B12 absorption The Schilling test measures B12 absorption. It is usually prescribed as the definitive test for pernicious anemia when other signs of the disease are present. A Schilling test does not measure the size of the spleen, gastric secretion levels, or thrombocytopenia severity.
The nurse is assessing a patient who was admitted to the emergency room after an anaphylactic reaction to an antibiotic. Which of these assessment findings may be indicative of the development of disseminated intravascular coagulation (DIC)?
Blood oozing from venipuncture sites Bleeding in a person with no previous history or obvious cause should be questioned because it may be one of the first manifestations of acute DIC. The patient will not have dyspnea or wheezing. Tachycardia and hypotension are found in patients with DIC (not bradycardia and hypertension). Text Reference - p. 659
The nurse is monitoring a patient who is receiving a transfusion of packed red blood cells (PRBCs). Which of these interventions are appropriate? Select all that apply.
Check the patient's vital signs after the first 15 minutes. Infuse the blood over two hours, but no longer than four hours. Remain with the patient during the first 15 minutes of blood infusion. Stop the infusion if the patient develops chills, fever, or low back pain. During the first 15 minutes or 50 mL of blood infusion, remain with the patient. If there are any untoward reactions, they are most likely to occur at this time. The rate of infusion during this period should be no more than 2 mL/minute. Most patients not in danger of fluid overload can tolerate the infusion of 1 unit of PRBCs over two hours. The transfusion should not take more than four hours to administer because of the increased risk of bacterial growth in the product once it is out of refrigeration. Chills, fever, low back pain, flushing, tachycardia, dyspnea, tachypnea, and hypotension are some manifestations of an acute hemolytic reaction. The nurse needs to stop the transfusion immediately if signs of a reaction are noted.
The nurse receives a health care provider's prescription to transfuse fresh frozen plasma to a patient suffering from an acute blood loss. Which procedure is most appropriate for infusing this blood product?
Infuse the fresh frozen plasma as rapidly as the patient will tolerate. The fresh frozen plasma should be administered as rapidly as possible and should be used within 24 hours of thawing to avoid a decrease in Factors V and VIII. 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.
The nurse reads the following prescription: "Infuse one unit of fresh frozen plasma before arrival to operating room (OR)." To complete this prescription safely, the nurse should take which action?
Infuse the fresh frozen plasma as rapidly as the patient will tolerate. The fresh frozen plasma should be administered as rapidly as possible and should be used within six hours. Fresh frozen plasma is infused with the use of any straight-line infusion set. Any existing IV should be interrupted while the fresh frozen plasma is infusing, unless a second IV line has been started for the transfusion.
A patient has recurrent episodes of fever and has a decreased neutrophil count (neutropenia). To prevent complications, which interventions should the nurse include in the patient's discharge teaching? Select all that apply.
Encourage frequent hand washing. Advise the patient to brush the teeth four times a day with a soft toothbrush. Advise the patient to notify the health care provider if a fever develops. Neutropenia, or decreased neutrophil count, increases the risk of developing infection. Therefore, measures should be taken to prevent infections. The self-care instructions provided by the nurse should include frequent hand washing to prevent transmission of germs. Brushing the teeth four times a day with a soft toothbrush prevents the risk of oral infections. Fever is an emergency situation in cases of neutropenia, and should be immediately reported to the healthcare provider. Eating raw eggs and staying in crowded areas increase the risk of acquiring infections, and should be avoided.
When caring for a patient with metastatic cancer, the nurse notes a hemoglobin level of 8.7 g/dL and hematocrit of 26%. What should the nurse place highest priority on initiating interventions to reduce?
Fatigue The patient with a low hemoglobin and hematocrit is anemic and would be most likely to experience fatigue. Fatigue develops because of the lowered oxygen-carrying capacity that leads to reduced tissue oxygenation to carry out cellular functions. Thirst, headache, and abdominal pain are not related to anemia.
The nurse is assessing the pain level of a patient who is in acute sickle cell crisis. The patient is crying and states that the pain is at a level of "10" on a 1 to 10 scale. Which type of medication is most appropriate for the patient's pain level?
Hydromorphone (Dilaudid) via patient-controlled analgesia (PCA) During an acute sickle cell crisis, optimal pain control usually includes large doses of continuous (rather than PRN) opioid analgesics along with breakthrough analgesia, often in the form of PCA. Morphine and hydromorphone are the drugs of choice. Acetaminophen is appropriate for minor pain or fever, not for severe pain. Meperidine is contraindicated because high doses can lead to the accumulation of a toxic metabolite, normeperidine, which can cause seizures.
The laboratory findings for a patient indicate acute myelogenous leukemia (AML). The nurse caring for the patient recognizes which symptom as indicative of AML?
Hyper cellular bone marrow with myeloblasts Hypercellular bone marrow with myeloblasts indicates AML. Hypercellular bone marrow with lymphoblasts and presence of lymphoblasts in cerebrospinal fluid are observed in acute lymphocytic leukemia (ALL). An increase in peripheral lymphocytes and lymphocytes in the bone marrow are noted in chronic lymphocytic leukemia (CLL).
The nurse cares for a patient with iron-deficiency anemia. Which nursing diagnostic statement associated with the condition is the highest priority?
Impaired gas exchange Iron is necessary for hemoglobin synthesis. Hemoglobin is responsible for oxygen transport in the body. With iron-deficiency anemia a subnormal hemoglobin level cannot carry enough oxygen to the tissues. This results in impaired tissue oxygenation caused by impaired gas exchange. Deficient fluid volume and decreased cardiac output are not directly associated with iron-deficiency anemia. Impaired breathing pattern may develop as a result of impaired gas exchange.
The blood bank notifies the nurse that the two units of blood prescribed for an anemic patient are ready for pick up. The nurse should take which action to prevent an adverse effect during this procedure?
Infuse the blood slowly for the first 15 minutes of the transfusion. Because a transfusion reaction is more likely to occur at the beginning of a transfusion, the nurse initially should infuse the blood at a rate no faster than 2 mL/min and remain with the patient for the first 15 minutes after hanging a unit of blood. Only one unit of blood can be picked up at a time, must be infused within four hours, and cannot be hung with dextrose.
A nurse is caring for a patient with mild hemophilia A. The primary health care provider prescribes desmopressin acetate for the patient. The nurse understands that it is an analog of vasopressin. What could be the reason for prescribing desmopressin acetate?
It stimulates an increase in factor VIII. Desmopressin acetate is a synthetic analog of vasopressin. This drug acts on platelets and endothelial cells and stimulates the release of vWF. vWF binds with factor VIII and increases its concentration to promote clotting. The drug does not suppress vWF but instead stimulates its release. Antifibrinolytic therapy inhibits plasminogen activation in the fibrin clot and stabilizes clots in areas of increased fibrinolysis. Desmopressin acetate is not an antifibrinolytic agent.
A patient who has sickle cell disease has developed cellulitis above the left ankle. What is the nurse's priority for this patient?
Maintain oxygenation Maintaining oxygenation is a priority as sickling episodes frequently are triggered by low oxygen tension in the blood, which commonly is caused by an infection. Antibiotics to treat cellulitis, pain control, and fluids to reduce blood viscosity also will be used, but oxygenation is the priority.
The patient is admitted with hypercalcemia, polyuria, and pain in the pelvis, spine, and ribs with movement. Which hematologic problem is likely to display these manifestations in the patient?
Multiple myeloma Multiple myeloma typically manifests with skeletal pain and osteoporosis that may cause hypercalcemia, which can result in polyuria, confusion, or cardiac problems. Serum hyperviscosity syndrome can cause renal, cerebral, or pulmonary damage. Thrombocytopenia , megaloblastic anemia, and myelodysplastic syndrome are not characterized by these manifestations.
A nurse is caring for a patient with acute blood loss following an accident. Which erythrocyte characteristic would the nurse expect to see in the laboratory findings?
Normocytic Normocytic, normochromic erythrocytes are seen in patients with acute blood loss following an accident. Microcytic, hypochromic erythrocytes are seen in patients with iron-deficiency anemia, vitamin B6 deficiency, copper deficiency, thalassemia, or lead poisoning. Megaloblastic erythrocytes are seen in patients with vitamin B12 deficiency, folic acid deficiency, or liver disease.
A nurse is providing care for a patient with hemophilia who has developed bleeding in one of the knee joints. Which self-care strategies will help the patient in rehabilitation? Select all that apply.
Packing the joint with ice Resting during an acute episode Avoiding weight bearing until swelling subsides Hemophilia increases the risk of bleeding in joints. Packing the joint with ice provides comfort and reduces inflammation. Providing rest to the affected joint is important to promote healing and prevent further bleeding. Weight bearing should be avoided until the swelling subsides and muscle strength improves. Aspirin-based medications should be avoided as they increase the risk of bleeding. Mobilization of the joint should be started as soon as the bleeding stops to facilitate healing; immobilization may cause stiffness of the joint.
Which strategy is most important for a nurse to include when planning care for a patient who has leukopenia?
Placing the patient in a private room Leukopenia is the reduction in the number of leukocytes in the blood. This leaves a patient prone to infection. The risk of infection can be reduced by placing a patient in a private room. Restriction of all visitors is not necessary; however, visitors with signs and symptoms of infections, such as a cough or fever, should be restricted. Use of an electric shaver would be recommended for a patient taking anticoagulants but is not required for this condition. Wearing a gown and gloves when in direct contact with the patient is not necessary; however, meticulous hand hygiene is a must. If the patient is in protective isolation, a mask will need to be worn.
The nurse is teaching a patient the proper intake of prescribed iron capsules. Which actions should the nurse teach the patient? Select all that apply.
Take the medication with orange juice. Do not worry if stools appear black. Take laxatives if needed. The nurse should teach the patient to take iron capsules with orange juice or vitamin C to enhance iron absorption. The patient should be informed that use of iron preparations will make the stool appear black because the gastrointestinal (GI) tract excretes excess iron. Constipation is a common side effect, and the patient should be started on stool softeners or laxatives. Iron should be taken at least 1 hour before meals, when the duodenal mucosa is most acidic to enhance absorption; however, gastric side effects may necessitate ingesting iron with meals. In order to replenish the body's stores, the patient needs to take iron therapy for 2 to 3 months after the hemoglobin level returns to normal.
A patient is taking iron tablets for the management of anemia. The nurse is aware that which measures will ensure maximum absorption of iron from the tablets? Select all that apply.
Take the tablet an hour before meals. Take the tablet with orange juice. Taking iron tablets an hour before food ensures maximum absorption as iron will not get bound to food. When iron binds with food, absorption of iron falls. Orange juice and ascorbic acid enhance iron absorption. Taking iron tablets with food can reduce iron absorption. Taking iron tablets before or after exercise does not affect absorption.
A 22-year-old female patient has been diagnosed with stage 1A Hodgkin's lymphoma. The nurse knows that which chemotherapy regimen is most likely to be prescribed for this patient?
Two to four cycles of doxorubicin (Adriamycin), bleomycin, vinblastine, and dacarbazine (ABVD) The patient with stage-favorable prognosis early-stage Hodgkin's lymphoma will receive two to four cycles of ABVD. Brentuximab vedotin is a newer agent that will be used to treat patients who have relapsed or refractory disease. The unfavorable prognostic featured (stage 1B) Hodgkin's lymphoma would be treated with four to six cycles of chemotherapy. Advanced-stage Hodgkin's lymphoma is treated more aggressively with more cycles or with BEACOPP.
The nurse is monitoring a patient for complications of polycythemia vera. Which disorder is the most common cause of mortality in patients with polycythemia vera?
Thrombosis The major cause of morbidity and mortality from polycythemia vera is related to thrombosis (e.g., stroke). Leukemia may develop in some patients with polycythemia vera; however, the incidence is low. The patient may develop heart failure, but it is not common. Pulmonary edema is not common in patients with polycythemia vera.
After the diagnosis of disseminated intravascular coagulation (DIC), what is the first priority of collaborative care?
Treat the causative problem Treating the underlying cause of DIC will interrupt the abnormal response of the clotting cascade and reverse the DIC. Blood product administration occurs based on the specific component deficiencies and is reserved for patients with life-threatening hemorrhage. Heparin will be administered if the manifestations of thrombosis are present and the benefit of reducing clotting outweighs the risk of further bleeding.
