Mobility, Clotting, and Transfusion EAQ
A client demonstrates signs and symptoms of a transfusion reaction. The nurse immediately stops the infusion; what should the nurse's next action be? A) Obtain blood pressure in both arms. B) Send a urine specimen to the laboratory. C) Hang a bag of normal saline with new tubing. D) Monitor the intake and output every 15 minutes.
C
A client has delivered her infant via cesarean birth. What is the most important nursing intervention to prevent thromboembolism on the client's first postpartum day? A) Providing oxygen therapy B) Administering pain medication C) Encouraging frequent ambulation D) Recommending an increase in oral fluids
C
A client is started on a continuous infusion of heparin. Which finding does the nurse use to conclude that the intervention is therapeutic? A) International normalized ratio (INR) is between 2 and 3 B) Prothrombin time (PT) is 2.5 times the control value C) Activated partial thromboplastin time (APTT) is double the control value D) Activated clotting time (ACT) is in the range of 70 to 120
C
A client with a suspected pulmonary embolism is scheduled for a spiral computed tomography scan. Which intervention should the nurse perform when preparing the client for the test? A) Check the client's blood glucose levels. B) Obtain informed consent from the client. C) Assess if the client is allergic to shellfish. D) Instruct the client to remove his or her dentures.
C
An elderly adult suffered an injury after falling down in the washroom. The primary healthcare provider performed a surgical procedure on the client and orders a blood transfusion. A family member of the client mentions that blood transfusions are not permitted in their community. What should the nurse do in order to handle the situation? A) The nurse should wait for the court's order to give blood to the client. B) The nurse should proceed with the transfusion in order to save the client's life. C) The nurse should inform the primary healthcare provider and not give blood to the client. D) The nurse should explain to the family member that the client needs this transfusion.
C
Warfarin is prescribed for a client who has been receiving intravenous (IV) heparin for a partial occlusion of the left common carotid artery. The client expresses concern about why both drugs are needed at the same time. What rationale does the nurse include to address the client's concern? A) This permits the administration of smaller doses of each medication. B) Giving both drugs allows clot dissolution while preventing new clot formation. C) Heparin provides anticoagulant effects until warfarin reaches therapeutic levels. D) Administration of heparin with warfarin provides immediate and maximum protection against clot formation.
C
The nurse provides back massage therapy to a client complaining of back pain. The nurse then monitors the client on an hourly basis to check if the client is feeling comfortable. Which standard of practice does the nurse perform? A) Evaluation B) Consultation C) Coordination of care D) Outcomes identification
A
While caring for a client receiving blood transfusion care, the nurse notices that the client is having an acute hemolytic reaction. What is the priority nursing intervention in this situation? A) Stop the blood transfusion immediately. B) Report to the primary healthcare provider. C) Recheck identifying tags and numbers on the client. D) Maintain a patent intravenous (IV) line with saline solution.
A
A nurse is caring for a client with compartment syndrome. Which nursing actions are appropriate? Select all that apply. A) Assisting with splitting the cast B) Assessing urine output C) Evaluating the pain on a scale D) Applying splints to the injured part E) Placing cold compresses to the affected area
A, B, C
A healthcare provider prescribes two units of blood for a client who is bleeding. Which nursing interventions are necessary before the blood transfusion is administered? Select all that apply. A) Obtain the client's vital signs. B) Monitor hemoglobin and hematocrit levels. C) Allow the blood to reach room temperature. D) Determine typing and crossmatching of blood. E) Use a Y-type infusion set to initiate 0.9% normal saline.
A, D, E
The nurse is caring for a client who has sustained blunt trauma to the forearm. The nurse assesses the client for which early sign of compartment syndrome? A) Warm skin at the site of injury B) Escalating pain in the fingers C) Rapid capillary refill in affected hand D) Bounding radial pulse in the injured arm
B
The team leader is making client assignments. Which team member should be assigned a client with a tracheostomy, chest tube, and blood transfusion? A) Charge nurse B) Registered nurse (RN) C) Unlicensed assistive personnel (UAP) D) Licensed practical nurse/licensed vocational nurse (LPN/LVN)
B
What should the nurse expect the healthcare provider to prescribe if a client exhibits clinical indicators of warfarin overdose? A) Heparin B) Vitamin K C) Iron dextran D) Protamine sulfate
B
Which factor does the nurse consider most likely contributes to the increased incidence of hip fractures in older adults? A) Carelessness B) Fragility of bone C) Sedentary existence D) Rheumatoid diseases
B
A client had a total knee replacement several days ago and has been receiving warfarin sodium therapy. An international normalized ratio (INR) is performed each afternoon, and the evening warfarin sodium dose is prescribed by the healthcare provider on a daily basis. The nurse identifies that the afternoon INR is 4.6. Which is the next action the nurse should take? A) Assist with meal planning to decrease the intake of foods high in vitamin K B) Obtain a blood specimen to have a partial thromboplastin time performed C) Contact the healthcare provider to request the day's dosage of warfarin sodium D) Maintain the client on bed rest until the healthcare provider reviews the laboratory results
D
The spouse of a comatose client who has severe internal bleeding refuses to allow transfusions of whole blood because they are Jehovah's Witnesses. The client does not have a Durable Power of Attorney for Healthcare. What action should the nurse take? A) Institute the prescribed blood transfusion because the client's survival depends on volume replacement. B) Clarify the reason why the transfusion is necessary and explain the implications if there is no transfusion. C) Phone the primary healthcare provider for an administrative prescription to give the transfusion under these circumstances. D) Give the spouse a treatment refusal form to sign and notify the primary healthcare provider that a court order now can be sought.
D
A client is receiving warfarin. Which test result should the nurse use to determine whether the daily dose of this anticoagulant is therapeutic? A) International normalized ratio (INR) B) Accelerated partial thromboplastin time (APTT) C) Bleeding time D) Sedimentation rate
A
A client with limited mobility is being discharged. To prevent urinary stasis and formation of renal calculi, what should the nurse instruct the client to do? A) Increase oral fluid intake to 2 to 3 L/day. B) Maintain bed rest after discharge. C) Limit fluid intake to 1 L/day. D) Void at least every hour.
A
A nurse is caring for a group of clients on a medical-surgical unit. Which client has the highest risk for developing a pulmonary embolism? A) An obese client with leg trauma B) A pregnant client with acute asthma C) A client with diabetes who has cholecystitis D) A client with pneumonia who is immunocompromised
A
A nurse is caring for a variety of clients. In which client is it most essential for the nurse to implement measures to prevent pulmonary embolism? A) A 59-year-old who had a knee replacement B) A 60-year-old who has bacterial pneumonia C) A 68-year-old who had emergency dental surgery D) A 76-year-old who has a history of thrombocytopenia
A
After surgery, a client reports sudden severe chest pain and begins coughing. The nurse suspects the client has a thromboembolism. What characteristic of the sputum supports the nurse's suspicion that the client has a pulmonary embolus? A) Pink B) Clear C) Green D) Yellow
A
Four days after the client's total hip arthroplasty, the nurse is preparing to transfer the client to a rehabilitation center. Before admission the client took warfarin sodium daily for a history of pulmonary embolus. While hospitalized, the client received subcutaneous heparin two times a day. The nurse does not see any anticoagulant therapy listed on the client's transfer prescriptions. What should the nurse do? A) Contact the healthcare provider to determine which anticoagulant therapy should be prescribed for this client. B) Arrange for a supply of heparin for the client to take to the rehab center. C) Explain to the client that anticoagulant therapy will no longer be needed. D) Instruct the client to talk about anticoagulant needs with the healthcare provider at the rehabilitation center.
A
Ten minutes after the initiation of a blood transfusion, a client reports lumbar pain. What is the next nursing action? A) Stop the transfusion. B) Obtain the vital signs. C) Assess the pain further. D) Increase the flow of normal saline.
A
The nurse is caring for a client who has undergone a total hip replacement. The nurse recognizes which clinical manifestations that indicate a pulmonary embolism? Select all that apply. A) Sudden chest pain B) Flushing of the face C) Elevation of temperature D) Abrupt onset of shortness of breath E) Pain rating increase from 2 to 8 in the hip
A, D
A client with a history of a pulmonary embolus is to receive 3 mg of warfarin daily. The client has blood drawn twice weekly to ascertain that the international normalized ratio (INR) stays within a therapeutic range. The nurse provides dietary teaching. Which food selected by the client indicates that further teaching is necessary? A) Poached eggs B) Spinach salad C) Sweet potatoes D) Cheese sandwich
B
A blood transfusion of packed cells has been prescribed for a client. The nursing unit is extremely busy. How should the nurse manager delegate for the task of blood administration? A) Assign a licensed practical nurse (LPN) and a nursing assistant (Canada: continuing care assistant) to verify the blood is correct, and have the LPN monitor the client 15 minutes after hanging the product. B) Have two registered nurses ascertain that the client identification and blood product are correct with no discrepancies, hang the blood, and check in 15 minutes. C) Have all identification verified by registered nurses, then have the registered nurse hang the product and monitor the client, staying with the client during the initial 15 minutes. D) Have the product and name band verified by a registered nurse, hang, and monitor every hour until infused within a 10-hour period or discontinued.
C
A client has a compound fracture of the femur. The nurse should assess the client for the typical signs and symptoms of a fat embolus. In comparison to thromboembolism, which unique clinical indicator can help the nurse identify a fat embolus? A) Anxiety B) Restlessness C) Pinpoint red spots on the chest D) Decreased arterial oxygen level
C
After surgery a client develops a deep vein thrombosis and a pulmonary embolus. Heparin via a continuous drip is prescribed. Several hours later, vancomycin intravenously every 12 hours is prescribed. The client has one intravenous (IV) site: a peripheral line in the left forearm. What action should the nurse take? A) Stop the heparin, flush the line, and administer the vancomycin. B) Use a piggyback setup to administer the vancomycin into the heparin. C) Start another IV line for the vancomycin and continue the heparin as prescribed. D) Hold the vancomycin and tell the healthcare provider that the drug is incompatible with heparin.
C
The nurse is teaching a client about management of low back pain. Which statements made by the client indicate effective learning? Select all that apply. A) "I should sleep in a prone position." B) "I should sleep with my legs out straight." C) "I should keep a check on my body weight." D) "I should stop exercising if the pain gets severe." E) "I should exercise by leaning forward without bending the knees."
C, D
A client is admitted to the hospital with a diagnosis of deep vein thrombosis, and intravenous (IV) heparin sodium is prescribed. If the client experiences excessive bleeding, what should the nurse be prepared to administer? A) Vitamin K B) Oprelvekin C) Warfarin sodium D) Protamine sulfate
D
A client is receiving warfarin for a pulmonary embolism. Which drug is often contraindicated when taking warfarin? A) Atenolol B) Ferrous sulfate C) Chlorpromazine D) Acetylsalicylic acid (Aspirin)
D
A client is receiving warfarin. The nurse explains the need for careful regulation of dietary intake of vitamin K. What is the rationale for the nurse's teaching? A) Vitamin K promotes platelet aggregation. B) Vitamin K promotes ionization of blood calcium. C) Vitamin K promotes fibrinogen formation by the liver. D) Vitamin K promotes prothrombin formation by the liver.
D
The nurse is caring for a client who is 1 day postoperative for a left hip fracture repair. During the assessment, which finding should the nurse assess further? A) Pain at the surgical site B) Small amount of serosanguinous drainage C) Decreased range of motion to the left extremity D) Sudden shortness of breath
D
The nurse is caring for an elderly client who has a right hip fracture. Which priority intervention should be included in the plan of care? A) Oxygen therapy B) Cardiac monitoring C) Nutrition supplements D) Venous thromboembolism (VTE) prevention
D
The nurse is caring for some clients with chronic anemia who are on blood transfusion therapy. The nurse notices that one of the clients requires immediate treatment. Which client is the nurse addressing in this situation? A) Client with itching B) Client with flushing C) Client with pruritus D) Client with wheezing
D
The primary healthcare provider prescribes one unit of packed red blood cells to be administered to the client who suffered a hip fracture. Several minutes after the start of the infusion, the client reports itching. Upon further assessment, the nurse observes hives on the client's chest. Which action should the nurse take next? A) Call the primary healthcare provider to obtain a prescription for an antihistamine. B) Flush packed red blood cells with 5% dextrose and 0.45% normal saline. C) Slow down the rate of the infusion. D) Stop the transfusion immediately.
D