Mobility, Clotting, Transfusion Quiz
A nurse is caring for a client with compartment syndrome. Which nursing actions are appropriate? Select all that apply. 1 Assisting with splitting the cast 2 Assessing urine output 3 Evaluating the pain on a scale 4 Applying splints to the injured part 5 Placing cold compresses to the affected area
1,2,3, Compartment syndrome is increased pressure in a limited space, which compromises the compartmental blood vessels, nerves, and tendons. The cast may be split to reduce the external circumferential pressures. The nurse should assess urine output because the myoglobin released from damaged muscle cells may precipitate and cause obstruction in renal tubules. The nurse should evaluate the pain on a scale from 0 to 10; this helps to plan care. Application of external pressure by splints, casts, and dressing to the injured area may worsen the client's symptoms. Application of cold compresses may result in vasoconstriction and exacerbate the symptoms.Test-Taking Tip: You have at least a 25% chance of selecting the correct response in multiple-choice items. If you are uncertain about a question, eliminate the choices that you believe are wrong and then call on your knowledge, skills, and abilities to choose from the remaining responses. Topics
A client is started on a continuous infusion of heparin. Which finding does the nurse use to conclude that the intervention is therapeutic? 1 International normalized ratio (INR) is between 2 and 3 2 Prothrombin time (PT) is 2.5 times the control value 3 Activated partial thromboplastin time (APTT) is double the control value 4 Activated clotting time (ACT) is in the range of 70 to 120
3 Activated partial thromboplastin time should be 1.5 to 2.5 for the control of heparin therapy. INR and PT are used to evaluate therapeutic levels of warfarin. The ACT increases to a range of 150 to 200 when heparin reaches therapeutic levels.
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? 1 Vitamin K 2 Oprelvekin 3 Warfarin sodium 4 Protamine sulfate
4 Protamine sulfate Protamine sulfate binds with heparin sodium to form a physiologically inert complex; it corrects clotting deficits. Vitamin K counteracts the effects of drugs like warfarin sodium (Coumadin). Oprelvekin is a thrombopoietic growth factor that stimulates the production of platelets. It would not be appropriate for emergency management. Warfarin sodium is an oral anticoagulant that interferes with the synthesis of prothrombin.
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? 1 A 59-year-old who had a knee replacement 2 A 60-year-old who has bacterial pneumonia 3 A 68-year-old who had emergency dental surgery 4 A 76-year-old who has a history of thrombocytopenia
1 Clients who have had a joint replacement have decreased mobility; they are at risk for developing thrombophlebitis, which may lead to pulmonary embolism if the clot becomes dislodged into the circulation. Bacterial pneumonia and emergency dental surgery are not associated with an increased risk for pulmonary embolism. A history of thrombocytopenia leads to a decreased ability to clot, so it increases the risk of bleeding but decreases the risk of a thrombus or embolus.
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? 1 Pink 2 Clear 3 Green 4 Yellow
1- pink With a pulmonary embolus, there is partial or complete occlusion of pulmonary blood flow; when infarcted areas or areas of atelectasis produce alveolar damage, red blood cells move into the alveoli, resulting in hemoptysis. Clear sputum is associated with a viral infection. Green and yellow sputum are associated with a bacterial infection.
Which factor does the nurse consider most likely contributes to the increased incidence of hip fractures in older adults? 1 Carelessness 2 Fragility of bone 3 Sedentary existence 4 Rheumatoid diseases
2 fragility of bone Bones become more fragile because of loss of bone density associated with the aging process; this often is associated with lower circulating levels of estrogens or testosterone. Carelessness is a characteristic applicable to certain individuals rather than to people within a developmental level. Although prolonged lack of weight-bearing activity is associated with bone demineralization, hip fractures also occur in active older adults. Rheumatoid diseases can affect the skeletal system but do not increase the incidence of hip fractures.
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? 1 An obese client with leg trauma 2 A pregnant client with acute asthma 3 A client with diabetes who has cholecystitis 4 A client with pneumonia who is immunocompromised
1 An obese client with leg trauma has two risk factors for the development of pulmonary embolism: obesity and leg trauma. A pregnant client with acute asthma has one risk factor for the development of pulmonary embolism: pregnancy. A client with diabetes who has cholecystitis has one risk factor for the development of pulmonary embolism: diabetes. A client with pneumonia who is immunocompromised has no risk factors for the development of pulmonary embolism.
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? 1 Increase oral fluid intake to 2 to 3 L/day. 2 Maintain bed rest after discharge. 3 Limit fluid intake to 1 L/day. 4 Void at least every hour.
1 Increasing oral fluid intake to 2 to 3 L/day, if not contraindicated, will dilute urine and promote urine flow, thus preventing stasis and complications such as renal calculi. Bed rest and limited fluid intake may lead to urinary stasis and increase risk for the formation of renal calculi. Voiding at least every hour has no effect on urinary stasis and renal calculi.
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. 1 Sudden chest pain 2 Flushing of the face 3 Elevation of temperature 4 Abrupt onset of shortness of breath 5 Pain rating increase from 2 to 8 in the hip
1,4 Sudden chest pain is caused by decreased oxygenation to pulmonary tissues. Because capillary perfusion is blocked by the pulmonary embolus, oxygen saturation drops and the client experiences shortness of breath, dyspnea, and tachypnea. Flushing of the face and fever are not classic signs of pulmonary embolus. The pain associated with pulmonary embolus generally is sudden in onset, severe, and located in the chest, not the hip.
What should the nurse expect the healthcare provider to prescribe if a client exhibits clinical indicators of warfarin overdose? 1 Heparin 2 Vitamin K 3 Iron dextran 4 Protamine sulfate
2 Warfarin depresses prothrombin activity and inhibits formation of several clotting factors by the liver. Its antagonist is vitamin K, which is involved in prothrombin formation. Heparin is an anticoagulant. Iron dextran is an iron supplement, not an antidote for warfarin. Protamine sulfate is the antidote for heparin overdose.Test-Taking Tip: Do not worry if you select the same numbered answer repeatedly, because there usually is no pattern to the answers.
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? 1 Stop the heparin, flush the line, and administer the vancomycin. 2 Use a piggyback setup to administer the vancomycin into the heparin. 3 Start another IV line for the vancomycin and continue the heparin as prescribed. 4 Hold the vancomycin and tell the healthcare provider that the drug is incompatible with heparin.
3 The vancomycin and heparin are incompatible in the same IV and therefore must be administered separately. By instituting a second line for the antibiotic, heparin can continue to infuse. Twice a day both drugs must run concurrently. Also, flushing the line may not eliminate remnants of the heparin, which is incompatible with vancomycin. Using a piggyback setup to administer the vancomycin into the heparin is unsafe because heparin and vancomycin are incompatible and should not be administered via the same intravenous line. The client has two medications prescribed, and it is a nurse's responsibility, not the healthcare provider's, to administer them safely.STUDY TIP: Study goals should set out exactly what you want to accomplish. Do not simply say, "I will study for the exam." Specify how many hours, what day and time, and what material you will cover.
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? 1 Client with itching 2 Client with flushing 3 Client with pruritus 4 Client with wheezing
orrect4 Client with wheezing Wheezing indicates anaphylactic and allergic reactions in the client who is on blood transfusion therapy. Therefore the client with wheezing should be treated first. Itching, flushing, and pruritus indicate a mild allergic reaction. Clients with itching, flushing, and pruritus can be treated after treating the client with wheezing symptoms.
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? 1 Stop the blood transfusion immediately. 2 Report to the primary healthcare provider. 3 Recheck identifying tags and numbers on the client. 4 Maintain a patent intravenous (IV) line with saline solution.
1 An incompatible blood transfusion can result in an acute hemolytic reaction in the client. During acute hemolytic reactions, the nurse should stop a blood transfusion as a priority nursing intervention. After stopping the blood transfusion, the nurse should report it to the primary healthcare provider. The nurse can then recheck the client's identifying tags and numbers and maintain a patent IV line with saline solution.
Ten minutes after the initiation of a blood transfusion, a client reports lumbar pain. What is the next nursing action? 1 Stop the transfusion. 2 Obtain the vital signs. 3 Assess the pain further. 4 Increase the flow of normal saline.
1 This is a sign of an acute hemolytic transfusion reaction, indicating that the recipient's blood is incompatible with the transfused blood; pain is caused by hemolysis, agglutination, and capillary plugging in the kidneys. Obtaining the vital signs and assessing the pain further are unsafe actions; more incompatible blood will be infused, increasing the severity of the transfusion reaction. Increasing the flow of normal saline is unsafe; the transfusion must be stopped first, and then normal saline should be infused to keep the line patent and to maintain blood volume.
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? 1 Evaluation 2 Consultation 3 Coordination of care 4 Outcomes identification
1 When the nurse evaluates progress toward attainment of outcomes, it is referred to as evaluation. When the nurse monitors the client on an hourly basis to check if the client is feeling comfortable after giving a back massage, this is considered evaluation. Consultation is when a nurse provides consultation to influence the identified plan, enhance the abilities of others, and effect change. Coordination of care is when a nurse coordinates care delivery with other team members. Outcomes identification is when a nurse identifies expected outcomes for a plan individualized to the client or the situation.Test-Taking Tip: Read the question carefully before looking at the answers: (1) Determine what the question is really asking; look for key words; (2) Read each answer thoroughly and see if it completely covers the material asked by the question; (3) Narrow the choices by immediately eliminating answers you know are incorrect.
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? 1 Contact the healthcare provider to determine which anticoagulant therapy should be prescribed for this client. 2 Arrange for a supply of heparin for the client to take to the rehab center. 3 Explain to the client that anticoagulant therapy will no longer be needed. 4 Instruct the client to talk about anticoagulant needs with the healthcare provider at the rehabilitation center.
1 Failure to clarify this omission can be life threatening because of the potential for an embolus. Waiting until the client is in the new facility to discuss the administration of an anticoagulant may jeopardize the client's status. Because anticoagulant therapy was not included in the transfer prescriptions, the nurse cannot legally supply the client with medications to take to the rehabilitation center. It is unclear what the anticoagulant needs are for this client; it is unsafe to tell the client that anticoagulants are no longer required. It is the nurse's, not the client's, responsibility to discuss this situation with the healthcare provider.Test-Taking Tip: Read carefully and answer the question asked; pay attention to specific details in the question.
A client is receiving warfarin. Which test result should the nurse use to determine whether the daily dose of this anticoagulant is therapeutic? 1 International normalized ratio (INR) 2 Accelerated partial thromboplastin time (APTT) 3 Bleeding time 4 Sedimentation rate
1 Warfarin initially is prescribed day by day, based on INR blood test results. This test provides a standard system to interpret prothrombin times. APTT is used to evaluate the effects of heparin, which acts on the intrinsic pathway. Bleeding time is the time required for blood to cease flowing from a small wound; it is not used for warfarin dosage calculation. Sedimentation rate is a test used to determine the presence of inflammation or infection; it does not indicate clotting ability.Test-Taking Tip: Do not worry if you select the same numbered answer repeatedly, because there usually is no pattern to the answers. Topics
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. 1 Obtain the client's vital signs. 2 Monitor hemoglobin and hematocrit levels. 3 Allow the blood to reach room temperature. 4 Determine typing and crossmatching of blood. 5 Use a Y-type infusion set to initiate 0.9% normal saline.
1.4.5 Obtaining the client's vital signs provides a baseline and should be done before the transfusion is initiated. Prior to beginning the transfusion, the nurse and another hospital-approved personnel should double-check client identification and blood product identification (blood unit number, blood type and crossmatch data like Rh factor along with expiration date) with another licensed nurse. Using a Y-type infusion set with 0.9% saline on one side of the Y is necessary to prevent an acute immunologic reaction if the donated blood is not compatible with the client's blood. A Y-type infusion set is specific for blood administration. It has a special blood filter, the drop factor is different, and it allows for quick shutoff and the administration of normal saline in the event of a transfusion reaction. The laboratory results for hemoglobin and hematocrit levels were part of the data used to determine the need for blood initially and do not need to be performed again until after the transfusion is completed. Blood must be kept cold until ready for use; if blood is kept at room temperature for 30 minutes before administration, it should be returned to the blood bank; after it is started, blood must be administered within four hours.STUDY TIP: Answer every question. A question without an answer is the same as a wrong answer. Go ahead and guess. You have studied for the test and you know the material well. You are not making a random guess based on no information. You are guessing based on what you have learned and your best assessment of the question.
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? 1 Poached eggs 2 Spinach salad 3 Sweet potatoes 4 Cheese sandwich
2 Dark green, leafy vegetables are high in vitamin K. Influencing the level of vitamin K alters the activity of warfarin because vitamin K acts as a catalyst in the liver for the production of blood-clotting factors and prothrombin. The intake of foods containing vitamin K must be consistent to regulate the warfarin dose so that the INR remains within the therapeutic range. Eggs contain protein and are permitted on the diet. Yellow vegetables contain vitamin A and are permitted on the diet. Dairy products containing protein and bread supplying carbohydrates are permitted on the diet.Test-Taking Tip: Relax during the last hour before an exam. Your brain needs some recovery time to function effectively.
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? 1 Warm skin at the site of injury 2 Escalating pain in the fingers 3 Rapid capillary refill in affected hand 4 Bounding radial pulse in the injured arm
2 Elevated tissue pressure restricts blood flow, causing increasing ischemia and increasing pain; it is the cardinal early symptom of compartment syndrome. The arm will feel cool, not warm, because of a decrease in circulation. Sluggish, not rapid, capillary refill is a sign of compartment syndrome. The pulse will be diminished, not bounding; increasing edema impairs circulation.
The team leader is making client assignments. Which team member should be assigned a client with a tracheostomy, chest tube, and blood transfusion? 1 Charge nurse 2 Registered nurse (RN) 3 Unlicensed assistive personnel (UAP) 4 Licensed practical nurse/licensed vocational nurse (LPN/LVN)
2 The team leader assigns the professional, technical, and ancillary personnel to the type of client care they are prepared to deliver and must be knowledgeable about the legal and organizational limits of each role. The registered nurse (RN) is qualified to meet all of the client's needs. The charge nurse does not receive a client assignment in team nursing. The client assignment is beyond the scope of unlicensed assistive personnel (UAP). The licensed practical nurse/licensed vocational nurse (LPN/LVN) may be qualified to address the client's tracheostomy and chest tube but is not able to support the blood transfusion.Test-Taking Tip: Start by reading each of the answer options carefully. Usually at least one of them will be clearly wrong. Eliminate this one from consideration. Now you have reduced the number of response choices by one and improved the odds. Continue to analyze the options. If you can eliminate one more choice in a four-option question, you have reduced the odds to 50/50. While you are eliminating the wrong choices, recall often occurs. One of the options may serve as a trigger that causes you to remember what a few seconds ago had seemed completely
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? 1 Check the client's blood glucose levels. 2 Obtain informed consent from the client. 3 Assess if the client is allergic to shellfish. 4 Instruct the client to remove his or her dentures.
3 A spiral computed tomography scan may be used to diagnose a pulmonary embolism. Before preparing the client for the test, the nurse should assess if the client is allergic to shellfish since the contrast used in the test is iodine based. The client may be asked to remove his or her dentures while preparing for magnetic resonance imaging. An informed consent may not be needed for the spiral computed tomography; it may be required for endoscopic procedures such as a bronchoscopy. High blood glucose levels may interfere with the positron emission tomography scan; therefore, the nurse should check the blood glucose levels of the client before preparing for this test.Test-Taking Tip: Make certain that the answer you select is reasonable and obtainable under ordinary circumstances and that the action can be carried out in the given situation. Topics
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? 1 Providing oxygen therapy 2 Administering pain medication 3 Encouraging frequent ambulation 4 Recommending an increase in oral fluids
3 Ambulation involves muscle contractions that promote an increase in circulation in the legs. During pregnancy, hypercoagulation is associated with an increase in clotting factors and fibrinogen, which increases the risk for thromboembolism. Oxygen therapy will not prevent thromboembolism. Relieving pain does not prevent thromboembolism, but pain medication may be needed to help the client tolerate ambulation. Increasing fluid intake will not prevent thromboembolism.
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? 1 Anxiety 2 Restlessness 3 Pinpoint red spots on the chest 4 Decreased arterial oxygen level
3 Fat emboli cause capillary fragility; rupture of capillary walls results in pinpoint red spots (petechiae) on the chest and conjunctiva of the eye. Anxiety occurs in both fat embolism and thromboembolism. There often is a feeling of dread or impending doom. Restlessness and confusion from cerebral hypoxia occur in both fat embolism and thromboembolism. The arterial oxygen may be decreased in both fat embolism and thromboembolism.Test-Taking Tip: Read the question carefully before looking at the answers: (1) Determine what the question is really asking; look for key words; (2) Read each answer thoroughly and see if it completely covers the material asked by the question; (3) Narrow the choices by immediately eliminating answers you know are incorrect.
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? 1 The nurse should wait for the court's order to give blood to the client. 2 The nurse should proceed with the transfusion in order to save the client's life. 3 The nurse should inform the primary healthcare provider and not give blood to the client. 4 The nurse should explain to the family member that the client needs this transfusion.
3 The client or the client's family member has the right to refuse treatment and the nurse should value their beliefs and traditions. Therefore, the nurse should inform the primary healthcare provider and not perform the blood transfusion. The nurse should not wait for a court's order or explain or convince the family member to change his or her mind. The nurse should not proceed with the treatment because this may cause severe legal implications.
A client demonstrates signs and symptoms of a transfusion reaction. The nurse immediately stops the infusion; what should the nurse's next action be? 1 Obtain blood pressure in both arms. 2 Send a urine specimen to the laboratory. 3 Hang a bag of normal saline with new tubing. 4 Monitor the intake and output every 15 minutes.
3 The tubing must be replaced to avoid infusing the blood left in the original tubing; the normal saline infusion will maintain an open line for any further intravenous (IV) treatment. All vital signs should be taken eventually; blood pressure may be taken on either arm, not necessarily both. A urine sample is collected after the blood transfusion is stopped, the tubing replaced, and a bag of normal saline hung. The specimen will be analyzed to determine kidney function. Although the intake, and especially the output, should be monitored to assess kidney function, this is not the priority.
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? 1 This permits the administration of smaller doses of each medication. 2 Giving both drugs allows clot dissolution while preventing new clot formation. 3 Heparin provides anticoagulant effects until warfarin reaches therapeutic levels. 4 Administration of heparin with warfarin provides immediate and maximum protection against clot formation.
3 Warfarin is administered orally for 2 to 3 days to achieve the desired effect on the international normalized ratio (INR) level before heparin is discontinued. These drugs do not dissolve clots already present. Because each drug affects a different part of the coagulation mechanism, dosages must be adjusted separately. That this approach immediately provides maximum protection against clot formation does not account for the reason for the administration of both drugs; warfarin will not exert an immediate therapeutic effect.Test-Taking Tip: Multiple-choice questions can be challenging, because students think that they will recognize the right answer when they see it or that the right answer will somehow stand out from the other choices. This is a dangerous misconception. The more carefully the question is constructed, the more each of the choices will seem like the correct response.
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? 1 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. 2 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. 3 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. 4 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.
3 The blood product must be checked by two registered nurses, and client identification must be verified. A registered nurse hangs the product and should stay in the room for at least the initial 15 minutes, during which time a reaction is most likely; if a reaction occurs the transfusion can be stopped. Assigning an LPN to administer blood is not within the scope of practice in some states (Canada: provinces), and the product should be checked by two registered nurses. Waiting to check in 15 minutes is too long if the client has a hemolytic reaction, so the nurse should stay with the client and obtain vital signs. Monitoring every hour, especially during the first hour, is too long of a delay. Packed cells usually are infused in 2 hours and cannot be hung longer than 4 hours.
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. 1 "I should sleep in a prone position." 2 "I should sleep with my legs out straight." 3 "I should keep a check on my body weight." 4 "I should stop exercising if the pain gets severe." 5 "I should exercise by leaning forward without bending the knees."
3,4 Increased body weight would put extra weight on the legs and back and thereby aggravate the pain; therefore keeping a check on body weight is beneficial. Pain during exercise suggests an injury; therefore exercise should be stopped if pain starts or becomes severe. Sleeping in a side-lying position with hips and knees bent would be beneficial. Sleeping with the legs out straight pulls the back muscles; this can cause pain. The client should not be allowed to exercise or walk by leaning forward without bending the knees because this may put pressure on the back. Topics
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? 1 Call the primary healthcare provider to obtain a prescription for an antihistamine. 2 Flush packed red blood cells with 5% dextrose and 0.45% normal saline. 3 Slow down the rate of the infusion. 4 Stop the transfusion immediately.
4 Stop the transfusion immediately. The client is experiencing an allergic reaction to the transfusion. The nurse should stop the transfusion immediately. The health care provider then should be notified. Flushing red blood cells with dextrose and normal saline will cause hemolysis and will not be effective in stopping the reaction. Slowing down the rate will make the situation worse.
A client is receiving warfarin for a pulmonary embolism. Which drug is often contraindicated when taking warfarin? 1 Atenolol 2 Ferrous sulfate 3 Chlorpromazine 4 Acetylsalicylic acid
Correct4 Acetylsalicylic acid Acetylsalicylic acid can cause decreased platelet aggregation, increasing the risk for undesired bleeding that may occur with administration of anticoagulants. It should not be administered unless specifically prescribed, usually by a cardiologist or other specialist, to manage serious risks of thrombosis. Ferrous sulfate does not affect warfarin; it is used for red blood cell synthesis. Atenolol is a beta-blocker that reduces blood pressure; it does not affect bleeding. Chlorpromazine is a neuroleptic; it does not affect bleeding.
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? 1 Institute the prescribed blood transfusion because the client's survival depends on volume replacement. 2 Clarify the reason why the transfusion is necessary and explain the implications if there is no transfusion. 3 Phone the primary healthcare provider for an administrative prescription to give the transfusion under these circumstances. 4 Give the spouse a treatment refusal form to sign and notify the primary healthcare provider that a court order now can be sought.
Correct4 Give the spouse a treatment refusal form to sign and notify the primary healthcare provider that a court order now can be sought. The client is unconscious. Although the spouse can give consent, there is no legal power to refuse a treatment for the client unless previously authorized to do so by a power of attorney or a healthcare proxy; the court can make a decision for the client. Explanations will not be effective at this time and will not meet the client's needs. Instituting the prescribed blood transfusion and phoning the primary healthcare provider for an administrative prescription are without legal basis, and the nurse may be held liable.
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? 1 Assist with meal planning to decrease the intake of foods high in vitamin K 2 Obtain a blood specimen to have a partial thromboplastin time performed 3 Contact the healthcare provider to request the day's dosage of warfarin sodium 4 Maintain the client on bed rest until the healthcare provider reviews the laboratory results
Correct4 Maintain the client on bed rest until the healthcare provider reviews the laboratory results An INR of 4.6 is higher than the desired therapeutic level of 2 to 3.5. It is prudent to maintain bed rest to prevent injury until the healthcare provider evaluates the client's INR result. Decreasing the intake of food high in vitamin K is contraindicated; vitamin K is the antidote for warfarin sodium. The client should have a consistent, limited intake of food high in vitamin K. A partial thromboplastin time is performed to evaluate a client's response to the administration of heparin. Another dose of warfarin sodium may be contraindicated in light of the client's increased INR result.
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? 1 Pain at the surgical site 2 Small amount of serosanguinous drainage 3 Decreased range of motion to the left extremity 4 Sudden shortness of breath
Correct4 Sudden shortness of breath The sudden onset of shortness of breath is indicative of a fat embolism, which can occur after a fracture of the long bones. This is a serious complication that could result in death. It is normal to have pain at the surgical site, a small amount of serosanguinous drainage, and decreased range of motion to the affected extremity.
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? 1 Oxygen therapy 2 Cardiac monitoring 3 Nutrition supplements 4 Venous thromboembolism (VTE) prevention
Correct4 Venous thromboembolism (VTE) prevention VTE is common after hip surgery and must be prevented; this is a component of core measures. Nutritional supplements, cardiac monitoring, and oxygen therapy may be necessary in some clients with hip fractures, but not in all.Test-Taking Tip: Answer the question that is asked. Read the situation and the question carefully, looking for key words or phrases. Do not read anything into the question or apply what you did in a similar situation during one of your clinical experiences. Think of each question as being an ideal, yet realistic, situation.
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? 1 Vitamin K promotes platelet aggregation. 2 Vitamin K promotes ionization of blood calcium. 3 Vitamin K promotes fibrinogen formation by the liver. 4 Vitamin K promotes prothrombin formation by the liver.
Correct4 Vitamin K promotes prothrombin formation by the liver. Vitamin K promotes the liver's synthesis of prothrombin, an important blood clotting factor, and will reverse the effects of warfarin. Platelet aggregation and fibrinogen formation by the liver are not promoted by vitamin K. Vitamin K does not affect calcium ionization.
