Unit 6- ch 32 with rationales
Which type of leukocyte contains histamine and is an important part of hypersensitivity reactions? Basophils B lymphocyte Plasma cell Neutrophil
Basophils Explanation: Basophils contain histamine and are an integral part of hypersensitivity reactions. B lymphocytes are responsible for humoral immunity. A plasma cell secretes immunoglobulins. The neutrophil functions in preventing or limiting bacterial infection via phagocytosis
In normal blood, monocytes account for approximately what percentage of the total leukocyte count? 5% 10% 15% 20%
5% Explanation: Monocytes account for approximately 5% of the total leukocyte count. The other percentages are incorrect.
A client is diagnosed with extreme thrombocytosis. The nurse knows this condition is a result of which elevated blood cell count? Neutrophils Platelets Erythocytes Eosinophils
Platelets Explanation: Extreme thrombocytosis is an elevation in platelets.
A patient will need a blood transfusion for the replacement of blood loss from the gastrointestinal tract. The patient states, "That stuff isn't safe!" What is the best response from the nurse? "I agree that you should be concerned with the safety of the blood, but it is important that you have this transfusion." "The blood is carefully screened, so there is no possibility of you contracting any illness or disease from the blood." "I understand your concern. The blood is carefully screened but is not completely risk free." "You will have to decide if refusing the blood transfusion is worth the risk to your health."
"I understand your concern. The blood is carefully screened but is not completely risk free." Explanation: Despite advances in donor screening and blood testing, certain diseases can still be transmitted by transfusion of blood components (Chart 32-4).
A preoperative client is discussing blood donation with the nurse. Which statement by the client indicates to the nurse the need for further teaching? "My family will donate blood, because it's safer." "I should expect blood withdrawal to take about 15 minutes." "Donated blood is tested for blood type and infections." "I could donate my own blood in case I need a transfusion."
"My family will donate blood, because it's safer." Explanation: Directed donations from friends and family members are not any safer than those provided by random donors. Withdrawal of 450 mL of blood usually takes about 15 minutes. Specimens from donated blood are tested to detect infections and to identify the specific blood type. Autologous blood donation is useful for many elective surgeries where the potential need for transfusion is high.
A nurse cares for a client with megaloblastic anemia who had a total gastrectomy three years ago. What statement will the nurse include in the client's teaching regarding the condition? "The condition is likely caused by a folate deficiency." "The condition causes abnormally small red blood cells." "The condition is likely caused by a vitamin B12 deficiency." "The condition causes abnormally rigid red blood cells."
"The condition is likely caused by a vitamin B12 deficiency." Explanation: Vitamin B12 combines with intrinsic factor produced in the stomach. The vitamin B12 -intrinsic factor complex is absorbed in the distal ileum. Clients who have had a partial or total gastrectomy may have limited amounts of intrinsic factor, and the absorption of vitamin B12 may be diminished. Megaloblastic anemia may be caused by a folate deficiency; however, the client's history of gastrectomy indicates the likely cause is a vitamin B12 deficiency. Megaloblastic anemia causes large erythrocytes (RBCs), not small or rigid.
Which client is not a candidate to be a blood donor according to the American Red Cross? 86-year-old male with blood pressure 110/70 mm Hg 50-year-old female with pulse 95 beats/minute 26-year-old female with hemoglobin 11.0 g/dL 18-year-old male weighing 52 kg
26-year-old female with hemoglobin 11.0 g/dL Explanation: Clients must meet a number of criteria to be eligible as blood donors, including the following: body weight at least 50 kg; pulse rate regular between 50 and 100 bpm; systolic BP 90-100 to 180 mm Hg and diastolic 50 to 100 mm Hg; hemoglobin level at least 12.5 g/dL. There is no upper age limit to donation. Reference
A nurse is preparing a dose of furosemide for an older adult with heart failure. The health care provider orders furosemide 1 mg/kg to be given intravenously. The client weighs 50 kg. The concentration of the drug is 40 mg/4mL (10 mg/mL). How many milliliters would the nurse administer? Record your answer using a whole number
5 Explanation: 1 mg/kg X 50 kg = 50 mg then divide by 10 mg/mL = 5 mL
The nurse is obtaining the health history of a client suspected of having a hematological condition. The nurse notes the client has a history of alcohol abuse. Which clinical presentation is related to alcohol consumption? Myelodysplastic syndrome Neutropenia Anemia Thrombocytopenia
Anemia Explanation: Individuals with a history of alcohol consumption may have anemia due to nutritional deficiencies. Myelodysplastic syndrome, neutropenia, and thrombocytopenia are not common findings in clients who consume or abuse alcohol.
The physician performs a bone marrow biopsy from the posterior iliac crest on a client with pancytopenia. What intervention should the nurse perform after the procedure? Pack the wound with half-inch sterile gauze Administer a topical analgesic to control pain at the site Apply pressure over the site for 5-7 minutes Elevate the head of the bed to 45 degrees
Apply pressure over the site for 5-7 minutes Explanation: Hazards of either bone marrow aspiration or biopsy include bleeding and infection. The risk of bleeding is somewhat increased if the client's platelet count is low or if the client has been taking a medication (e.g., aspirin) that alters platelet function. After the marrow sample is obtained, pressure is applied to the site for several minutes. The site is then covered with a sterile dressing.
A client with myelodysplastic syndromes (MDS) receives routine blood transfusions. Which treatment will the nurse expect to be prescribed to prevent the development of iron overload? Romiplostim Eltrombopag Epoetin alpha Chelation therapy
Chelation therapy Explanation: Iron overload is a problem for clients with MDS, especially in those who routinely receive PRBC transfusions (transfusion dependent). Surplus iron is deposited in cells within the reticuloendothelial system, and later in parenchymal organs. To prevent or reverse the complications of iron overload, iron chelation therapy is commonly implemented. Romiplostim and eltrombopag are used to stimulate the proliferation and differentiation of megakaryocytes into platelets within the bone marrow. Epoetin alpha may be used to improve anemia and decrease the need for blood transfusions.
A nursing instructor in a BSN program is preparing for a lecture on disorders of the hematopoietic system. Included in the lecture are conditions caused by reduced levels or absence of blood-clotting proteins. Which of the following is the instructor most likely referring to? Coagulopathy Aplastic anemia Pancytopenia Sickle cell disease
Coagulopathy Explanation: The term coagulopathy refers to conditions in which a component that is necessary to control bleeding is missing or inadequate.
A client seeks medical attention for the spontaneous development of bruises over the arms and legs. Which laboratory tests will the nurse anticipate being prescribed for this client? Select all that apply. Bilirubin Blood urea nitrogen Complete blood count International normalized ratio Activated partial prothrombin time
Complete blood count International normalized ratio Activated partial prothrombin time For most hematologic conditions, continued monitoring via specific blood tests is required because it is very important to assess for changes in test results over time. Tests commonly used include the complete blood count, which identifies the total number of blood cells, hemoglobin, hematocrit, and RBC indices. The international normalized ratio and activated partial thromboplastin time are used to evaluate clotting ability. Bilirubin is used to measure liver function. BUN is a renal function test.
A nurse is transfusing whole blood to a client with impaired renal function. During the transfusion, the client tells the nurse, "I feel very short of breath all of a sudden." What is the nurse's primary action? Assess the client's vital signs. Stop the infusion. Call the health care provider. Slow the infusion.
Correct response: Stop the infusion. Explanation: A client with impaired renal function is at increased risk for transfusion-associated circulatory overload (TACO). Signs of circulatory overload include dyspnea, orthopnea, tachycardia, an increase in blood pressure, and sudden anxiety. If the symptoms are mild, the nurse may be able to slow the infusion and administer diuretics; however, sudden shortness of breath should clue the nurse to immediately stop the infusion and sit the client upright with feet dangling. Next, the nurse will notify the health care provider after normal saline is infused into the site. Only after stopping the infusion will the nurse obtain the client's vital signs.
The nurse expects which assessment finding when caring for a client with a decreased hemoglobin level? Bright red venous blood. Elevated temperature. Decreased oxygen level. Increased bruising.
Decreased oxygen level. Explanation: Hemoglobin carries oxygen; a decreased hemoglobin level results in decreased oxygen. An elevated temperature is a sign of infection and can result from decreased white blood cells. Arterial blood is more oxygen saturated and brighter red in color than venous blood. Increased bruising results from a decreased platelet level, not decreased hemoglobin.
A client donated two units of blood to be used for transfusion during spinal fusion surgery. The client received one unit of autologous blood during the procedure but the second unit is not needed during the procedure. The nurse knows which action will come after the procedure is completed? Discard the additional unit. Use the unit for platelets and albumin. Provide it to the client before discharge. Release the additional unit for use to the general population.
Discard the additional unit. Explanation: In autologous donation, the client's own blood is collected for a future transfusion, particularly for an elective surgery where the potential for transfusion is high, such as an orthopedic procedure. If the blood is not used, it is discarded. The blood is not used for its components. The client will not be given the unit of blood unless it is required. The additional unit will not be released to the general population for use.
A client receiving a unit of packed red blood cells (PRBCs) has been prescribed morphine 1 mg intravenously now for pain. What is the best method for the nurse to administer the morphine? Add the morphine to the blood to be slowly administered. Inject the morphine into a distal port on the blood tubing. Administer the morphine into the closest tubing port to the client for fast delivery. Disconnect the blood tubing, flush with normal saline, and administer morphine.
Disconnect the blood tubing, flush with normal saline, and administer morphine. Explanation: Never add medications to blood or blood products. The transfusion must be temporarily stopped in order to administer the morphine.
A client receiving a blood transfusion reports shortness of breath, appears anxious, and has a pulse of 125 beats/minute. What is the best action for the nurse to take after stopping the transfusion and awaiting further instruction from the health care provider? Place the client in a recumbent position with legs elevated. Remove the intravenous line. Ensure there is an oxygen delivery device at the bedside. Administer prescribed PRN anti-anxiety agent.
Ensure there is an oxygen delivery device at the bedside. Explanation: The client is exhibiting signs of circulatory overload. After stopping the transfusion and notifying the healthcare provider, the nurse should place the client in a more upright position with the legs dependent to decrease workload on the heart. The IV line is kept patent in case emergency medications are needed. Oxygen and morphine may be needed to treat severe dyspnea. Administering an anti-anxiety agent is not a priority action over ensuring oxygen is available.
A client receiving a blood transfusion reports shortness of breath, appears anxious, and has a pulse of 125 beats/minute. What is the best action for the nurse to take after stopping the transfusion and awaiting further instruction from the health care provider? Place the client in a recumbent position with legs elevated. Remove the intravenous line. Ensure there is an oxygen delivery device at the bedside. Administer prescribed PRN anti-anxiety agent.
Ensure there is an oxygen delivery device at the bedside. Explanation: The client is exhibiting signs of circulatory overload. After stopping the transfusion and notifying the healthcare provider, the nurse should place the client in a more upright position with the legs dependent to decrease workload on the heart. The IV line is kept patent in case emergency medications are needed. Oxygen and morphine may be needed to treat severe dyspnea. Administering an anti-anxiety agent is not a priority action over ensuring oxygen is available.
A client with chronic kidney disease has chronic anemia. What pharmacologic alternative to blood transfusion may be used for this client? GM-CSF Erythropoietin Eltrombopag Thrombopoietin
Erythropoietin Explanation: Erythropoietin (epoetin alfa [Epogen, Procrit]) is an effective alternative treatment for clients with chronic anemia secondary to diminished levels of erythropoietin, as in chronic renal disease. This medication stimulates erythropoiesis.
A nurse is completing a detailed health history and assessment in the electronic medical record (EMR) for a client with a disorder of the hematopoietic system. Which symptom is the most commonly reported in association with hematologic diseases? Extreme fatigue Severe headaches Dyspnea Blurred vision
Extreme fatigue Explanation: When assessing a client with a disorder of the hematopoietic system, it is essential to assess for the most common symptom in hematologic diseases, which is extreme fatigue.
Which term describes the percentage of blood volume that consists of erythrocytes? Hematocrit Differentiation Erythrocyte sedimentation rate (ESR) Hemoglobin
Hematocrit Explanation: Hematocrit is the percentage of blood volume consisting of erythrocytes. Differentiation is the development of functions and characteristics that differ from those of the parent stem cell. ESR is a laboratory test that measures the rate of settling of red blood cells (RBCs); an elevated rate is indicative of inflammation. Hemoglobin is the iron-containing protein of RBCs.
A client is scheduled for surgery to remove an abdominal mass. The nurse knows that which reason hemodilution would be contraindicated as a method to provide blood to the client during the surgery? History of renal disease Previous thyroidectomy Treatment for osteoarthritis Takes medications for seasonal allergies
History of renal disease Explanation: Hemodilution is the removal of 1 to 2 units of blood after induction of anesthesia and replaced with a colloid or crystalloid solution. The blood is then reinfused after the surgery. The purpose of this approach is to reduce the amount of erythrocytes lost during the surgery because the intravenous fluids dilute the concentration of red blood cells and lowers the hematocrit. Hemodilution has been linked to tissue ischemia in the kidneys and would be contraindicated in the client with a history of renal disease. Hemodilution would not be contraindicated for a previous thyroidectomy, treatment for osteoarthritis, or medication used to treat seasonal allergies. Reference
Splenic sequestration is diagnosed in a client admitted with splenomegaly. What is the priority of care for this client? Infection Hypovolemia Hyperthermia Hypertension
Hypovolemia Explanation: If the spleen is enlarged, a greater proportion of red cells and platelets can be sequestered. With less red blood cells in circulation, the client can become -> hypovolemic resulting in shock. Decreased white blood cells in circulation, not red blood cells, increases the chance of infection. Decreased circulatory volume results in hypotension, not hypertension. Hyperthermia is not a result of decreased red blood cells in circulation.
A client scheduled for hip replacement surgery did not have enough time to have autologous donations completed. The nurse knows that which action will be performed if the client requires blood during the surgery? Hemodilution Plasmapheresis Direct donation Intraoperative blood salvage
Intraoperative blood salvage Explanation: Intraoperative blood salvage is a method for clients who are unable to donate blood before surgery and are having an orthopedic surgery. During the procedure, blood lost into a sterile cavity is suctioned into a cell-saver machine where is it is washed, filtered, and then infused into the client. Hemodilution is a transfusion method where 1 to 2 units of blood are removed after the induction of anesthesia and then reinfused after surgery. This approach has been linked to tissue ischemia of the kidneys. Plasmapheresis is the removal of plasma proteins and used for hyperviscosity syndromes and to treat some renal and neurologic diseases. It would not be applicable after joint replacement surgery. Direct donation is not routinely accepted by blood centers and would not be an action if the client requires blood during the surgery.
The nurse is caring for a client who has a unit of whole blood removed every 6 weeks as treatment for polycythemia vera. Which laboratory test will the nurse monitor to determine if the procedure is adversely affecting the client? Iron Calcium Potassium White blood cell count
Iron Explanation: Therapeutic phlebotomy is the removal of a certain amount of blood under controlled conditions. A client with an elevated hematocrit from polycythemia vera can usually be managed by periodically removing 1 unit (about 500 mL) of whole blood. Over time, this process can produce iron deficiency, Therapeutic phlebotomy does not affect the calcium or potassium levels or the white blood cell count.
A nurse cares for a client with myelodysplastic syndrome who requires frequent PRBC transfusions. What blood component does the nurse recognize as being most harmful if accumulated in the tissues due to chronic blood transfusions? Iron Calcium Hemoglobin Potassium
Iron Explanation: Iron overload is a complication unique to people who have had long-term PRBC transfusion. Over time, the excess iron deposits in body tissues can cause organ damage, particularly in the liver, heart, testes, and pancreas.
The client's CBC with differential reveals small-shaped hemoglobin molecules. The nurse expects to administer which medication to this client? Iron Vitamin B12 Folate Fresh frozen plasma
Iron Explanation: With iron deficiency, the erythrocytes produced by the marrow are small and low in hemoglobin. Vitamin B12 and folate deficiencies are characterized by the production of abnormally large erythrocytes. Fresh frozen plasma are infused due to a low platelet level, not light-colored hemoglobin.
The nurse is preparing a patient for a bone marrow aspiration and biopsy from the site of the posterior superior iliac crest. What position will the nurse place the patient in? Lateral position with one leg flexed Lithotomy position Supine with head of the bed elevated 30 degrees Jackknife position
Lateral position with one leg flexed Explanation: Bone marrow aspiration procedure. The posterior superior iliac crest is the preferred site for bone marrow aspiration and biopsy because no vital organs or vessels are nearby. The patient is placed either in the lateral position with one leg flexed or in the prone position.
The nurse is preparing a patient for a bone marrow aspiration and biopsy from the site of the posterior superior iliac crest. What position will the nurse place the patient in? Lateral position with one leg flexed Lithotomy position Supine with head of the bed elevated 30 degrees Jackknife position
Lateral position with one leg flexed Explanation: Bone marrow aspiration procedure. The posterior superior iliac crest is the preferred site for bone marrow aspiration and biopsy because no vital organs or vessels are nearby. The patient is placed either in the lateral position with one leg flexed or in the prone position.
Albumin is important for the maintenance of fluid balance within the vascular system. Albumin is produced by which of the following? Liver Pancreas Kidney Large intestine
Liver Explanation: Albumin is produced by the liver. Albumin is not produced in the pancreas, kidney, or large intestine. Reference:
Which term refers to a form of white blood cell involved in immune response? Granulocyte Lymphocyte Spherocyte Thrombocyte
Lymphocyte Explanation: Both B and T lymphocytes respond to exposure to antigens. Granulocytes include basophils, neutrophils, and eosinophils. A spherocyte is a red blood cell without central pallor, seen with hemolysis. A thrombocyte is a platelet.
The body responds to infection by increasing the production of white blood cells (WBCs). The nurse should evaluate the differential count for what type of WBCs, which are the first WBCs to respond to an inflammatory event? Basophils Neutrophils Eosinophils Monocytes
Neutrophils Explanation: Neutrophils, the most abundant type of white blood cell, are the first of the WBCs to respond to infection or inflammation. The normal value is 3,000 to 7,000/cmm (males) and 1,800 to 7,700/cmm (females).
Which is the major function of neutrophils? Rejection of foreign tissue Phagocytosis Destruction of tumor cells Production of immunoglobulins
Phagocytosis Explanation: Once a neutrophil is released from the marrow into the circulation, it stays there for only about 6 hours before it migrates into the body tissues to perform its function of phagocytosis (ingestion and digestion of bacteria and particles). Neutrophils die there within 1 to 2 days. T lymphocytes are responsible for rejection of foreign tissue and destruction of tumor cells. Plasma cells produce antibodies called immunoglobulins.
Under normal conditions, the adult bone marrow produces approximately 70 billion neutrophils. What is the major function of neutrophils? Phagocytosis Rejection of foreign tissue Destruction of tumor cells Production of antibodies called immunoglobulin (Ig)
Phagocytosis Explanation: The major function of neutrophils is phagocytosis. T lymphocytes are responsible for rejection of foreign tissue and destruction of tumor cells. Plasma cells produce antibodies call immunoglobulin.
The client is planned to have a splenectomy. The nurse should prepare which medication to administer to this client? Aspirin Immunoglobulin G (IgG) Pneumococcal vaccine Factor VIII
Pneumococcal vaccine Explanation: Without a spleen, the client's risk of infection is greatly increased. The pneumococcal vaccine should be administered, preferable before splenectomy. Aspirin should not be administered due to the increased risk of bleeding. IgG is administered to client with increased chance of bacterial infections but is not routinely given to client undergoing splenectomy, as is the pneumococcal vaccine. Factor VII is given to treat bleeding disorders.
A nurse cares for several mothers and babies in the postpartum unit. Which mother does the nurse recognize as being most at risk for a febrile nonhemolytic reaction? Rh-negative mother; Rh-negative child Rh-positive mother; Rh-negative child Rh-negative mother; Rh-positive child Rh-positive mother; Rh-positive child
Rh-negative mother; Rh-positive child Explanation: A mother who is Rh negative and gives birth to an Rh positive child is at greatest risk for a febrile nonhemolytic reaction because exposure to an Rh-positive fetus raises antibody levels in the Rh negative mother. An Rh-negative mother can carry an Rh-negative child without being at greatest risk for a febrile nonhemolytic reaction; however, these mothers are often treated prophylactically. An Rh-positive mother may carry either an Rh-positive or Rh-negative child without increased risk.
Which type of lymphocyte is responsible for cellular immunity? B lymphocyte Plasma cell T lymphocyte Basophil
T lymphocyte Explanation: T lymphocytes are responsible for delayed allergic reactions, rejection of foreign tissue (e.g., transplanted organs), and destruction of tumor cells. This process is known as cellular immunity. B lymphocytes are responsible for humoral immunity. A plasma cell secretes immunoglobulin. A basophil contains histamine and is an integral part of hypersensitivity reactions.
A nurse, caring for a client with human immunodeficiency virus (HIV), reviews the client's differential WBC count. What type of WBC will the nurse check the level of? Monocytes B lymphocytes Leukocytes T lymphocytes
T lymphocytes Explanation: Lymphocytes (T cells, B cells, and natural killer cells) are WBCs that are the major components of the body's immune response. T cells are primarily responsible for cell-mediated immunity, whereas B cells are involved in antibody production
A nurse is caring for a client with a diagnosis of lymphocytopenia. Which assessment finding will the nurse consider most concerning when caring for this client? Prothrombin time 12 seconds INR 0.9 Temperature of 37.7 degrees Celsius Blood pressure 132/92
Temperature of 37.7 degrees Celsius Explanation: Lymphocytopenia is a decrease in the number of lymphocytes. Lymphocytes help to fight foreign invaders, such as infectious organisms. A temperature of 37.7 degree Celsius is a Fahrenheit temperature of 99.9. A low-grade fewer may be indicative of an infection. The other answer choices do not suggest infection and are not the priority concern.
A client is returning home after having a bone marrow aspiration and biopsy. Which statement indicates that teaching by the nurse has been effective? "I can resume my normal activities." "The area might ache for 1 to 2 days." "I should take aspirin if I have any pain." "I can go to the gym to lift weights later."
The area might ache for 1 to 2 days." Explanation: Potential complications of either bone marrow aspiration or biopsy include bleeding and infection. After the marrow sample is obtained, pressure is applied to the site for several minutes. The site is then covered with a sterile dressing. Most clients have no discomfort after a bone marrow aspiration, but the site of a biopsy may ache for 1 or 2 days. The client should be instructed to perform no rigorous activity for 1 to 2 days. Aspirin-containing analgesics should be avoided immediately after the procedure as this might cause or aggravate bleeding. Rigorous exercise should be avoided for 1 to 2 days.
The nurse is administering a blood transfusion to a client over 4 hours. After 2 hours, the client reports chills and has a fever of 101°F, an increase from a previous temperature of 99.2°F. What does the nurse recognize is occurring with this client? The client is having an allergic reaction to the blood. The client is experiencing vascular collapse. The client is having decrease in tissue perfusion from a shock state. The client is having a febrile nonhemolytic reaction.
The client is having a febrile nonhemolytic reaction. Explanation: The signs and symptoms of a febrile nonhemolytic transfusion reaction are chills (minimal to severe) followed by fever (more than 1°C elevation). The fever typically begins within 2 hours after the transfusion is begun. Although the reaction is not life threatening, the fever, and particularly the chills and muscle stiffness, can be frightening to the client
The nurse is caring for a client with hypoxia. What does the nurse understand is true regarding the client's oxygen level and the production of red blood cells? The kidneys sense low oxygen levels in the blood and stimulate erythropoietin, stimulating the marrow to produce more red blood cells. The bone marrow is stimulated by low oxygen levels in the blood and stimulates erythropoietin, maturing the red blood cells. The brain senses low oxygen levels in the blood and stimulates hemoglobin, which binds to more red blood cells. The kidneys sense low oxygen levels in the blood and stimulate hemoglobin, stimulating the marrow to produce more red blood cells.
The kidneys sense low oxygen levels in the blood and stimulate erythropoietin, stimulating the marrow to produce more red blood cells. Explanation: If the kidney detects low levels of oxygen, as occurs when fewer red cells are available to bind oxygen (as with anemia), erythropoietin levels increase, stimulating the marrow to produce more erythrocytes (red blood cells).
While caring for a client, the nurse notes petechiae on the client's trunk and lower extremities. What precaution will the nurse take when caring for this client? Use an electric razor when assisting client with shaving. Elevate the client's head of the bed. Where a mask when entering the client's room. Apply supplemental oxygen to maintain the client's oxygenation.
Use an electric razor when assisting client with shaving. Explanation: Petechiae are associated with severe thrombocytopenia, placing the client at risk for bleeding. The nurse should use an electric razor when assisting the client with shaving. Elevating the head of the bed and applying supplemental oxygen would be appropriate for a client with decreased oxygenation. Wearing a mask when entering the client's room would be appropriate for a client with neutropenia, not thrombocytopenia.
While caring for a client, the nurse notes petechiae on the client's trunk and lower extremities. What precaution will the nurse take when caring for this client? Use an electric razor when assisting client with shaving. Elevate the client's head of the bed. Where a mask when entering the client's room. Apply supplemental oxygen to maintain the client's oxygenation.
Use an electric razor when assisting client with shaving. Explanation: Petechiae are associated with severe thrombocytopenia, placing the client at risk for bleeding. The nurse should use an electric razor when assisting the client with shaving. Elevating the head of the bed and applying supplemental oxygen would be appropriate for a client with decreased oxygenation. Wearing a mask when entering the client's room would be appropriate for a client with neutropenia, not thrombocytopenia.
The client is to receive a unit of packed red blood cells. What is the nurse's first action? Check the label on the unit of blood with another registered nurse. Ensure that the intravenous site has a 20-gauge or larger needle. Observe for gas bubbles in the unit of packed red blood cells. Verify that the client has signed a written consent form.
Verify that the client has signed a written consent form. Explanation: All the options are interventions the nurse will do to ensure the blood transfusion is safe. The question asks about the first action of the nurse. The first action would be verifying that the client has signed a written consent form. Then, the nurse would ensure the intravenous site has a 20-gauge or larger needle. The nurse would proceed to obtain the unit of blood, check the blood with another registered nurse, and observe for gas bubbles in the unit of blood.
A client with severe anemia is admitted to the hospital. Because of religious beliefs, the client is refusing blood transfusions. The nurse anticipates pharmacologic therapy with which drug to stimulate the production of red blood cells? Filgrastim Sargramostim Epoetin alfa Eltrombopag
Epoetin alfa Explanation: Erythropoietin (epoetin alfa) is an effective alternative treatment for clients with chronic anemia secondary to diminished levels of erythropoietin. This medication stimulates erythropoiesis. Filgratism ( Neupogen) and Sargramostim stimulate granulocytosis( increasing WBC count) , Eltrombopag (Promacta) is used to treat aplastic anemia and thrombocytopenia.
A nursing instructor is reviewing the role and function of stem cells in the bone marrow with a group of nursing students. After providing the explanation, the instructor asks the students to use their knowledge of anatomy and physiology to determine an alternate way in which adults with diseases that destroy marrow can resume production of blood cells. Which explanation by the students is correct? Fat found in yellow bone marrow can be replaced by active marrow when more blood cell production is required. The remaining stem cells have the ability to continue with the process of self-replication, creating an endless supply. The liver and spleen can resume production of blood cells through extramedullary hematopoiesis. The three cell types—erythrocytes, leukocytes, and platelets—can resume production of stem cells.
The liver and spleen can resume production of blood cells through extramedullary hematopoiesis. Explanation: In adults with disease that destroy marrow or cause fibrosis or scarring, the liver and spleen can also resume production of blood cells through a process known as extramedullary hematopoiesis.
A patient who has long-term packed RBC (PRBC) transfusions has developed symptoms of iron toxicity that affect liver function. What immediate treatment should the nurse anticipate preparing the patient for that can help prevent organ damage? Iron chelation therapy Oxygen therapy Therapeutic phlebotomy Anticoagulation therapy
Iron chelation therapy Explanation: Iron overload is a complication unique to people who have had long-term PRBC transfusions. One unit of PRBCs contains 250 mg of iron. Patients with chronic transfusion requirements can quickly acquire more iron than they can use, leading to iron overload. Over time, the excess iron deposits in body tissues and can cause organ damage, particularly in the liver, heart, testes, and pancreas. Promptly initiating a program of iron chelation therapy can prevent end-organ damage from iron toxicity. Reference:
What food should the nurse recommend for a client diagnosed with vitamin B12 deficiency? Whole-grain bread Citrus fruit Green vegetables Lean meat
Lean meat Explanation: Vitamin B12 is only found in foods of animal origin. Therefore, whole-grain bread, green vegetables, and citrus fruit do not contain this vitamin.
The nurse is caring for a client with hypoxia. What does the nurse understand is true regarding the client's oxygen level and the production of red blood cells? The kidneys sense low oxygen levels in the blood and produce erythropoietin, stimulating the bone marrow to produce more red blood cells. The bone marrow is stimulated by low oxygen levels in the blood to produce erythropoietin, maturing the red blood cells. The brain senses low oxygen levels in the blood and produces hemoglobin, which binds to more red blood cells. The kidneys sense low oxygen levels in the blood and produce hemoglobin, stimulating the marrow to produce more red blood cells.
The kidneys sense low oxygen levels in the blood and produce erythropoietin, stimulating the bone marrow to produce more red blood cells. Explanation: If normally functioning kidneys detect low levels of blood oxygen, they produce more of the hormone erythropoietin (EPO). As EPO levels increase, the bone marrow responds by producing more erythrocytes (red blood cells). EPO is not made by the bone marrow. Hemoglobin, an iron-rich protein that allows erythrocytes to transport oxygen, is synthesized in the erythrocytes as they mature.
