Hematology/Immunology Review Part 2
The nurse cares for the client diagnosed with ITP. Which admission lab result does the nurse report immediately?
Platelet count 19,000 mm^3
The nurse teaches a pregnant client about taking carbonyl iron. It is most important for the nurse to include which statment?
"Sit upright for 15 to 30 minutes."
The nurse identifies which reaction as an adverse effect most often identified with the MMR vaccine?
Arthritis
The nurse cares for the client diagnosed with AIDS. The client's sibling asks the nurse, "What kills people who have AIDS?" Which is the best response by the nurse?
"AIDS virtually cripples the body's normal protective immune response."
The nurse cares for the client diagnosed with AIDS 5 years ago and is now in the advanced stage of the disease. The client is trying to control the problem of diarrhea. The nurse intervenes when the client makes which statement?
"I will take a liquid nutritional supplement at least twice a day."
What does incubation period mean?
"Incubation period is the time between when a person gets infected and when actual symptoms appear."
The client has just been diagnosed with the HIV virus. The nurse provides info on the transmission of the virus. Which client statement indicates the best understanding of the info provided by the nurse?
"It is OK for someone to share food with me."
The nurse in the well-child clinic receives a phone call from the parent of the 6-month-old child who received the DTaP vaccine 3 days ago. The nurse is most concerned if the patient makes which statement?
"My baby is crying continuously."
A toddler diagnosed with sickle cell anemia comes to the clinic with the parent.
"My child should drink fluids throughout the day and have frequent breaks to stay healthy."
The nurse provides discharge teaching to the parent of a preschool-aged child diagnosed with sickle cell disease. Which parent statement demonstrates the need for further teaching?
"My child's immunizations should be withheld."
The nurse presents info about ITP to nursing students. A student asks, "Which cells are destroyed when a client has ITP?" Which is the best response by the nurse?
"Platelets"
The nurse provides discharge instructions to the parents of a preschool-aged child diagnosed as HIV positive. Which statement by the parents indicates an understanding of the guidelines for preventing HIV transmission?
"We can cuddle and kiss our child when the child cries"
The nurse prepares a presentation about AIDS for a group of students. Which information is important for the nurse to inlcude?
- Abstinence is the most effective preventative method for HIV related to sexual transmission. - Limit the number of sexual partners and engage only in protected sex. - Use latex condoms for oral, vaginal, or anal intercourse - Do not share items that may be contaminated with blood or bodily fluids, such as razors or needles.
What are some nursing interventions that can be provided with sickle cell disease?
- Rest - Oxygen - IV fluids and electrolytes - Sedation - Analgesia - Possible infusion
The instructor teaches nursing students about the chronic form of ITP. A person in which age group is most likely to develop chronic ITP?
A young child
The nurse cares for the client diagnosed with sickle cell anemia who is scheduled for a splenectomy. Which is ESSENTIAL to include in the postoperative plan of care for this client?
Assess for signs of infection due to decreased WBC l
The nurse presents information on ITP to nursing students. Which medication does the nurse expect to administer to a client with ITP?
Azathioprine
The nurse cares for a client diagnosed with AIDS reporting diarrhea. It is most important for the nurse to include which implementation in the client's plan of care?
Decrease roughage in the diet Rationale: Avoid foods that stimulate intestinal motility, such as veggies and fruits, fatty, spicy, and sweet foods, alcohol, and caffiene
The nurse cares for the client who has tested positive for HIV. The nurse is the best friend of the client's spouse. Which action is most ethical for the nurse to take?
Discuss with the client the need to tell the client's spouse so the spouse may be treated if needed.
The nurse cares for the client admitted 3 days ago with a gunshot wound to the abdomen. The client has developed DIC. Which symptom would the nurse expect to see in the client?
Ecchymosis
The nurse presents info on the prevention of AIDS to a group of adolescents. Which activity will most likley capture the attention of the adolescents?
Facilitated discussion of AIDS prevention with samples of condoms available
The nurse cares for a client diagnosed with sickle cell crisis. The client's child comes to visit the parent, and the nurse observes the child has an URI. It is most important for the nurse to take which action?
Give the child a mask to wear when visiting the client
The client with a history of IV drug use and numerous sexual partners requests HIV testing. The HIV test returns a negative result. Which should be the priority action for the nurse?
Help the client identify high-risk behaviors and provide information to help decrease these risks.
The nurse understands which best describes what clients diagnosed with DIC experience?
Hemorrhage and clotting
The nurse cares for the client with a two year history of sickle cell disease. Which factor increases the risk of vasoocclusive crisis?
Influenza infection Rationale: Infection, cold temperatures, fluid volume deficit, exposure to high altitudes, and stress cause local and systemic hypoxemia; red cells assume a sickle shape, clump together and adhere to blood vessel walls; blood flow to organs is diminished; spleen, kidneys, heart, and retinal microcirculation frequently affected
The nurse notes these lab values for the client: WBC 7,500/mm^3, RBC 5 million/mm^3, Hgb 13 g/dL, Hct 42.2%, and platelets 18,000/mm^3. Based on these lab results, which intervention does the nurse add to the client's care plan?
Institute bleeding precautions
The nurse cares for the client with AIDS. The nurse knows the client is at high risk to develop which disease?
Kaposi Sarcoma
The nurse cares for a client receiving intermittent infusion of ceftriaxone IV. Prior to administering the next dose, the health care provider orders 10 units of heparin IV. The nurse understands the heparin is ordered for which reason?
Maintain the patency of the IV
The nurse cares for the client with AIDS who has a CD4+ T cell count of 120 cells per microliter. The nurse knows the client is at great risk to develop which infection?
Mycobacterium TB infection
The adult male client's admitting blood work results are Hct 47%, Hgb 15.5 g/dl, RBCs 5.3 million/mm^3, WBCs 7,500, and platelets 50,000 mm^3. Based on these lab results, which action is MOST appropriate?
Observe for signs and symptoms of bleeding
The nurse cares for a child diagnosed as HIV positive. Which is an appropriate nursing strategy to facilitate the child's physical growth and development?
Offer nutritional supplements in addition to whatever food the child eats.
The nurse cares for the client diagnosed with acute DIC. Which medication should the nurse administer?
Oxygen
The nurse cares for the client diagnosed with sickle cell disease in a vaso-occlusive crisis. The client reports severe joint pain, epigastric distress, and extreme fatigue. Lab results include hematocrit 28%, Hgb 8, and indirect bilirubin 2.2 mg/dl. The nurse's physical assessment reveals jaundice, bilaterally yellow-tinged sclera, an open right 3 cm leg ulcer, poor skin turgor, and pale oral mucous membranes. Which nursing diagnosis does the nurse recognize as most important when planning the client's care?
Pain
The nurse cares for a client beginning intermittent heparin therapy. The nurse knows which lab test is used to monitor the effectiveness of heparin?
Partial thromboplastin time
Which nursing intervention is most likely to decrease joint pain for a child in vaso-occlusive crisis?
Perform passive range of motion exercises and apply warm compresses
The nurse understands that Hct measures which of the following?
Ratio of red blood cells to fluid volume
The nurse cares for pediatric clients diagnosed with AIDS. All of the clients are school-aged. How can the nurse coordinate the necessary isolation precautions?
Remind the staff that standard precautions are needed
The nurse cares for a client diagnosed with immune thrombocytopenia purpura. Which nursing diagnosis is a priority when caring for this client?
Risk for injury
The nursing instructor presents a class about inherited autosomal recessive disorders. Which disorder does the instructor include in the presentation?
Sickle cell anemia
The home care nurse visits a client diagnosed with AIDS. The nurse intervenes if which observation is made?
Soiled linens are placed in a laundry hamper
The nurse identifies a staff member is using standard precautions appropriately if which action is observed?
The staff member placed contaminated linens in a leak-proof bag
Which of the following symptoms indicates to the home health nurse that a client has an infection?
The client has lymphadenopathy.
The nurse cares for the client diagnosed with ITP. The nurse encourages the client to read the labels of all medications, including OTC medications, for the inclusion of aspirin. Which is the primary reason the nurse makes this recommendation?
The client may have an increased bleeding risk.
The nurse obtains a history from a client admitted with a diagnosis of sickle cell crisis. The nurse identifies which factor contributed to the sickle cell crisis?
The client recently had an URI
The nurse cares for a client with a sickle cell crisis. The nurse determines care is appropriate if which observation is made?
The client's intake is 1,600 ml for 8 hours. Rationale: Dehydrations precipitates sickle cell crisis; the client should take in at least 200 ml per hour by oral or parenteral route; do not offer caffeinated beverages
The nurse cares for the client diagnosed with sickle cell disease recuperating from splenectomy. Which health care need should be addressed in the immediate postoperative period?
The need to breathe deeply and frequently.
The nurse observes a staff member prepare to leave the room of a client on droplet precautions. The nurse should intervene if which action is observed?
The staff member holds onto the outer surface of the facemask while pulling the mask away from the face.
A new client comes to the HIV clinic and asks the nurse which test will confirm the client's suspected diagnosis of HIV. Which is the best test for the nurse to give to the client?
Western blot
