Module C Group Questions on Discussion Board for Test FA15
"The physician orders 2 units of packed RBCs to be administered to the client. At 0600 the night shift nurse initiates the first unit's transfusion before going off shift. At 1000 the day shift nurse notes the IV line has clotted off and the transfusion has not been completed. The nursing assessment revealed the transfusion was only approximately 75% complete. Which of the actions by the nurse is most appropriate? A. Advise the blood bank about the delay for the next unit. B. Restart another peripheral line with 0.9% NS and restart the blood transfusion with the remaining blood unit. C. Discontinue the transfusion. D. Document the amount infused thus far and continue the transfusion
"Answer C Rationale: A unit of blood should be administered within a 4 hour period of time. The nurse should discontinue the transfusion, document the findings and notify the blood bank. The agency policy will need to be followed concerning the documentation process and notification of appropriate personnel. Continuing the transfusion with the "open" unit will expose the client to an increase risk of injury."
"In formulating a nursing diagnosis of risk for infection for a client with chronic lymphoid leukemia (CLL), nursing measures should include: (Select all that apply.) "A. Maintaining a clean technique for all invasive procedures. B. Placing the client in protective isolation. C. Limiting visitors who have colds and infections. D. Ensuring meticulous handwashing by all persons coming in contact with the client."
"Correct Answers: B, C, D Rationale: Chronic lymphoid leukemia (CLL) is characterized by a proliferation and accumulation of small, abnormal mature lymphocytes in bone marrow, peripheral blood, and body tissues. Infections and fever are frequent complications of CLL."
1. Newly diagnosed client with acute leukemia, ask why he is at extreme risk for infection when his white blood cell count is so high. What is the nurse's best response? A. "Even though you have many white blood cells, they are too immature to fight infection" B. "For now, your risk is low; however, when the chemotherapy begins, your risk for infection will be hight" C. "These white blood cells are cancerous and live longer than normal white blood cells, so they are top old to fight infection." D. "It is not the white blood cells that provide protection; it is the red blood cells, which are very low in your blood right now"
ANS: A Rationale: For clients who understand that white blood cells are a great protection against infection, being at great risk for infection even when WBC counts are sometimes ten times normal is confusing. These are leukemic cells that overgrow at a very immature level. Therefore even though there can be huge numbers of circulating WBCs, these cells are so immature that they are nonfunctional. In addition, the heavy production of immature leukemic cells prevents normal WBCs, RBCs, and platelets from forming and maturing into functional cells.
2. A client has a bone marrow biopsy done. Which nursing intervention is the priority post procedure? A. Applying pressure to the biopsy site B. Inspecting the site of ecchymoses C. Sending the biopsy specimens to the laboratory D. Teaching the client about avoiding vigorous activity
ANS: A Rationale: The initial action should be to stop bleeding by applying pressure to the site. If you were to chose any of the rest of the answers the patient could bleed out.
1. The nurse is caring for clients on an oncology unit. Which neutropenia precautions should be implemented? a. Hold all venipuncture sites for at least five minutes. b. Restrict fresh fruits and flowers. c. Place all clients in reverse isolation. d. Have the clients use a soft-bristle toothbrush.
Answer & Rationale: B. Fresh fruits and flowers may carry bacteria or insects on the skin of the fruit or dirt on the flowers and leaves; therefore, these items are restricted around clients with low WBCs.
2. Six weeks after hematopoietic stem cell transplantation for leukemia, the client's white blood cell count is 8200. What is the nurse's best action in view of this laboratory result? a. Notify the health care provider immediately. b. Assess the client for other symptoms of infection. c. Document the laboratory report as the only action. d. Remind the client to avoid crowds and people who are ill.
Answer & Rationale: C. Normal white blood cell count is 5000-10000; therefore, this value is within normal limits. The only action needed is to document this result as a normal finding.
1.A client has a bone marrow aspiration performed. After the procedure, what is the first nursing action? A. Position the client on the affected side. B. Cleanse the site with an antiseptic solution. C. Briefly apply pressure over the aspiration site. D. Begin frequent monitoring of the client's vital signs.
Answer : C
Which question by the nurse would be beneficial in assessing the needs of a client with multiple myeloma? a.) "Are you comfortable?" b.) "Do you need anything now?" c.) "Describe your pain." d.) "How long have you had the pain?"
Answer: C Rationale: Multiple myeloma is a malignancy that results from the overproduction and accumulation of immature plasma cells in the bone marrow. Bone pain in the lower back or ribs is the most common early symptom of multiple myeloma.
2) The nurse is preparing to administer a unit of blood to a client who is anemic. After its removal from the refrigerator, the blood should be administered within: A. 1 hour B. 2 hours C. 4 hours D. 6 hours
Answer: C - Rationale: After the blood is removed from the refrigerator, it must be administered within 4 hours. Refrigeration delays the growth of bacteria in the blood. 6 hours is too long because the extended time outside of refrigeration increases the risk of contamination and growth of bacteria.
1) A client is receiving chemotherapy for cancer. The nurse reviews the client's laboratory report and notes that he has thrombocytopenia. To which nursing diagnosis should the nurse give the highest priority? A. Activity Intolerance B. Impaired Tissue Integrity C. Impaired Oral Mucous Membranes D. Ineffective Tissue Perfusion: Cerebral, Cardiopulmonary, GI
Answer: D - Rationale: These are all appropriate nursing diagnoses for the client with thrombocytopenia. However, the risk of cerebral and GI hemorrhage and hypotension pose the greatest risk of physiological integrity of the client.
"In formulating a nursing diagnosis of risk for infection for a client with chronic lymphoid leukemia (CLL), nursing measures should include: (Select all that apply.) "A. Maintaining a clean technique for all invasive procedures. B. Placing the client in protective isolation. C. Limiting visitors who have colds and infections. D. Ensuring meticulous handwashing by all persons coming in contact with the client."
Answers: B, C, D Rationale: Chronic lymphoid leukemia (CLL) is characterized by a proliferation and accumulation of small, abnormal mature lymphocytes in bone marrow, peripheral blood, and body tissues. Infections and fever are frequent complications of CLL."
2. The nurse is making rounds on a client who has developed severe bone marrow depression after receiving chemotherapy for cancer. Which of these actions by the nurse is appropriate? Select all that apply. A. Monitor for signs of alopecia. B. Encourage an increase in fluids. C. Wash hands before entering the client's room. D. Advise use of a soft toothbrush for oral hygiene. E. Report an elevation in temperature immediately. F. Encourage the client to eat raw, fresh fruits and vegetables.
C, D and E are all correct. It is essential to prevent infection in a client with severe bone marrow depression; thorough hand-washing before touching the client or client's belongings is important. Thrombocytopenia occurs with most chemotherapy treatment programs; using a soft toothbrush helps prevent bleeding gums. Any temperature elevation in a client with neutropenia must be reported to the health care provider immediately as it may be a sign of infection. Although alopecia does occur with chemotherapy, it is not related to bone marrow suppression. Increasing fluids will neither reverse bone marrow suppression nor stimulate hematopoiesis. This is not related to bone marrow suppression. Clients who have severe bone marrow depression must avoid eating raw fruits and vegetables, and undercooked meat, eggs, and fish to avoid possible exposure to microbes.
2. Which client is at greatest risk for having a hemolytic transfusion reaction? A. 34-year-old client with type O blood B. 42 year-old client with allergies C. 58 year-old immune suppressed client D. 78-year-old client
Correct Answer is A: Hemolytic transfusion reactions are caused by blood type or Rh incompatibility. When blood that contains antigens different from the client's own antigens is infused, antigen-antibody complexes are formed in the client's blood. Type O is considered the universal donor but not the universal recipient B is Incorrect: The client with allergies would be most susceptible to an allergic transfusion reaction. C is Incorrect: The immune suppressed client would be most susceptible to a transfusion-associated graft-versus-host disease. D is Incorrect: The older adult client would be most susceptible to circulatory overload.
A nurse is teaching a client about induction therapy for acute leukemia. Which client statement indicates a need for additional education? A. "After this therapy, I will not need to have any more." B. "I will need to avoid people with a cold or flu." C. "I will probably lose my hair during this therapy." D. "The goal of this therapy is to put me in remission."
Correct Answer is A: induction therapy is not a cure for leukemia, it is a treatment. B is Incorrect: Because of infection risk, clients with leukemia should avoid people with a cold or flu. C is Incorrect: Induction therapy will most likely cause the client with leukemia to lose his or her hair. D is Incorrect: The goal of induction therapy is to force leukemia into remission
1. The nurse is preparing to initiate a blood transfusion. The client has a peripheral intravenous infusion in their left arm that the physician has ordered not to be slowed or rate reduced. The nurse prepares to start another line in the right arm. the client asks the nurse to use the existing site to avoid the trauma of having another line started. Which of the following statements by the nurse is correct? A. "That will be fine." B. " I will need to infuse the blood through a separate IV line." C. " I will let the physician know about your preferences." D. " We will need to assess the line before I can make a determination about your request."
Correct Answer: B Rationale: A blood transfusion must be administered via a separate IV line. The other responses indicate to the client their request is being considered.
2. A child with Leukemia will be undergoing an allogenic bone marrow transplant. When teaching the parents about the procedure, which information should the healthcare provider include? Select all that apply. A. Your child's stem cells are removed before the chemotherapy and radiation. B. The stem cells for this transplant might come from a baby's umbilical cord blood. C. Your child's immune system will improve as soon as the transplant is complete. D. You child may need periodic blood transfusions after the procedure. E. It is possible that the donor cells will attack your child's cells.
Correct Answers: B, D, E Rationale: "Allo" means other so the bone marrow is coming from a donor, Graft-versus-host disease may occur in allogenic transplants. The newly transplanted cells might attack the recipient's body because the donor cells regard the patient's cells to be foreign.One type of allogenic transplant is a stem cell transplant from umbilical cord blood collected at the time of delivery. Umbilical cord blood is rich in immature hematopoietic cells. The transplanted cells will take some time to begin making new cells, so the patient will be at risk for infection and bleeding. The patient may also require transfusions of red blood cells to maintain oxygen carrying capacity of the blood.
What are the risk factors for the development of leukemia? Select all that apply. A. Bone marrow hypoplasia B. Chemical exposure C. Down syndrome D. Ionizing radiation E. Multiple blood transfusions F. Prematurity at birth
Correct Feedback: A,B,C,D A Correct: Reduced production of blood cells in the bone marrow is one of the risk factors for developing leukemia. B Correct: Exposure to chemicals through medical need or by environmental events contributes to the development of leukemia. C Correct: Certain genetic factors contribute to the development of leukemia. Down syndrome is one such condition. D Correct: Radiation therapy for cancer or other exposure to radiation, perhaps through the environment, contributes to the development of leukemia.
1. Packed red blood cells have been prescribed for a client with low hemoglobin and hematocrit levels. The nurse takes the client's temperature before hanging the blood transfusion and records 100.6° F orally. Which action should the nurse take?
Delay hanging the blood and notify the health care provider (HCP). Rationale: If the client has a temperature higher than 100° F, the unit of blood should not be hung until the HCP is notified and has the opportunity to give further prescriptions. The HCP likely will prescribe that the blood be administered regardless of the temperature, but the decision is not within the nurse's scope of practice to make. The nurse needs an HCP's prescription to administer medications to the client.
2. The nurse is reviewing the laboratory results of a client diagnosed with multiple myeloma. Which would the nurse expect to note specifically in this disorder?
Increased calcium level Rationale: Findings indicative of multiple myeloma are an increased number of plasma cells in the bone marrow, anemia, hypercalcemia caused by the release of calcium from the deteriorating bone tissue, and an elevated blood urea nitrogen level. An increased white blood cell count may or may not be present and is not related specifically to multiple myeloma.
1. A 21-year-old male with Hodgkin's lymphoma is a senior at the local university. He is engaged to be married and is to begin a new job upon graduation. Which of the following diagnoses would be a priority for this client? " a. Sexual dysfunction related to radiation therapy b. Anticipatory grieving related to terminal illness c. Tissue integrity related to prolonged bed rest d. Fatigue related to chemotherapy"
Rationale: Answer A is correct. Radiation therapy often causes sterility in male clients and would be of primary importance to this client. The psychosocial needs of the client are important to address in light of the age and life choices. Hodgkin's disease, however, has a good prognosisy when diagnosed early. Answers B, C, and D are incorrect because they are of lesser priorit
2. A 68-year-old woman is diagnosed with thrombocytopenia due to acute lymphocytic leukemia. She is admitted to the hospital for treatment. The nurse should assign the patient: " A. To a private room so she will not infect other patients and healthcare workers B. To a private room so she will not be infected by other patients and healthcare workers C. To a semiprivate room so she will have stimulation during her hospitalization D. To a semiprivate room so she will have the opportunity to express her feelings about her illness
Rationale: Correct Answer: B A. To a private room so she will not infect other patients and health care workers — poses little or no threat B. To a private room so she will not be infected by other patients and health care workers — CORRECT: protects patient from exogenous bacteria, risk for developing infection from others due to depressed WBC count, alters ability to fight infection C. To a semiprivate room so she will have stimulation during her hospitalization — should be placed in a room alone D. To a semiprivate room so she will have the opportunity to express her feelings about her illness — ensure that patient is provided with opportunities to express feelings about illness
A nurse is teaching a client about what to expect during a bone marrow biopsy. Which statement by the nurse accurately describes the procedure? A. "The doctor will place a small needle in your back and will withdraw some fluid." B. "You may experience a crunching sound or a scraping sensation as the needle punctures your bone." C. "You will be alone because the procedure is a sterile one; we cannot allow additional people to contaminate the area." D. "You will be sedated, so you will not be aware of anything."
Rationale: Correct answer B. This description is accurate. Proper expectations minimize the client's fear during the procedure.
2) The new registered nurse is giving a blood transfusion to a patient. Which statement made by the new nurse indicates the need for action by the supervising nurse? A. "I will be sure to complete the red blood cell transfusions within 6 hours of removal from refrigeration." B. "I will check the patient verification with another registered nurse." C. "I will use normal saline solution to dilute the blood." D. "I will remain with the patient for the first 15 to 30 minutes of the infusion."
The correct answer is A. The red blood cell transfusion should be given within 4 hours of removal from refrigeration. The other statements indicate proper understanding of blood transfusion protocols. Chart 42-13, pg. 898
1) A client who has been newly diagnosed with leukemia is admitted to the hospital. Avoiding which potential problem takes priority in the client's nursing care plan? A. Fluid overload B. Hemorrhage C. Hypoxia D. Infection
The correct answer is D. The major objective in caring for a newly diagnosed patient with leukemia is protection from infection. Infection is a major cause of death in a patient with leukemia because the white blood cells are immature and cannot function. PG. 883