CM 3 Exam 4 Heme

A nurse is assessing a child who is postoperative and received a unit of packed RBCs during a surgical procedure. Which of the following findings indicates the child is experiencing a hemolytic transfusion reaction? A. Chills and flank pain B. Pruritus and flushing C. Rales and cyanosis D. Bradycardia and diarrhea

A

A nurse is caring for an adolescent who has sickle cell anemia. Which of the following manifestations is/are the result of chronic vaso-occlusive phenomena? (Select all that apply.) A. Enlarged heart B. Enuresis C. Leg ulcers D. Extrahepatic cholestasis E. Retinal detachment Check Answer Question Feedback Show Explanation

ABCE

A nurse is assessing for disseminated intravascular coagulation (DIC) in a client who has septic shock secondary to an untreated foot wound. Which of the following findings should the nurse expect? (Select all that apply.) A. Bradycardia B. Bleeding at the venipuncture site C. Petechiae on the chest and arms D. Flushed, dry skin E. Abdominal distension

BCE

A nurse is caring for a child who has sickle cell anemia and is experiencing a vaso-occlusive crisis. Which of the following actions should the nurse take? A. Administer ibuprofen B. Limit daily fluid intake C. Apply cold compresses to painful joints D. Withhold live virus immunizations

A

A nurse is caring for an 8-year-old child who has sickle cell anemia. Which of the following actions should the nurse take? A. Apply cool compresses to the painful area B. Initiate contact isolation precautions C. Give the child flavored popsicles D. Administer phytonadione

C

A nurse is reviewing the medical record of a 2-month-old infant who has rotavirus. The nurse notes a hemoglobin level of 12 g/dL and a hematocrit of 51%. Which of the following statements by the nurse indicates an understanding of the laboratory values? A. "The infant might be dehydrated." B. "The infant might be anemic." C. "The infant might have received too much fluid." D. "The infant might have leukemia." Check Answer Question Feedback Show Explanation

A

A nurse is reviewing the laboratory report of a toddler who is receiving chemotherapy for leukemia. Which of the following laboratory values should the nurse report to the provider? A. Platelets 150,000/mm^3 B. Hgb 6 g/dL C. WBC 6,000/mm^3 D. Potassium 4.5 mEq/L Check Answer Question Feedback Show Explanation

B

A nurse is providing teaching about home care to the guardian of an adolescent who has hemophilia. Which of the following pieces of information should the nurse provide? A. Encourage the adolescent to participate in non-contact sports B. Provide the adolescent with a firm-bristled toothbrush C. Administer aspirin to the adolescent for episodes of pain D. Provide disposable razors to the adolescent for shaving Check Answer Question Feedback Show Explanation

A

A nurse is caring for a child who has epistaxis. Which of the following actions should the nurse take? A. Administer aspirin B. Tilt the child's head back and apply pressure C. Have the child lie down and rest D. Apply continuous pressure to the lower part of the child's nose

D

A nurse is caring for a school-aged child who has sickle cell anemia. Which of the following actions should the nurse plan to take to help decrease the risk of a vaso-occlusive crisis? A. Provide adequate fluid intake throughout the day B. Provide oxygen at 2 L/min via nasal cannula C. Administer a blood transfusion D. Give ibuprofen to manage pain

A

A nurse is creating a plan of care for a child who has aplastic anemia. Which of the following interventions should the nurse include? A. Initiate protective-environment isolation for the child B. Apply pressure for 1-2 min at the puncture site following blood specimen collection C. Mix the child's ferrous sulfate elixir twice per day into a glass of milk for administration D. Check the child's blood glucose level every 4 hr Check Answer Question Feedback Show Explanation

A

A nurse is teaching the parents of a 10-year-old child who has iron-deficiency anemia. Which of the following statements by a parent indicates an understanding of the teaching? A. "I will give my child an iron tablet once each day at bedtime." B. "I will administer the iron tablet with orange juice." C. "I will encourage my child to take an antacid with the iron tablet." D. "I will crush the iron tablet prior to giving it to my child." Check Answer Question Feedback Show Explanation

B

A nurse is caring for a child who has epistaxis. Which of the following actions should the nurse perform? A. Apply a warm cloth to the bridge of the child's nose B. Tilt the child's head back C. Apply continuous pressure to the child's nose for at least 10 min D. Administer aspirin for the child's pain

C

A nurse is caring for a school-aged child who has hemophilia and fell on the playground. The child reports a pain level of 4 on a scale of 0 to 10. Which of the following actions should the nurse take? A. Administer an NSAID B. Perform passive range-of-motion exercises on the joint C. Administer cryoprecipitate D. Apply an ice pack to the joint Check Answer Question Feedback Show Explanation

D

A nurse is caring for a school-aged child who has sickle cell anemia and was admitted for a vaso-occlusive crisis. Which of the following findings should the nurse report to the provider immediately? A. Slurred speech B. Hemoglobin level of 9 g/dL C. Hematuria D. Pain level of 7 on FACES scale

A The nurse should identify that slurred speech in a child who has sickle cell anemia is an indication of a stroke. The nurse should report this finding to the provider immediately.

A nurse on the pediatric unit is caring for a group of clients. Which of the following findings should be the nurse's priority? A. A child who has asthma and a pulse oximetry of 94% B. A child who has nephrotic syndrome and 1+ protein on urine dipstick C. A child who has sickle cell anemia and a urine specific gravity of 1.030 D. A child who has insulin-dependent diabetes mellitus and a fingerstick glucose reading of 110 mg/dL

C

A nurse is planning care for a 6-year-old child who is receiving chemotherapy. The child has a highlight platelet count of 20,000/mm^3. Based on this laboratory value, which of the following interventions should the nurse include in the plan of care? A. Provide foods high in iron B. Avoid people who have infections C. Administer PRN oxygen D. Encourage quiet play Check Answer Question Feedback Show Explanation

D A platelet count of 20,000/mm^3 will predispose the client to excessive bleeding. Quiet play will lessen the client's risk of injury, thereby reducing the chance of hemorrhage.

A home health nurse is developing a plan of care a toddler who has hemophilia. Which of the following instructions for the parents should the nurse include in the plan? A. Administer low-dose aspirin for pain. B. Inspect the toddler's toys for sharp edges. C. Perform passive range-of-motion of the affected joint during a bleeding episode. D. Avoid contact with people who have respiratory infections. Check Answer Question Feedback Show Explanation

B

A nurse is providing teaching to a 12-year-old client who is recovering from an acute episode of hemophilia A. Which of the following statements should the nurse include in the teaching? A. "Have your parent stretch and move your legs for you." B. "Apply heat to joints that become painful, stiff, and swollen." C. "Take aspirin at the first sign of a headache." D. "You will be able to participate in physical exercises."

D

A nurse is creating a plan of care for a child who has sickle cell anemia and is experiencing a vaso-occlusive crisis. Which of the following interventions is the priority for the nurse to include? A. Monitor the child's oxygen saturation level B. Administer prescribed antibiotics to the child C. Increase the child's fluid intake D. Apply warm compresses to the child's affected joints

A When using the airway, breathing, and circulation (ABC) approach to client care, the priority intervention is to monitor the child's oxygen saturation level. Promoting oxygen utilization prevents further sickling of the child's red blood cells and allows adequate oxygenation of the surrounding tissue. Incorrect Answers: B. The nurse should administer prescribed antibiotics to treat any existing infection. However, another intervention is the priority to include in the plan of care. C. The nurse should encourage fluid intake to prevent dehydration and clumping of red blood cells. However, another intervention is the priority to include in the plan of care. D. The nurse should apply a warm compress to the joints to reduce pain and inflammation. However, another intervention is the priority to include in the plan of care.

A nurse is planning care for an adolescent who has sickle cell anemia and is experiencing a vaso-occlusive crisis. Which of the following interventions should the nurse include in the plan? A. Apply cold compresses to the child's extremities B. Administer meperidine every 4 hr until the crisis has resolved C. Maintain the child on bed rest D. Decrease the child's fluid intake for 8 hr Check Answer Question Feedback Show Explanation

C The nurse should maintain bed rest for this child who is experiencing a vaso-occlusive crisis to minimize energy expenditure and avoid additional oxygen needs. Incorrect Answers: A. Cold compresses are contraindicated because they enhance sickling and vasoconstriction. B. Meperidine is not recommended because this central nervous system stimulant can produce anxiety, tremors, and generalized seizures. D. A child who has sickle cell anemia and is in a vaso-occlusive crisis requires increased fluid intake to prevent sickling.

A nurse is caring for a child who has tetralogy of Fallot. Which of the following laboratory values should the nurse expect to find? A. Platelet count of 20,000/mm^3 B. WBC 4,000/mm^3 C. Thyroid stimulating hormone 7.0 microunits/mL D. RBC 6.8 million/uL Check Answer Question Feedback Show Explanation

D A child who has tetralogy of Fallot experiences cyanosis; therefore, the body responds by increasing RBC production (polycythemia) in an attempt to supply oxygen to all body parts.