Exam 1 hematology

he nurse who is about to begin a blood transfusion knows that blood cells start to deteriorate after a certain period of time. Which item is important to check regarding the age of blood cells before the transfusion is begun? 1) Expiration date 2) Presence of clots 3) Blood group and type 4) Blood identification number

1) Expiration dateRationale:The nurse notes the expiration date on the unit of blood to ensure that the blood is fresh. Blood cells begin to deteriorate over time, so safe storage is usually limited to 35 days. Careful notation of the expiration date by the nurse is an essential part of the verification process before hanging a unit of blood.The nurse also notes the blood identification (unit) number, blood group and type, and client's name.The nurse also inspects the unit of blood for leaks, abnormal color, clots, and bubbles and returns the unit to the blood bank if clots are noted.

A nurse is caring for a client who is reducing blood transfusion therapy. Which clinical manifestations would alert he burst to a hemolytic transfusion rxn? 1) headache 2) tachycardia 3) hypertension 4) apprehension 5) distended neck veins 6) a sense of impending doom

1, 2, 3, 4, 6

A nurse is assisting with caring for a client who is receiving a unit of packed RBCs. The nurse tells the client that it is most important to report which of the following signs immediately? 1. Sore throat or earache 2. Chills, itching, or rash 3. Unusual sleepiness or fatigue 4. Mild discomfort at the catheter site

2.

The nurse has just received a unit of packed red blood cells from the blood bank for transfusion to an assigned client. The nurse is careful to select tubing especially made for blood products, knowing that this tubing is manufactured with which item? 1) An air vent 2) Tinted tubing 3) An in-line filter 4) A microdrip chamber

3) An in-line filterRationale:The tubing used for blood administration has an in-line filter. The filter helps ensure that any particles larger than the size of the filter are caught in the filter and are not infused into the client.Tinted tubing is incorrect because blood does not need to be protected from light.The tubing should be macrodrip, not microdrip, to allow blood to flow freely through the drip chamber.An air vent is unnecessary because the blood bag is not made of glass.

client who was receiving a blood transfusion has experienced a transfusion reaction. The nurse sends the blood bag that was used for the client to which of the following areas? 1. The pharmacy 2. The laboratory 3. The blood bank 4. The risk-management department

3. Blood Bank

A patient with an abnormal mammogram is scheduled for stereotactic core biopsy. Which information will the nurse include when teaching the patient about the procedure? a. "You will need to avoid eating or drinking anything for 6 hours before the procedure." b. "Any discomfort after the biopsy may be treated with mild pain relievers such as aspirin." c. "The core biopsy is evaluated immediately and you will get the results before leaving." d. "Several samples of tissue in the abnormal area will be obtained during the procedure."

Answer: D Rationale: During stereotactic breast biopsy, a biopsy gun is used to remove several core samples in the area of abnormality. The procedure is done using a local anesthetic, so there is no need to be NPO before the procedure. Aspirin should not be used because it will increase bleeding at the site. The biopsy is sent to pathology, and results are not usually available immediately.

A 34-year-old woman has undergone a modified radical mastectomy for a breast tumor. The pathology report identified the tumor as a stage I, estrogen-receptor-positive adenocarcinoma. The nurse will plan on teaching the patient about a. raloxifene (Evista). b. estradiol (Estrace). c. trastuzumab (Herceptin). d. tamoxifen (Nolvadex).

Answer: D Rationale: Tamoxifen is used for estrogen-dependent breast tumors in premenopausal women. Raloxifene is used to prevent breast cancer, but it is not used post-mastectomy to treat breast cancer. Estradiol will increase the growth of estrogen-dependent tumors. Trastuzumab is used to treat tumors that have the HER-2/neu antigen.

The nurse provides discharge teaching for a patient who has had a left modified radical mastectomy and axillary lymph node dissection. The nurse determines that teaching has been successful when the patient says, a. "I should keep my left arm supported in a sling when I am up until my incision is healed." b. "I may expose my left arm to the sun for several hours each day to increase circulation and promote healing." c. "I can do whatever exercises and activities I want as long as I do not elevate my left hand above my head." d. "I will continue to exercise my left arm with finger-walking up the wall or combing my hair."

Answer: D Rationale: The patient should continue with arm exercises to regain strength and range of motion. The left arm should be elevated to the level of the heart when the patient is up. Sun exposure is avoided because of the risk of sunburn. The left hand should be elevated at or above heart level to reduce swelling and lymphedema.

A nurse is examining a patient who has been diagnosed with a fibroadenoma. The nurse should recognize what implication of this patient's diagnosis? A) The patient will be scheduled for radiation therapy. B) The patient might be referred for a biopsy. C) The patient's breast mass is considered an age-related change. D) The patient's diagnosis is likely related to her use of oral contraceptives.

B (Feedback: Fibroadenomas are firm, round, movable, benign tumors. These masses are nontender and are sometimes removed for biopsy and definitive diagnosis. They are not considered to be an age-related change, even though they are benign. Radiation therapy is unnecessary and fibroadenomas do not result from oral contraceptive use.)

A 42-year-old man has come to the clinic for an annual physical. The nurse notes in the patient's history that his father was treated for breast cancer. What should the nurse provide to the patient before he leaves the clinic? A) A referral for a mammogram B) Instructions about breast self-examination (BSE) C) A referral to a surgeon D) A referral to a support group

B (Feedback: Instructions about BSE should be provided to men if they have a family history of breast cancer, because they may have an increased risk of male breast cancer. It is not within the scope of the practice of a nurse to refer a patient for a mammogram or to a surgeon; these actions are not necessary or recommended. In the absence of symptoms or a diagnosis, referral to a support group is unnecessary.)

What is auto transfusion?

Blood collected during and after surgery using an intraoperative blood salvage device. The autotransfusion is utilized in surgeries where there is expected a large volume blood loss - e.g. aneurysm, total joint replacement, and spinal surgeries. (*only collected above the diaphragm*)

When planning discharge teaching with a patient who has undergone a total mastectomy with axillary dissection, the nurse knows to instruct the patient that she should report what sign or symptom to the physician immediately? A) Fatigue B) Temperature greater than 98.5ºF C) Sudden cessation of output from the drainage device D) Gradual decline in output from the drain

C (Feedback: The patient should report sudden cessation of output from the drainage device, which could indicate an occlusion. Gradual decline in output is expected. A temperature of 100.4°F or greater should also be reported to rule out postoperative infection, but a temperature of 98.5°F is not problematic. Fatigue is expected during the recovery period.)

a patient is about to receive a unit of packed red blood cells. the unit of blood has arrived and you are about to initiate the transfusion, which of the following procedure will help you protect the pt against the possibility of a blood-group incompatibility? A) Observing the patient for 15 to 30 minutes after the transfusion is initiated B) Giving a prescribed pre-medication 30 minutes prior to starting the transfusion C) Comparing the ID numbers on the blood unit with those on the order form and the wristband D) Obtaining a blood sample from the patient for typing and crossmatching

C) Comparing the ID numbers on the blood unit with those on the order form and the wristband

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? A. Filgrastim B. Sargramostim C. Epoetin alfa D. Eltrombopag

C. Epoetin alfa

When providing teaching for the patient with iron-deficiency anemia who has been prescribed iron supplements, you should include taking the iron with which beverage? A. Milk B. Ginger ale C. Orange juice D. Water

C. Orange juice Taking iron with vitamin C (ascorbic acid) or orange juice, which contains ascorbic acid, also enhances iron absorption. Milk may interfere with iron absorption. Ginger ale and water do not facilitate iron absorption.

when infusing a unit of packed red blood cells it is important to? A) allow the blood to warm to room temperature for 1 hour. B) begin the blood transfusion at a rate of 10 mL/hr. C) make sure the entire unit is transfused within 4 hours. D) change the blood tubing after every unit infused.

C. make sure the entire unit is transfused within 4 hours

What test determines Rh status?

Coombs test

Your patient has a unit of blood infusing. It probably will be completed within 5 mins. The phlebotomist comes to you and asks if it is OK to draw the pt's CBC. How will you respond?

No, come back in 1 hour. Blood circulates and calibrates in 1 hour.

WHich component of blood transports waste products to the kidneys and liver?

Plasma

What to do if reaction

STOP INFUSION Restart IV Fluids Correct intervention- i.e Benadryl - Antihistamine Draw Blood sample Collect Urine KEEP ALL BAGS and TUBING Call HCP

What would you do if your patient was O- and the blood bank sent you O+ blood?

Send back to blood bank due to mismatched Rh factors.

A client requiring surgery is anxious about the possible need for a blood transfusion during or after the procedure. The nurse suggests to the client to do which of the following to reduce the risk of possible transfusion complications? a. give an autologous blood donation before the surgery b. ask a friend or family member to donate blood ahead of time c. take iron supplements before surgery to boost hemoglobin levels d. request that any donated blood be screened twice by the blood bank.

a. give an autologous blood donation before the surgery A donation of the client's own blood before a scheduled procedure is autologous. Donating autologous blood to be reinfused as needed during or after surgery reduces the risk of disease transmission and potential transfusion complications. The next most effective way is ask a family member to donate blood before surgery. Blood banks do not provide extra screening on request. Preoperative iron supplements are not helpful in replacing blood lost during the surgery.

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 100.6F orally. Which of the following is the appropriate nursing action? a. Begin the transfusion as prescribed b. Delay hanging the blood and notify the physician c. Administer an antihistamine and begin the transfusion d. Administer two tablets of acetaminophen (Tylenol) and begin the transfusion

b. Delay hanging the blood and notify the physician If the client's temperature is higher than 100F the unit of blood should not be hung until the physician is notified and has the opportunity to give further prescriptions. The physician will likely prescribe that the blood be administered regardless of the temperature, but the decision is not within the nurse's scope of practice to make.

Which of the following nursing interventions should be incorporated into the plan of care for a patient with impaired liver function and low albumin levels? a) Apply prolonged pressure to needle sites or other sources of external bleeding b) Monitor temperature at least once per shift c) Monitor for edema at least once per shift d) Implement neutropenic precautions

c) Monitor for edema at least once per shift Explanation: Albumin is particularly important for the maintenance of fluid balance within the vascular system. Capillary walls are impermeable to albumin, so its presence in the plasma creates an osmotic force that keeps fluid within the vascular space. People with impaired hepatic function may have low concentrations of albumin, with a resultant decrease in osmotic pressure and the development of edema.

A client has received a transfusion of platelets. The nurse evaluates that the client is benefiting most from this therapy if the client exhibits which of the following? a. Increased hematocrit level b. Increased hemoglobin level c. Decline of elevated temperature to normal d. Decreased oozing of blood from puncture sites and gums

d. Decreased oozing of blood from puncture sites and gums Platelets are necessary for proper blood clotting. The client with insufficient platelets may exhibit frank bleeding or oozing of blood from puncture sites, wounds, and mucous membranes. Increased hemoglobin and hematocrit levels would occur when the client has received a transfusion of red blood cells. An elevated temperature would decline to normal after infusion of granulocytes if those cells were instrumental in fighting infection in the body.

A patient about to receive a unit of packed red blood cells states, "This is my third unit of blood today. I don't want to get some disease from all this blood." Which of the following would be your best response?

"Donated blood is carefully screened for infectious diseases." -This is your best response because it offers the patient some factual information to help allay his concerns. You might continue to explain that the approach to blood safety in the U.S. includes stringent donor selection practices and the use of screening tests for HIV/AIDS, hepatitis B and C, syphilis, and other infectious diseases. Infected blood and blood products are safely discarded and are not used for transfusions.

49. The client has a hematocrit of 22.3% and a hemoglobin of 7.7 g/dL. The HCP has ordered two (2) units of packed red blood cells to be transfused. Which interventions should the nurse implement? Select all that apply. 1. Obtain a signed consent. 2. Initiate a 22-gauge IV. 3. Assess the client's lungs. 4. Check for allergies. 5. Hang a keep-open IV of D5W.

. The client must give permission to receive blood or blood products because of the nature of potential complications. 2. Most blood products require at least a 20-gauge IV because of the size of the cells. RBCs are best infused through an 18-gauge IV. If unable to achieve cannulation with an 18-gauge, a 20-gauge is the smallest acceptable IV. Smaller IVs damage the cell walls of the RBCs and reduce the life expectancy of the RBCs. *3. Because infusing IV fluids can cause a fluid volume overload, the nurse must assess for congestive heart failure. Assessing the lungs includes auscultating for crackles and other signs of left-sided heart failure. Additional assessment findings of jugular vein distention, peripheral edema, and liver engorgement indicate right-sided failure.* 4. Checking for allergies is important prior to administering any medication. Some medications are administered prior to blood administration.

A client requiring surgery is anxious about the possible need for a blood transfusion during or after the procedure. The nurse suggests to the client to take which action(s) to reduce the risk of possible transfusion complications? SELECT ALL THAT APPLY. 1) Ask a family member to donate blood ahead of time. 2) Give an autologous blood donation before the surgery. 3) Take iron supplements before surgery to boost hemoglobin levels. 4) Request that any donated blood be screened twice by the blood bank. 5) Take adequate amounts of vitamin C several days prior to the surgery date.

1) Ask a family member to donate blood ahead of time. 2) Give an autologous blood donation before the surgery.Rationale:A donation of the client's own blood before a scheduled procedure is autologous. Donating autologous blood to be reinfused as needed during or after surgery reduces the risk of disease transmission and potential transfusion complications. The next most effective way is to ask a family member to donate blood before surgery. Blood banks do not provide extra screening on request. Preoperative iron supplements are helpful for iron deficiency anemia but are not helpful in replacing blood lost during the surgery. Vitamin C enhances iron absorption, but also is not helpful in replacing blood lost during surgery.

A nurse has just finished assisting the physician in placing a central IV line. Which of the following is a priority intervention after central line insertion? 1) prepare the client for a chest radiograph 2) assess the clients temperature to monitor for infection 3) label the dressing with the date and time of the catheter insertion 4) monitor the BP to asses for FVE

1) prepare the client for a chest radiograph for possible pneumothorax for accidental puncture of the lung.

Which of the following clients are most likely to develop circulatory overload? (select all that apply) 1. A premature infant 2. A 101-year-old man 3. The client on renal dialysis 4. The client with diabetes mellitus 5. A 29-year-old woman with pneumonia 6. The client with CHF

1, 2, 3, 6

54. The client undergoing knee replacement surgery has a "cell saver" apparatus attached to the knee when he arrives in the post-anesthesia care unit (PACU). Which intervention should the nurse implement to care for this drainage system? 1. Infuse the drainage into the client when a prescribed amount fills the chamber. 2. Attach an hourly drainage collection bag to the unit and discard the drainage. 3. Replace the unit with a continuous passive motion unit and start it on low. 4. Have another nurse verify the unit number prior to reinfusing the blood.

1. A cell saver is a device to catch the blood lost during orthopedic surgeries to reinfuse into the client, rather than giving the client donor blood products. The cells are washed with saline and reinfused through a filter into the client. The salvaged cells cannot be stored and must be used within four (4) hours or discarded because of bacterial growth.

The client is admitted to the emergency department after a motor-vehicle accident. The nurse notes profuse bleeding from a right-sided abdominal injury. Which intervention should the nurse implement first? 1. Type and crossmatch for red blood cells immediately (STAT). 2. Initiate an IV with an 18-gauge needle and hang normal saline. 3. Have the client sign a consent for an exploratory laparotomy. 4. Notify the significant other of the client's admission.

1. This should be done, but the client requires the IV first. This client is at risk for shock. ********2. The first action in a situation in which the nurse suspects the client has a fluid volume loss is to replace the volume as quickly as possible. 3. The client will probably need to have surgery to correct the source of the bleeding, but stabilizing the client with fluid resuscitation is first priority. 4. This is the last thing on this list in order of priority. TEST-TAKING HINT: The question requires the test taker to decide which of the actions comes first. Only one of the options actually has the nurse treating the client. The test taker must not read into a question—for example, that consent is needed to send a client to surgery to correct the problem, so that could be first. Only one answer option has the potential to stabilize the client.

Following infusion of a unit of packed red blood cells, the client has developed new onset of tachycardia, bounding pulses, crackles, and wheezes. Which action should the nurse implement FIRST? 1) Maintain bed rest with legs elevated 2) Place the client in high-Fowler's position 3) Increase the rate of infusion of intravenous fluids 4) Consult with the HCP regarding initiation of oxygen therapy.

2) Place the client in high-Fowler's positionRationale:New onset of tachycardia, bounding pulses, crackles and wheezes post-transfusion are evidence of fluid overload, a complication associated with blood transfusions. Placing the client in a high-Fowler's (upright) position will facilitate breathing.Measures that increase blood return to the heart, such as leg elevation and administration of intravenous fluids, should be avoided at this time. In addition, administration of fluids cannot be initiated without a prescription.Consulting with the HCP regarding administration of oxygen may be necessary, but positional changes take a short amount of time to do and should be initiated first.

55. Which statement is the scientific rationale for infusing a unit of blood in less than four (4) hours? 1. The blood will coagulate if left out of the refrigerator for >four (4) hours. 2. The blood has the potential for bacterial growth if allowed to infuse longer. 3. The blood components begin to break down after four (4) hours. 4. The blood will not be affected; this is a laboratory procedure.

2. Blood is a medium for bacterial growth, and any bacteria contaminating the unit will begin to grow if left outside of a controlled refrigerated temperature for longer than four (4) hours, placing the client at risk for septicemia.

A nurse is doing a routine assessment of a client's peripheral IV site. The nurse notes that the site is cool, pale, and swollen and that the IV has stopped running. The nurse determines that which of the following has probably occurred? 1. Phlebitis 2. Infection 3. Infiltration 4. Thrombosis

3.

A client with severe blood loss resulting from multiple trauma requires rapid transfusion of several units of blood. The nurse asks another health team member to obtain which device for use during the transfusion procedure to help reduce the risk of cardiac dysrhythmias? 1) Infusion pump 2) Pulse oximeter 3) Cardiac monitor 4) Blood-warming device

4) Blood-warming device Rationale: If several units of blood are to be administered, a blood warmer should be used. Rapid transfusion of cool blood places the client at risk for cardiac dysrhythmias. To prevent this, the nurse warms the blood with a blood-warming device. Pulse oximetry and cardiac monitoring equipment are useful for the early assessment of complications but do not reduce the occurrence of cardiac dysrhythmias. Electronic infusion devices are not helpful in this case because the infusion must be rapid, and infusion devices generally are used to control the flow rate. In addition, not all infusion devices are made to handle blood or blood products.

The nurse, listening to the morning report, learns that an assigned client received a unit of granulocytes the previous evening. The nurse makes a note to assess the results of which daily serum laboratory studies to assess the effectiveness of the transfusion? 1) Hematocrit level 2) Erythrocyte count 3) Hemoglobin level 4) White blood cell count

4) White blood cell countRationale:The client who has neutropenia may receive a transfusion of granulocytes, or white blood cells. These clients often have severe infections and are unresponsive to antibiotic therapy. The nurse notes the results of follow-up white blood cell counts and differential to evaluate the effectiveness of the therapy. The nurse also continues to monitor the client for signs and symptoms of infection.Erythrocyte count and hemoglobin and hematocrit levels are determined after transfusion of packed red blood cells.

57. The client receiving a unit of PRBCs begins to chill and develops hives. Which action should be the nurse's first response? 1. Notify the laboratory and health-care provider. 2. Administer the histamine-1 blocker, Benadryl, IV. 3. Assess the client for further complications. 4. Stop the transfusion and change the tubing at the hub.

57. The client receiving a unit of PRBCs begins to chill and develops hives. Which action should be the nurse's first response? 1. Notify the laboratory and health-care provider. 2. Administer the histamine-1 blocker, Benadryl, IV. 3. Assess the client for further complications. 4. Stop the transfusion and change the tubing at the hub.

A patient has been referred to the breast clinic after her most recent mammogram revealed the presence of a lump. The lump is found to be a small, well-defined nodule in the right breast. The oncology nurse should recognize the likelihood of what treatment? A) Lumpectomy and radiation B) Partial mastectomy and radiation C) Partial mastectomy and chemotherapy D) Total mastectomy and chemotherapy

A (Feedback: Treatment for breast cancer depends on the disease stage and type, the patient's age and menopausal status, and the disfiguring effects of the surgery. For this patient, lumpectomy is the most likely option because the nodule is well-defined. The patient usually undergoes radiation therapy afterward. Because a lumpectomy is possible, mastectomy would not be the treatment of choice.)

Which patient is most likely to experience anemia caused by increased destruction of RBCs? A. An African American man who has a diagnosis of sickle cell disease B. A 59-year-old man whose alcoholism has precipitated folic acid deficiency C. A 30-year-old woman with a history of "heavy periods" accompanied by anemia D. A 3-year-old child whose impaired growth and development is attributable to thalassemia

A. An African American man who has a diagnosis of sickle cell disease The cause of sickle cell anemia involves increased hemolysis. Thalassemias and folic acid deficiencies decrease erythropoiesis, whereas the anemia related to menstruation is a direct result of blood loss.

During a blood transfusion with packed red blood cells (RBCs), a client reports chills, low back pain, and nausea. What priority action should the nurse take? A. Discontinue the infusion immediately and maintain the IV line with normal saline solution using new IV tubing B. Discontinue the infusion immediately and notify the physician C. Slow the infusion rate and continue to monitor the client every 15 minutes D. Observe for additional symptoms and notify the physician

A. Discontinue the infusion immediately and maintain the IV line with normal saline solution using new IV tubing

A patient has suffered from a gastrointestinal hemorrhage. Which agent will assist in raising the hemoglobin? A. Epoetin alfa (Epogen, Procrit) B. Pentoxifylline (Pentoxil) C. Estazolam (ProSom) D. Dextromethorphan hydrobromide

A. Epoetin alfa (Epogen, Procrit

One hour after a transfusion of packed red blood cells (RBCs) is started, a client develops redness on the trunk and reports itching. The nurse stops the RBC infusion and administers diphenhydramine 25 mg po, as ordered. Thirty minutes later, the redness and itching are gone. What action should the nurse take next? A. Resume the transfusion B. Obtain blood and urine samples from the client C. Position the client in an upright position with the feet in a dependent position D. Send the blood back to the blood bank

A. Resume the transfusion

A client receiving a transfusion of packed red blood cells (PRBCs) begins to vomit. The client's blood pressure is 90/50 from a baseline of 125/78. The client's temperature is 100.8F orally from a baseline of 99.2F orally. The nurse determines that the client may be experiencing which complication of a blood transfusion? a. Septicemia b. Hyperkalemia c. Circulatory overload d. Delayed transfusion reaction

A. Septicemia Septicemia occurs with the transfusion of blood contaminated with microorganisms. Signs include chills, fever, vomiting, diarrhea, hypotension, and the development of shock. Hyperkalemia causes weakness, paresthesias, abdominal cramps, diarrhea, and dysrythmias. Circulatory overload causes cough, dyspnea, chest pain, wheezing, tachycardia, and hypertension. A delayed transfusion reaction can occur days or weeks after a tranfusion. Signs include fever, mild jaundice, and a decreased hematocrit level.

In a severely anemic patient, you expect to find A. dyspnea and tachycardia. B. cyanosis and pulmonary edema. C. cardiomegaly and pulmonary fibrosis. D. ventricular dysrhythmias and wheezing.

A. dyspnea and tachycardia. Patients with severe anemia (hemoglobin <6 g/dL) exhibit the following cardiovascular and pulmonary manifestations: tachycardia, increased pulse pressure, systolic murmurs, intermittent claudication, angina, heart failure, myocardial infarction; tachypnea, orthopnea, dyspnea at rest.

The nurse is teaching a 45-year-old woman about her fibrocystic breast condition. Which statement by the client indicates a lack of understanding? a. "This condition will become malignant over time." b. "I should refrain from using hormone replacement therapy." c. "One cup of coffee in the morning should be enough for me." d. "This condition makes it more difficult to examine my breasts."

ANS: A Fibrocystic breast condition does not increase a woman's chance of developing breast cancer. Hormone replacement therapy is not indicated since the additional estrogen may aggravate the condition. Limiting caffeine intake may give relief for tender breasts. The fibrocystic changes to the breasts make it more difficult to examine the breasts because of fibrotic changes and lumps.

Which finding in a female client by the nurse would receive the highest priority of further diagnostics? a. Tender moveable masses throughout the breast tissue b. A 3-cm firm, defined mobile mass in the lower quadrant of the breast c. Nontender immobile mass in the upper outer quadrant of the breast d. Small, painful mass under warm reddened skin

ANS: C Malignant lesions are hard, nontender, and usually located in the upper outer quadrant of the breast and would be the priority for further diagnostic study. The other lesions are benign breast disorders. The tender moveable masses throughout the breast tissue could be a fibrocystic breast condition. A firm, defined mobile mass in the lower quadrant of the breast is a fibroadenoma, and a painful mass under warm reddened skin could be a local abscess or ductal ectasia.

The nurse is examining a woman's breast and notes multiple small mobile lumps. Which question would be the most appropriate for the nurse to ask? a. "When was your last mammogram at the clinic?" b. "How many cans of caffeinated soda do you drink in a day?" c. "Do the small lumps seem to change with your menstrual period?" d. "Do you have a first-degree relative who has breast cancer?"

ANS: C The most appropriate question would be one that relates to benign lesions that usually change in response to hormonal changes within a menstrual cycle. Reduction of caffeine in the diet has been shown to give relief in fibrocystic breast conditions, but research has not found that it has a significant impact. Questions related to the client's last mammogram or breast cancer history are not related to the nurse's assessment.

The nursing management of a patient in sickle cell crisis includes (select all that apply) A. monitoring of the complete blood cell (CBC) count. B. blood transfusions if required and iron chelation. C. optimal pain management and oxygen therapy. D. rest as needed and deep vein thrombosis prophylaxis.

All answers are correct. The CBC count is monitored. Infections are common with an elevated white blood cell (WBC) count, and anemia may occur with low hemoglobin and red blood cell (RBC) levels. Oxygen may be administered to treat hypoxia and control sickling. Rest may be instituted to reduce metabolic requirements and DVT protocols may be prescribed. Transfusion therapy is indicated when an aplastic crisis occurs. Patients may require iron chelation therapy to reduce transfusion-produced iron overload. Pain occurring during an acute crisis usually is undertreated. Patients should have optimal pain control with opioid analgesics, nonsteroidal antiinflammatory agents, antineuropathic pain medications, local anesthetics, or nerve blocks.

4. A patient with a small breast lump is advised to have a fine needle aspiration (FNA) biopsy. The nurse explains that an advantage to this procedure is that a. only a small incision is necessary, resulting in minimal breast pain and scarring. b. if the specimen is positive for malignancy, the patient can be told at the visit. c. if the specimen is negative for malignancy, the patient's fears of cancer can be put to rest. d. FNA is guided by a mammogram, ensuring that cells are taken from the lesion.

Answer: B Rationale: An FNA should only be done when an experienced cytologist is available to read the specimen immediately. If the specimen is positive for malignancy, the patient can be given this information immediately. No incision is needed. If the specimen is negative for malignancy, the patient will require biopsy of the lump. FNA is not guided by mammography.

6. A 20-year-old student comes to the student health center after discovering a small painless lump in her right breast. She is worried that she might have cancer because her mother had cervical cancer. The nurse's response to the patient is based on the knowledge that the most likely cause of the breast lump is a. fibrocystic complex. b. fibroadenoma. c. breast abscess. d. adenocarcinoma.

Answer: B Rationale: Fibroadenoma is the most frequent cause of breast lumps in women under 25 years of age. Fibrocystic changes occur most frequently in women ages 35 to 50. Breast abscess is associated with pain and other systemic symptoms. Breast cancer is uncommon in women younger than 25. Cognitive Level: Application Text Reference: p. 1347 Nursing Process: Implementation NCLEX: Physiological Integrity

A patient with a breast biopsy positive for cancer is to undergo lymphatic mapping and sentinel lymph node dissection (SLND). The nurse explains that this procedure a. can identify specific lymph nodes that have malignant cells, so only involved nodes need to be excised. b. reduces the need for extensive lymph node dissection for pathologic examination. c. eliminates the need for excision of more than one lymph node for staging of breast cancer. d. will confirm the absence of tumor spread if the sentinel lymph node is negative for malignant changes.

Answer: B Rationale: The SLND may eliminate further lymph node dissection if the initial nodes are negative for malignancy. The procedure identifies which lymph nodes drain first from the tumor site, but not which ones are malignant. Several lymph nodes may be dissected for pathologic examination. Tumor may have distant metastases even when no malignancies are found in the lymph nodes.

A woman with a positive biopsy for breast cancer is considering whether to have a modified radical mastectomy or breast conservation surgery (lumpectomy) with radiation therapy. Which information should the nurse provide? a. The postoperative survival rate for each is about the same, but there is a decreased rate of cancer recurrence after mastectomy. b. The lumpectomy and radiation will preserve the breast, but this method can cause changes in breast sensitivity. c. The hair loss associated with post-lumpectomy chemotherapy is not acceptable to some patients. d. The treatment period for the mastectomy is shorter, and breast reconstruction can provide a normal-appearing breast.

Answer: B Rationale: The impact on breast function and appearance is less with lumpectomy and radiation, but there is some effect on breast sensitivity. The rate of cancer recurrence is the same for the two procedures. Chemotherapy may be used after either lumpectomy or mastectomy, but it is not always needed. The treatment period is shorter after mastectomy, but breast reconstruction does not provide a normal-appearing breast.

5. A 33-year-old patient tells the nurse that she has fibrocystic breasts but reducing her sodium and caffeine intake and other measures have not made a difference in the fibrocystic condition. An appropriate patient outcome for the patient is a. calls the health care provider if any lumps are painful or tender. b. states the reason for immediate biopsy of new lumps. c. monitors changes in size and tenderness of all lumps in relation to her menstrual cycle. d. has genetic testing for BRCA-1 and BRCA-2 to determine her risk for breast cancer.

Answer: C Rationale: Because fibrocystic breasts may increase in size and tenderness during the premenstrual phase, the patient is taught to monitor for this change and to call if the changes persist after menstruation. Pain and tenderness are typical of fibrocystic breasts, and the patient should not call for these symptoms. New lumps may be need biopsy if they persist after the menstrual period, but the biopsy is not done immediately. The existence of fibrocystic breasts is not associated with the BRCA genes. Cognitive Level: Application Text Reference: pp. 1346-1347 Nursing Process: Planning NCLEX: Health Promotion and Maintenance

A patient at the clinic who has metastatic breast cancer has a new prescription for trastuzumab (Herceptin). The nurse will plan to a. teach the patient about the need to monitor serum electrolyte levels. b. ask the patient to call the health care provider before using any over-the-counter (OTC) pain relievers. c. instruct the patient to call if she notices ankle swelling. d. have the patient schedule frequent eye examinations.

Answer: C Rationale: Herceptin can lead to ventricular dysfunction, so the patient is taught to self-monitor for symptoms of heart failure. There is no need to monitor serum electrolyte levels. OTC pain relievers do not interact with Herceptin. Changes in visual acuity may occur with tamoxifen, but not with Herceptin.

Following a modified radical mastectomy, a patient tells the nurse the health care provider has recommended a flap procedure for breast reconstruction but that she did not understand how this was done. The nurse explains that the most common procedure, a transverse rectus abdominis musculocutaneous (TRAM) flap, involves a. relocating muscle tissue from the back and using it to form a breast. b. removing a portion of an abdominal muscle to use as breast tissue. c. pulling part of the abdominal muscle up to the breast area through a tunnel in the chest. d. relocating the arteries from the abdominal muscle to improve circulation to the implant.

Answer: C Rationale: In the TRAM flap, part of the rectus abdominis muscle is tunneled to the breast area and molded to form a breast. In the latissimus dorsi musculocutaneous flap, muscle tissue from the back is used to replace breast tissue. The abdominal muscle is not detached but is still attached to the rectus muscle. The arteries are not relocated.

Following a modified radical mastectomy, the health care provider recommends chemotherapy even though the lymph nodes were negative for cancer cells. The patient tells the nurse that she does not know what to do about chemotherapy because she has heard that she may not even need chemotherapy and that the side effects are uncomfortable. The nursing diagnosis that best reflects the patient's problem is a. anxiety related to prospect of additional cancer therapy. b. fear related to uncomfortable side effects of chemotherapy. c. decisional conflict related to lack of knowledge about prognosis and treatment options. d. risk for ineffective health maintenance related to reluctance to consider additional treatment.

Answer: C Rationale: The patient's statements indicate that she is having difficulty making a decision about treatment because of a lack of understanding about prognosis and treatment. Although she may have some anxiety and fear, these are not the priorities at this time. The patient expresses concerns about chemotherapy rather than reluctance to consider additional treatment.

A 42 year-old patient tells the nurse that she has found a painless lump in her right breast during her monthly self-examination. She says that she is afraid that she has cancer. Which assessment finding would most strongly suggest that this patient's lump is cancerous? A) Eversion of the right nipple and mobile mass B) A nonmobile mass with irregular edges C) A mobile mass that is soft and easily delineated D) Nonpalpable right axillary lymph nodes

B (Feedback: Breast cancer tumors are typically fixed, hard, and poorly delineated with irregular edges. A mobile mass that is soft and easily delineated is most commonly a fluid-filled benign cyst. Axillary lymph nodes may or may not be palpable on initial detection of a cancerous mass. Nipple retraction, not eversion, may be a sign of cancer.)

A platelet transfusion is indicated for a patient who....? A) is in hypovolemic shock. B) has thrombocytopenia. C) has a systemic infection. D) has hemolytic anemia.

B) has thrombocytopenia. Rationale: Thrombocytopenia is a low platelet count. When platelet counts drop below 20,000/mm3, a transfusion of platelets is generally indicated.

You are caring for a patient with a diagnosis of iron-deficiency anemia. Which clinical manifestations are you most likely to observe when assessing this patient? A. Convex nails, bright red gums, and alopecia B. Brittle nails; smooth, shiny tongue; and cheilosis C. Tenting of the skin, sunken eyes, and complaints of diarrhea D. Pale pink tongue; dull, brittle hair; and blue mucous membranes

B. Brittle nails; smooth, shiny tongue; and cheilosis Specific clinical manifestations may be related to iron-deficiency anemia. Pallor is the most common finding, and glossitis (inflammation of the tongue) is the second most common; another finding is cheilitis (inflammation of the lips). The patient may report headache, paresthesias, and a burning sensation of the tongue, all of which are caused by lack of iron in the tissues.

The nurse should notify the healthcare provider before administering fresh frozen plasma (FFP) based on which assessment finding? A. White sclera B. Jugular venous distention C. Strong pedal pulses D. Absence of tenting skin turgor

B. Jugular Vein Distention

The nurse should notify the healthcare provider before administering fresh frozen plasma (FFP) based on which assessment finding? A. White sclera B. Jugular venous distention C. Strong pedal pulses D. Absence of tenting skin turgor

B. Jugular venous distention

A patient receiving plasma develops transfusion-related acute lung injury (TRALI) 4 hours after the transfusion. What type of aggressive therapy does the nurse anticipate the patient will receive to prevent death from the injury? (Select all that apply.) A. Serial chest x-rays B. Oxygen C. Fluid support D. Intubation and mechanical ventilation E. Intra-aortic balloon pump

B. Oxygen C. Fluid support D. Intubation and mechanical ventilation

The nurse is administering 2 units of packed RBCs to an older adult patient who has a bleeding duodenal ulcer. The patient begins to experience difficulty breathing and the nurse assesses crackles in the lung bases, jugular vein distention, and an increase in blood pressure. What action by the nurse is necessary if the reaction is severe? (Select all that apply.) A. Continue the infusion but slow the rate down B. Place the patient in an upright position with the feet dependent C. Administer diuretics as prescribed D. Discontinue the transfusion E. Administer oxygen

B. Place the patient in an upright position with the feet dependent C. Administer diuretics as prescribed D. Discontinue the transfusion E. Administer oxygen

you are caring for a patient with severe-trauma whose blood type is A. a blood transfusion is ordered STAT. you know that the patient can safely receive blood from blood group O because.....? A) type O blood contains no A antibodies. B) type O blood contains no A antigens. C) type A blood contains O antibodies. D) type A blood contains O antigens.

B. Type O blood contains no A antigens

When obtaining assessment data from a patient with a microcytic, hypochromic anemia, you question the patient about A. folic acid intake. B. dietary intake of iron. C. a history of gastric surgery. D. a history of sickle cell anemia.

B. dietary intake of iron. Iron deficiency anemia is a type of microcytic, hypochromic anemia.

When caring for a patient with metastatic cancer, you note a hemoglobin level of 8.7 g/dL and hematocrit of 26%. You place highest priority on initiating interventions that can reduce A. thirst. B. fatigue. C. headache. D. abdominal pain.

B. fatigue. The patient with a low hemoglobin level and hematocrit is anemic and is most likely to experience fatigue. Fatigue develops because of the lowered oxygen-carrying capacity that leads to reduced tissue oxygenation with which to carry out cellular functions.

A client is brought to the emergency department having experienced blood loss related to an arterial laceration. Fresh-frozen plasma is prescribed and transfused to replace fluid and blood loss. The nurse understands that the rationale for transfusing fresh-frozen plasma in this client is: A. to treat the loss of platelets B. to promote rapid volume expansion C. That the transfusion must be done slowly D. That it will increase the hemoglobin and hematocrit levels.

B. to promote rapid volume expansion Fresh-frozen plasma is often used for volume expansion as a result of fluid and blood loss. It does not contain platelets, so it is not used to treat any type of low platelet count disorder. It is rich in clotting factors and can be thawed quickly and transfused quickly. It will not specifically increase the hemoglobin and hematocrit level.

Prior to administering a blood transfusion, it is essential to explain to the patient that......? A) you will check his vital signs every 15 minutes throughout the blood transfusion. B) you might have a nursing assistant check on him periodically during the transfusion. C) he must immediately report any subjective symptoms like chills, nausea, or itching. D) if he has no reaction in the first 15 to 30 minutes, he will not have any adverse effects later.

C

23-year-old woman comes to the free clinic stating I think I have a lump in my breast. Do I have cancer? The nurse instructs the patient that a diagnosis of breast cancer is confirmed by what? A) Supervised breast self-examination B) Mammography C) Fine-needle aspiration D) Chest x-ray

C (Feedback: Fine-needle aspiration and biopsy provide cells for histologic examination to confirm a diagnosis, although falsenegative and falsepositive findings are possibilities. A breast self-examination, if done regularly, is the most reliable method for detecting breast lumps early, but is not diagnostic of cancer. Mammography is used to detect tumors that are too small to palpate. Chest x-rays can be used to pinpoint rib metastasis. Neither test is considered diagnostic of breast cancer, however.)

During a recent visit to the clinic a woman presents with erythema of the nipple and areola on the right breast. She states this started several weeks ago and she was fearful of what would be found. The nurse should promptly refer the patient to her primary care provider because the patient's signs and symptoms are suggestive of what health problem? A) Peau d'orange B) Nipple inversion C) Paget's disease D) Acute mastitis

C (Feedback: Paget's disease presents with erythema of the nipple and areola. Peau d'orange, which is associated with breast cancer, is caused by interference with lymphatic drainage, but does not cause these specific signs. Nipple inversion is considered normal if long-standing; if it is associated with fibrosis and is a recent development, malignancy is suspected. Acute mastitis is associated with lactation, but it may occur at any age.)

The nurse leading an educational session is describing self-examination of the breast. The nurse tells the women's group to raise their arms and inspect their breasts in a mirror. A member of the women's group asks the nurse why raising her arms is necessary. What is the nurse's best response? A) It helps to spread out the fat that makes up your breast. B) It allows you to simultaneously assess for pain. C) It will help to observe for dimpling more closely. D) This is what the American Cancer Society recommends.

C (Feedback: The primary reason for raising the arms is to detect any dimpling. To elicit skin dimpling or retraction that may otherwise go undetected, the examiner instructs the patient to raise both arms overhead. Citing American Cancer Society recommendations does not address the woman's question. The purpose of raising the arms is not to elicit pain or to redistribute adipose tissue.(

Which findings do you expect to find for a patient with acute loss of blood? A. Weakness, lethargy, and warm, dry skin B. Restlessness, hyperthermia, and bradycardia C. Tachycardia, hypotension, and cool, clammy skin D. Widened pulse pressure, anxiety, and hypoventilation

C. Tachycardia, hypotension, and cool, clammy skin Tachycardia, hypotension, and cool, clammy skin can be found in a person who has had an acute loss of blood. These are manifestations of hypovolemic shock. A person with a bleeding peptic ulcer who had a 750-mL hematemesis (15% of a normal total blood volume) within the past 30 minutes may have postural hypotension. Because blood is shunted to major organs, the skin in the periphery is cool to the touch. Tachycardia is the body's attempt to maintain adequate cardiac output.

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 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.

A nurse is transfusing 2 units of packed red blood cells (PRBCs) to a postoperative client. What post-transfusion electrolyte imbalance does the nurse want to rule out? A. Hypercalcemia B. Hyperkalemia C. Hypomagnesemia D. Hyponatremia

Correct answer B During transfusion, some cells are damaged. These cells release potassium, thus raising the client's serum potassium level (hyperkalemia). This complication is especially common with packed cells and whole blood products.

A woman is being treated for a tumor of the left breast. If the patient and her physician opt for prophylactic treatment, the nurse should prepare the woman for what intervention? A) More aggressive chemotherapy B) Left mastectomy C) Radiation therapy D) Bilateral mastectomy

D (Feedback: Right mastectomy would be considered a prophylactic measure to reduce the risk of cancer in the patient's unaffected breast. None of the other listed interventions would be categorized as being prophylactic rather than curative.)

The nurse is caring for a 52-year-old woman whose aunt and mother died of breast cancer. The patient states, My doctor and I talked about Tamoxifen to help prevent breast cancer. Do you think it will work? What would be the nurse's best response? A) Yes, it's known to have a slight protective effect. B) Yes, but studies also show an increased risk of osteoporosis. C) You won't need to worry about getting cancer as long as you take Tamoxifen. D) Tamoxifen is known to be a highly effective protective measure.

D (Feedback: Tamoxifen has been shown to be a highly effective chemopreventive agent. However, it cannot reduce the risk of cancer by 100%. It also acts to prevent osteoporosis.)

patient newly diagnosed with breast cancer states that her physician suspects regional lymph node involvement and told her that there are signs of metastatic disease. The nurse learns that the patient has been diagnosed with stage IV breast cancer. What is an implication of this diagnosis? A) The patient is not a surgical candidate. B) The patient's breast cancer is considered highly treatable. C) There is a 10% chance that the patient's cancer will self-resolve. D) The patient has a 15% chance of 5-year survival

D (Feedback: The 5-year survival rate is approximately 15% for stage IV breast cancer. Surgery is still a likely treatment, but the disease would not be considered to be highly treatable. Self-resolution of the disease is not a possibility.)

A patient in her 30s has two young children and has just had a modified radical mastectomy with immediate reconstruction. The patient shares with the nurse that she is somewhat worried about her future, but she appears to be adjusting well to her diagnosis and surgery. What nursing intervention is most appropriate to support this patient's coping? A) Encourage the patient's spouse or partner to be supportive while she recovers. B) Encourage the patient to proceed with the next phase of treatment. C) Recommend that the patient remain optimistic for the sake of her children. D) Arrange a referral to a community-based support program.

D (Feedback: The patient is not exhibiting clear signs of anxiety or depression. Therefore, the nurse can probably safely approach her about talking with others who have had similar experiences. The nurse may educate the patient's spouse or partner to listen for concerns, but the nurse should not tell the patient's spouse what to do. The patient must consult with her physician and make her own decisions about further treatment. The patient needs to express her sadness, frustration, and fear. She cannot be expected to be optimistic at all times.)

a patient who is anticipating a total hip replacement is considering autologus transfusion. when teaching this pt about autologus transfusion it is important to emphasize that....? A) donations may be made every other day. B) there is no need to test the blood for infectious diseases. C) a hemoglobin level above 9.5 mg/dL is required. D) it reduces the risk of mismatched blood.

D.

type of protein the immune system produces to neutralize a threat of some kind, such as an incompatible substance in the blood is called____? A) agglutinogen. B) allergen. C) antigen. D) antibody.

D. Antibody

A nurse is completing a detailed health history and assessment in the electronic medical record (EMR) on a patient with a disorder of the hematopoietic system. Based on the patient's responses, which of the following symptoms is the most common complaint associated with hematologic diseases? a) Blurred vision b) Dyspnea c) Severe headaches d) Extreme fatigue

D. Extreme fatigue

you started a blood transfusion 1hr ago. your pt suddenly develops shaking, chills, muscle stiffness, temp of 101.4. he appears flushed, c/o HA, & nervousness. what kind of reaction is your pt most likely experiencing? A) Septic B) Acute hemolytic C) Allergic D) Febrile nonhemolytic

D. Febrile NonHemolytic

The care plan for a patient with aplastic anemia should include activities to minimize the risk for which complications? A. Dyspnea and pain B. Diarrhea and fatigue C. Nausea and malnutrition D. Infection and hemorrhage

D. Infection and hemorrhage You must assist the patient in reducing infection risk. The patient is susceptible to infection and is at risk for septic shock and death. Even a low-grade temperature (>100.4° F) should be considered a medical emergency. Thrombocytopenia manifests as a predisposition to bleeding evidenced by petechiae, ecchymosis, and epistaxis. Pain is not experienced nor is diarrhea. Nausea and malnutrition are not related to this disease except as a by-product of infection.

A nurse is transfusing a unit of whole blood to a client when the health care provider requests the following: "Furosemide (Lasix) 20 mg IV push." What does the nurse do? A. Adds Lasix to the normal saline that is infusing with the blood B. Administers Lasix to the client intramuscularly (IM) C. Piggy-backs Lasix into the infusing blood D. Waits until the transfusion has been completed to administer Lasix.

D. Wait until the transfusion has been completed to administer Lasix

A patient comes into the emergency room with complaints of an enlarged tongue. The tongue appears smooth and beefy red in color. The nurse also observes a 5-cm incision on the upper left quadrant of the abdomen. When questioned, the patient states, "I had a partial gastrostomy 2 years ago." Based on this information, the nurse attributes these symptoms to which of the following problems? a) Folic acid deficiency b) Vitamin A deficiency c) Vitamin B12 deficiency d) Vitamin C deficiency

Explanation: Because vitamin B12 is found only in foods of animal origin, strict vegetarians may ingest little vitamin B12. Vitamin B12 combines with intrinsic factor produced in the stomach. The vitamin B12-intrinsic factor complex is absorbed in the distal ileum. People who have had a partial or total gastrectomy may have limited amounts of intrinsic factor, and therefore the absorption of vitamin B12 may be diminished. The effects of either decreased absorption or decreased intake of vitamin B12 are not apparent for 2-4 years. This results in megaloblastic anemia. Some symptoms are smooth, beefy red, enlarged tongue and cranial nerve deficiencies.

The doctor may order an antiviral medication before the transfusion to decrease the risk of disease transmission true/false

FALSE

What would you do if your patient was B+ and the blood bank sent you O+ blood?

Go ahead with transfusion; O+ blood is universal.

Albumin is important for the maintenance of fluid balance within the vascular system. Albumin is produced by which of the following?

Liver Explanation: Albumin is produced by the liver.

What interventions are indicated for a client who develops circulatory overload as the result of their transfusion? Check all that apply. Notify the MD Establish a second IV site. Give a diuretic as ordered. Slow (or stop) the transfusion. Place the patient in an upright position Apply anti-embolic stockings (i.e. TEDS) Send the used blood tubing to the blood bank for analysis.

Notify the MD Give a diuretic as ordered. Slow (or stop) the transfusion. Place the patient in an upright position

Your patient has a unit of PRBC's infusing. The physician comes to you and wants a unit of platelets transfused as well. He tells you that it has to be now while the blood is infusing since the platelet count is 25,000. The unit of blood just went up and needs to go over 2 hours. The pt has a second IV access. What would you do?

Tell the doctor we have to do this one at a time.

You are caring for a pt who is requiring frequent transfusions for continued bleeding. The MD writes orders: Keep 2 units ahead at all times and check a serum Ca level. What is the rationale for both of these orders?

You should always keep 2 units in blood bank ready to go. Ca level is checked for hypocalcemia (anemic pts can get hypocalcemia due to citrate binding in the transfusion).

Which of the following is a symptom of severe thrombocytopenia? a) Petechiae b) Dyspnea c) Inflammation of the tongue d) Inflammation of the mouth

a) Petechiae Explanation: Patients with severe thrombocytopenia have petechiae (i.e. pinpoint hemorrhagic lesions, usually more prominent on the trunk or anterior aspects of the lower extremities).

During a blood transfusion with packed red blood cells (RBCs), a patient begins to complain of chills, low back pain, and nausea. What priority action should the nurse take? a) Observe for additional symptoms and notify the physician b) Discontinue the infusion immediately and notify the physician c) Discontinue the infusion immediately and maintain the IV line with normal saline solution using new IV tubing d) Slow the infusion rate and continue to monitor the patient every 15 minutes

c) Discontinue the infusion immediately and maintain the IV line with normal saline solution using new IV tubing Explanation: The following steps are taken to determine the type and severity of the reaction: Stop the transfusion. Maintain the IV line with normal saline solution through new IV tubing, administered at a slow rate. Assess the patient carefully. Notify the physician. Continue to monitor the patient's vital signs and respiratory, cardiovascular, and renal status. Notify the blood bank that a suspected transfusion reaction has occurred and send the blood container and tubing to the blood bank for repeat typing and culture.

After the nurse completes discharge teaching for a patient who has had a left modified radical mastectomy and lymph node dissection, which statement by the patient indicates that no further teaching is needed? a. "I will avoid reaching over the stove with my left hand." b. "I will need to do breast self-examination on my right breast monthly." c. "I will keep my left arm elevated until I go to bed." d. "I will remember to use my right arm and to rest the left one."

nswer: A Rationale: The patient should avoid any activity that might injure the left arm, such as reaching over a burner. Breast self-examination should be done to the right breast and the left mastectomy site. The left arm should be elevated when the patient is lying down also. The left arm should be used to improve range of motion and function.