Exam 2

before blood transfusion

-VS 30 mins before -prime tubing -check orders, needs to say "give" -check name, birthday, blood bank number, order, expiration date -start slow -check in 15 minutes from time blood hits IV site

which of the following may be associated with a transfusion reaction? (select all that apply) fever pruritus back pain hemiplegia tachycardia chest pain dyspnea

?

A client newly diagnosed with acute leukemia asks why he is at such extreme risk for infection when his white blood cell count is so high. What is the nurse's best response? "Even though you have many white blood cells, they too immature to fight infection." "For now, your risk is low; however, when the chemotherapy begins, your risk for infection will be high." "These white blood cells are cancerous and live longer than normal white blood cells, so they are too old to fight infection." "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."

A

The nurse is administering oral care on a client with disseminated intravascular coagulopathy (DIC). Which if the following is the most appropriate for this client? Flossing should be limited to once a day. Alcohol-based mouthwashes should be used to prevent infection. Oral swabs should be used in administering oral care. Tooth brushing should be limited to once a shift.

c

no private room available. whats the best room to put patient in with another person colon resection and colostomy patient pneumonia patient cardiac cath patient larygeal cancer and trach patient

c

A female client diagnosed with multiple myeloma and the client asks the nurse about the diagnosis. The nurse bases the response on which description of this disorder? Altered red blood cell production Altered production of lymph nodes Malignant exacerbation in the number of leukocytes Malignant proliferation of plasma cells within the bone

d

NADIR

lowest point, all counts are at lowest really at risk for infection, bleeding, anemia

The client with Acute lymphocytic leukemia is at risk for infection. What should the nurse do? Place the client in a private room Have the client wear a mask Have staff wear gowns and gloves Restrict visitors

A

The home health nurse is visiting a client with autoimmune thrombocytopenic purpura (ATP). The client's platelet count currently is 80,000 It will be most important to teach the client and family about: Bleeding precautions Prevention of falls Oxygen therapy Conservation of energy

A

The nurse is developing a plan of care for the client with multiple myeloma and includes which priority intervention in the plan? Encouraging fluids Providing frequent oral care Coughing and deep breathing Monitoring the red blood cell count

A

in an effort to limit risk for infection, which interventions are incorporated into plan of care (select all that apply) use proper hand hygiene assist with oral hygiene several times per day assess breath sounds frequently encourage daily bathing restrict visitors to family members only check temp frequently

ABCDF only restrict sick visitors

Which of the following about BM aspiration are true (select all that apply) the hip area will be cleaned with antimicrobial solution before procedure the hip area will be shaved before the procedure a local anesthetic will be admin a sedative many be admin

ACD

BM aspiration is done without complication. immediately after the procedure you appropriately: perform passive ROM exercises with the affected hip apply pressure at the BM aspiration site apply heat at BM site massage BM site

B look for signs of bleeding

Mrs. Hogan complains of mild pain at the bone marrow aspiration site. She has the following medications ordered for pain. Which one would you administer? Ibuprofen 800mg PO acetaminophen 1000mg PO acetaminophen 650mg rectally Naproxen 220mg PO

B no NSAIDs--> bleeding rectally--> bleeding risk

The client is 22 days post transplant from an allogeneic stem cell transplantation and has been having 6 to 10 watery stools per day for the last 3 days. The nurse's assessment findings include all of the following. Which data support the possibility graft-versus-host disease (GVHD)? The patient's skin turgor on the arms and hands is poor. Today's platelet count is 5,000/mm3 and the WBCs are low. There is some peeling of skin on the patient's palms. The patient's urine output is less than 800 mL in 24 hours.

C

A patient with acute myelogenous leukemia is starting chemotherapy. When teaching the patient about the induction stage of chemotherapy, what is an appropriate statement? "The drugs are started slowly to minimize side effects." "You will be at increased risk for bleeding and infection." "High doses will be administered every day for several months." "Most patients have more energy and are resistant to infection."

B

During the induction phase of treatment for leukemia, the nurse should remove which items that the family has brought into the room? A bible A picture A sachet of Lavender A hairbrush

C

The goal of nursing care for a client with acute myeloid leukemia is to prevent: Cardiac Arrhythmias Liver Failure Renal Failure Hemorrhage

D

Mrs. Hogan has a low platelet count. A low platelet count is called thrombocytopenia. Thrombocytopenia increases risk for:

bleeding

where does leukemia orignate

bone marrow

To boost Mrs. Hogan's immune system function, her diet should be well-balanced and include an increased amount of: protein carbs fat calories

a