Exam 2
The nurse is preparing a client for skin testing. The client has been taking an over-the-counter allergy medication. The nurse would instruct the client to stop taking the medication at which time before the test?
2-4 days
When a nurse infuses gamma globulin intravenously, the rate should not exceed
3ml/min
An intensive care nurse is aware of the need to identify patients who may be at risk of developing disseminated intravascular coagulation (DIC). Which ICU client most likely faces the highest risk of DIC?
A client who is being treated for septic shock Sepsis is a common cause of DIC. A wide variety of acute illnesses can precipitate DIC, but sepsis is specifically identified as a cause.
A nurse knows of several clients who have achieved adequate control of their allergy symptoms using over-the-counter antihistamines. Antihistamines would be contraindicated in the care of which client?
A pregnant women at 30 weeks gestation Antihistamines are contraindicated during the third trimester of pregnancy. Previous tuberculosis, hormone therapy, and food allergies do not contraindicate the use of antihistamines.
A patient describes numbness in the arms and hands with a tingling sensation. The patient also frequently stumbles when walking. What vitamin deficiency does the nurse determine may cause some of these symptoms?
B12 The hematologic effects of vitamin B12 deficiency are accompanied by effects on other organ systems, particularly the gastrointestinal tract and nervous system. Patients with pernicious anemia may become confused; more often, they have paresthesias in the extremities (particularly numbness and tingling in the feet and lower legs). They may have difficulty maintaining their balance because of damage to the spinal cord, and they also lose position sense (proprioception).
A client is prescribed an oral corticosteroid for 2 weeks to relieve asthma symptoms. The nurse educates the client about side effects, which include
Adrenal suppression The nurse should instruct the client that side effects of oral corticosteroid therapy include adrenal suppression, fluid retention, weight gain, glucose intolerance, hypertension, and gastric irritation.
The nurse is caring for a client with acute myeloid leukemia (AML) with high uric acid levels. What medication does the nurse anticipate administering that will prevent crystallization of uric acid and stone formation?
Allopurinol Massive leukemic cell destruction from chemotherapy results in the release of intracellular electrolytes and fluids into the systemic circulation. Increases in uric acid levels, potassium, and phosphate are seen; this process is referred to as tumor lysis (cell destruction) syndrome. The increased uric acid and phosphorus levels make the client vulnerable to renal stone formation and renal colic, which can progress to acute renal failure. Clients require a high fluid intake, and prophylaxis with allopurinol (Zyloprim) to prevent crystallization of uric acid and subsequent stone formation.
A client diagnosed with arthritis doesn't want to take medications. Physical therapy and occupational therapy have been consulted for nonpharmacologic measures to control pain. What might physical and occupational therapy include in the care plan to help control this client's pain?
An exercise routine that includes ROM
A client comes to the walk-in clinic reporting weakness and fatigue. While assessing this client, the nurse finds evidence of petechiae and ecchymoses and notes that the spleen appears enlarged. What would the nurse suspect is wrong with this client?
Aplastic anemia Clients with aplastic anemia experience all the typical characteristics of anemia (weakness and fatigue). In addition, they have frequent opportunistic infections plus coagulation abnormalities that are manifested by unusual bleeding, small skin hemorrhages called petechiae, and ecchymoses (bruises). The spleen becomes enlarged with an accumulation of the client's blood cells destroyed by lymphocytes that failed to recognize them as normal cells, or with an accumulation of dead transfused blood cells. The blood cell count shows insufficient numbers of blood cells.
A client with rheumatoid arthritis tells the nurse about experiencing mild tinnitus, gastric intolerance, and rectal bleeding. What medication does the nurse suspect is causing these side effects?
Asprin Salicylates like aspirin may have side effects such as tinnitus, gastric intolerance and bleeding. While celecoxib, methotrexate, and hydroxychloroquine have GI upset effects, the tinnitus is unique to aspirin.
A patient with chronic kidney disease is being examined by the nurse practitioner for anemia. The nurse has reviewed the laboratory data for hemoglobin and RBC count. What other test results would the nurse anticipate observing?
Decreased level of erythropoietin Differentiation of the primitive myeloid stem cell into an erythroblast is stimulated by erythropoietin, a hormone produced primarily by the kidney. If the kidney detects low levels of oxygen, as occurs when fewer red cells are available to bind oxygen (i.e., anemia), or with people living at high altitudes with lower atmospheric oxygen concentrations, erythropoietin levels increase. The increased erythropoietin then stimulates the marrow to increase production of erythrocytes. The entire process of erythropoiesis typically takes 5 days. For normal erythrocyte production, the bone marrow also requires iron, vitamin B12, folate, pyridoxine (vitamin B6), protein, and other factors. A deficiency of these factors during erythropoiesis can result in decreased red cell production and anemia
A client is receiving radiation therapy for lesions in the abdomen from non-Hodgkin's lymphoma. Because of the effects of the radiation treatments, what will the nurse assess for?
Diarrheal stools Side effects of radiation therapy are limited to the area being irradiated. Clients who have abdominal radiation therapy may experience diarrhea. If the lesions were in the upper chest, then the client may experience adventitious lung sounds or laryngeal edema as side effects. Hair loss is associated more with chemotherapy than radiation therapy.
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?
Discontinue the infusion immediately and maintain the IV with normal saline solution using new IV tubing 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 client carefully. Notify the physician. Continue to monitor the client's vital signs and respiratory, cardiovascular, and renal status. Notify the blood bank that a suspected transfusion reaction has occurred. Send the blood container and tubing to the blood bank for repeat typing and culture.
Which nursing instructions help parents of a child with hemophilia provide a safe home environment for their child?
Establish a written emergency plan including what to do in specific situations and the names and phone numbers of emergency contacts
A nurse at a blood donation clinic has completed the collection of blood from a woman. The woman states that she feels "lightheaded" and she appears visibly pale. What is the nurse's most appropriate action?
Help her into a sitting position with her head below her knees A donor who appears pale or complains of faintness should immediately lie down or sit with the head lowered below the knees. He or she should be observed for another 30 minutes. There is no immediate need for a physician's care. Supplementary oxygen may be beneficial, but may take too much time to facilitate before a syncopal episode. Repositioning must precede assessment of vital signs.
A home health nurse is caring for a client with multiple myeloma. What intervention should the nurse prioritize when addressing the client's severe bone pain?
Helping the patient manage the opioid analgesic regimen For severe pain resulting from multiple myeloma, opioids are likely necessary. NSAIDs would likely be ineffective and are associated with significant adverse effects. Hot and cold packs as well as distraction would be insufficient for severe pain, though they may be useful as adjuncts.
A client diagnosed with acute myelogenous leukemia has just been admitted to the oncology unit. When writing this client's care plan, what potential complication should the nurse address?
Hemorrhage Pancreatitis, arteritis, and liver dysfunction are generally not complications of leukemia. However, the client faces a high risk of hemorrhage.
The nurse is assessing a new client with complaints of acute fatigue and a sore tongue that is visibly smooth and beefy red. This client is demonstrating signs and symptoms associated with what form of hematologic disorder?
Megaloblastic Anemia
A patient is suspected of having myositis. The nurse prepares the patient for what procedure that will confirm the diagnosis?
Muscle biopsy
Which statement would alert the nurse to suspect a client is experiencing a mild anaphylactic reaction?
My throat feels like its full Manifestations of a mild anaphylactic reaction include peripheral tingling and a sensation of warmth, a sensation of fullness in the mouth and throat, nasal congestion, periorbital swelling, pruritus, sneezing, and tearing of the eyes. Flushing, warmth, anxiety, and itching in addition to the mild symptoms indicate a moderate reaction. A severe systemic reaction begins abruptly with the mild and moderate symptoms rapidly progressing to bronchospasm, laryngeal edema, severe dyspnea, cyanosis, and hypotension as well as dysphagia, abdominal cramping, vomiting, diarrhea, and possibly seizures.
A nurse is planning the care of a client who has a diagnosis of hemophilia A. When addressing the nursing diagnosis of Acute Pain Related to Joint Hemorrhage, what principle should guide the nurse's choice of interventions?
NSAIDs are contraindicated due to risk for bleeding NSAIDs may be contraindicated in clients with hemophilia due to the associated risk of bleeding. Opioids do not have a similar effect and they do not inhibit platelet synthesis. The pain associated with hemophilia is not neuropathic.
The nurse, caring for a client in the emergency room with a severe nosebleed, becomes concerned when the client asks for a bedpan. The nurse documents the stool as loose, tarry, and black looking. The nurse suspects the client may have thrombocytopenia. What should be the nurse's priority action?
Notify the physician Thrombocytopenia is evidenced by purpura, small hemorrhages in the skin, mucous membranes, or subcutaneous tissues. Bleeding from other parts of the body, such as the nose, oral mucous membrane, and the gastrointestinal tract, also occurs. Internal hemorrhage, which can be severe and even fatal, is possible. This nurse should notify the physician of the suspected disorder.
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?
Resume the transfusion Some clients develop urticaria (hives) or generalized itching during a transfusion. The cause of these reactions is thought to be a sensitivity reaction to a plasma protein within the blood component being transfused. Symptoms of an allergic reaction are urticaria, itching, and flushing. The reactions are usually mild and respond to antihistamines. If the symptoms resolve after administration of an antihistamine (e.g., diphenhydramine), the transfusion may be resumed.
A 40-year-old woman was diagnosed with Raynaud phenomenon several years earlier and has sought care because of a progressive worsening of her symptoms. The client also states that many of her skin surfaces are "stiff, like the skin is being stretched from all directions." The nurse should recognize the need for medical referral for the assessment of what health problem?
Scleroderma Scleroderma starts insidiously with Raynaud phenomenon and swelling in the hands. Later, the skin and the subcutaneous tissues become increasingly hard and rigid and cannot be pinched up from the underlying structures. This progression of symptoms is inconsistent with GCA, FM, or RA.
An older adult client is to receive 2 units of packed red blood cells. During the transfusion of the first unit at 125 mL/hour, the client reports shortness of breath 30 minutes into the process. The client exhibits the vital signs shown in the accompanying table. What is the nurse's best intervention?
Slow the rate of transfusion and administer furosemide The description is consistent with a client who is experiencing circulatory overload. The nurse is to slow the rate of the transfusion and administer a diuretic. Oxygen is administered with a prescription and for severe dyspnea. This option does not allow for the nurse to slow the transfusion. The nurse would still be administering the blood at the current rate of 125 mL/hour. Diphenhydramine (Benadryl) would be prescribed for an allergic reaction. Blood and urine specimens are obtained for acute hemolytic reactions.
An older adult client who is a vegetarian has a hemoglobin of 10.2 gm/dL, vitamin B12 of 68 pg/mL (normal: 200-900 pg/mL), and MCV of 110 cubic micrometers. After interpreting the data, what instruction should the nurse give to the client?
Supplement the diet with vitamin B12 Data support that the client is experiencing megaloblastic anemia. Findings include the laboratory test results, the client's older age, and the client's status as a vegetarian. Many vegetarians need to supplement their diet with vitamin B12. Eating more foods with vitamin B12 will not provide enough of this vitamin for the client's body. Increasing iron sources will not resolve the client's anemia. Telling the client to discontinue the vegetarian practice and eat red meat is nontherapeutic.
A nurse, caring for a client with human immunodeficiency virus (HIV), reviews the client's differential WBC count. What type of WBC will the nurse check the level of?
T lymphocytes Lymphocytes (T cells, B cells, and natural killer cells) are WBCs that are the major components of the body's immune response. T cells are primarily responsible for cell-mediated immunity, whereas B cells are involved in antibody production.
A client is diagnosed with pneumocystis pneumonia (PCP). What medication does the nurse anticipate educating the client about for treatment?
TMP-SMZ TMP-SMZ (Bactrim, Cotrim, Septra) is the treatment of choice for PCP; it is as effective as parenteral pentamidine isethionate (Pentacarinat) and more effective than other regimens.
The nurse is gathering data from laboratory studies for a client who has HIV. The clients T4-cell count is 200/mm3, and the client has been diagnosed with Pneumocystis pneumonia. What does this indicate to the nurse?
The client has converted from HIV to AIDS AIDS is the end stage of HIV infection. Certain events establish the conversion of HIV infection to AIDS: a markedly decreased T4 cell count from a normal level of 800 to 200/mm3 and the development of certain cancers and opportunistic infections. The client does not have advanced HIV; they meet the criteria for the development of AIDS. The T4-cell count is not decreasing due to an infection.
A nurse is assessing a client for risk factors known to contribute to osteoarthritis. What assessment finding should the nurse interpret as a risk factor?
The clients BMI is 34 (Obese) Risk factors for osteoarthritis include obesity and previous joint damage. Risk factors of OA do not include smoking or hypertension. Incidence increases with age, but a client who is 58 years old would not yet face a significantly heightened risk.
A client with a pulmonary embolism is being treated with a heparin infusion. What diagnostic finding suggests to the nurse that treatment is effective?
The clients activated partial thromboplastin time (aPTT) is 1.5 to 2.5 times the control value. The therapeutic effect of heparin is monitored by serial measurements of the aPTT; the dose is adjusted to maintain the range at 1.5 to 2.5 times the laboratory control. Heparin dosing is not determined on the basis of platelet levels, the presence or absence of clotting factors, or PT levels.
A client with a myelodysplastic syndrome is being treated on the medical unit. What assessment finding should prompt the nurse to contact the client's primary care provider?
The clients oral temp is 37.5 (99.5)
A client is being treated in the ICU after a medical error resulted in an acute hemolytic transfusion reaction. What was the etiology of this client's adverse reaction?
The donor blood was incompatible with the client An acute hemolytic reaction occurs when the donor blood is incompatible with that of the recipient. In the case of a febrile nonhemolytic reaction, antibodies to donor leukocytes remain in the unit of blood or blood component. An allergic reaction is a sensitivity reaction to a plasma protein within the blood component. Hypervolemia does not cause an acute hemolytic reaction
A child has been diagnosed with a severe walnut allergy after suffering an anaphylactic reaction. What is the nurse's priority for health education?
The need for the parent to carry an EpiPen
A client is scheduled for a splenectomy. During discharge education, what teaching point should the nurse prioritize?
The need to report any signs or symptoms of infection immediately After splenectomy, the client is instructed to seek prompt medical attention if even relatively minor symptoms of infection occur. Often, clients with high platelet counts have even higher counts after splenectomy, which can predispose them to serious thrombotic or hemorrhagic problems. However, this increase is usually transient and therefore often does not warrant additional treatment. Dietary modifications are not normally necessary and immunosuppressants would be strongly contraindicated.
One hour after the completion of a fresh frozen plasma transfusion, a client reports shortness of breath and is very anxious. The client's vital signs are BP 98/60, HR 110, temperature 99.4°F, and SaO2 88%. Auscultation of the lungs reveals posterior coarse crackles to the mid and lower lobes bilaterally. Based on the symptoms, the nurse suspects the client is experiencing which problem?
Transfusion related acute lung injury Transfusion-related acute lung injury (TRALI) is a potentially fatal, idiosyncratic reaction that is defined as the development of acute lung injury within 6 hours after a blood transfusion. It is more likely to occur when plasma and platelets are transfused. Onset is abrupt (usually within 6 hours of transfusion, often within 2 hours). Signs and symptoms include acute shortness of breath, hypoxia (arterial oxygen saturation [SaO2] less than 90%; pressure of arterial oxygen [PaO2] to fraction of inspired oxygen [FIO2] ratio less than 300), hypotension, fever, and eventual pulmonary edema
The nurse explains to a client that immunotherapy initially starts with injections at which interval?
Weekly Typically, immunotherapy begins with very small amounts and gradually increases, usually at weekly intervals until a maximum tolerated dose is attained. Then maintenance booster injections are administered at 2- to 4-week intervals, frequently for a period of several years.
An interdisciplinary team has been commissioned to create policies and procedures aimed at preventing acute hemolytic transfusion reactions. What action has the greatest potential to reduce the risk of this transfusion reaction?
be vigilant in identifying the client and blood component
The charge nurse should intervene when observing a new nurse perform which action after a client has suffered a possible hemolytic blood transfusion reaction?
disposing of the blood container and tubing into biohazard waste The blood container and tubing should be returned to the blood bank for repeat typing and culture, and the blood bank should be notified of the reaction
The nurse is conducting an initial assessment of a hospitalized client who states that he has a latex allergy. The nurse notes that the skin of the client's hands is dry, thick, and cracked. The nurse documents the client's reaction to latex as which condition?
irritant contact dermatitis Dry, thickened, and cracked skin is a symptom of a chronic irritant contact dermatitis, a common reaction to latex. Symptoms of allergic contact dermatitis in reaction to latex include pruritus, swelling, crusting and thickened skin, blisters, and other lesions. Symptoms of latex allergy include rhinitis, flushing, urticaria, laryngeal edema, bronchospasms, asthma, and cardiovascular collapse.
A client has a serum study that is positive for the rheumatoid factor. What will the nurse tell the client about the significance of this test result?
it is suggestive of rheumatoid arthritis Rheumatoid factor is present in about 70% to 80% of patients with rheumatoid arthritis, but its presence alone is not diagnostic of rheumatoid arthritis, and its absence does not rule out the diagnosis. The antinuclear antibody (ANA) test is used to diagnose Sjögren's syndrome and systemic lupus erythematosus.
A client with a diagnosis of acute myeloid leukemia (AML) is being treated with induction therapy on the oncology unit. What nursing action should be prioritized in the client's care plan?
protective isolation and vigilant use of standard precaution
A 21-year-old male has just been diagnosed with spondyloarthropathy. What nursing intervention should the nurse prioritize?
teaching about symptom management Major nursing interventions in the spondyloarthropathies are related to symptom management and maintenance of optimal functioning. This is a priority over the use of assistive devices, smoking cessation, and exercise programs, though these topics may be of importance for some clients.
The nurse is administering a blood transfusion to a client over 4 hours. After 2 hours, the client reports chills and has a fever of 101°F, an increase from a previous temperature of 99.2°F. What does the nurse recognize is occurring with this client?
the client is having a febrile nonhemolytic reaction The signs and symptoms of a febrile nonhemolytic transfusion reaction are chills (minimal to severe) followed by fever (more than 1°C elevation). The fever typically begins within 2 hours after the transfusion is begun. Although the reaction is not life-threatening, the fever, and particularly the chills and muscle stiffness, can be frightening to the client.
A client is scheduled to receive an intravenous immunoglobulin (IVIG) infusion. The client asks the nurse about the infusion's administration and its adverse effects. Which condition should the nurse instruct this client to report immediately?
tickle in the throat Continually assess the client for adverse reactions; be especially aware of complaints of a tickle or lump in the throat, which could be the precursor to laryngospasm that precedes bronchoconstriction.
A client with suspected exposure to HIV has been tested with the enzyme-linked immunosorbent assay (ELISA) with positive results twice. The next step for the nurse to explain to the client for confirmation of the diagnosis is to perform a:
western blot test for confirmation of diagnosis
A nurse is assisting a client into position prior to bone marrow aspiration. Which position will the nurse place the client prior to the procedure?
Prone Prior to the bone marrow aspiration, the nurse should place the client in either the prone position or lateral position with one leg flexed. The aspiration usually is performed on the anterior iliac crest. It would not be appropriate for the nurse to place the client in supine, knee-chest, or Trendelenburg positions.
A nurse is preparing to administer an antiretroviral medication to a client who is positive for HIV. The nurse identifies the drug as a nucleoside reverse transcriptase inhibitor (NRTI). What drug will the nurse administer?
Lamivudine Lamivudine (Epivir) is an antiretroviral agent that belongs to the class of NRTIs. Delavirdine (Rescriptor), etravirine (Intelence), and nevirapine (Viramune) are examples of non-nucleoside reverse transcriptase inhibitors (NNRTIs).
A client involved in a motor vehicle accident arrives at the emergency department unconscious and severely hypotensive. The nurse suspects the client has several fractures in the pelvis and legs. Which parenteral fluid is the best choice for the client's current condition?
Packed Red Blood cells In a trauma situation, the first blood product given is unmatched (O negative) packed RBCs. Fresh frozen plasma is commonly used to replace clotting factors. Normal saline or lactated Ringer's solution is used to increase volume and blood pressure; however, too much colloid will hemodilute the blood and doesn't improve oxygen-carrying capacity as well as packed RBCs do.
When administering intravenous immunoglobulin (IVIG), what is the most important action for the nurse to take?
Pre-medicate the patient with acetaminophen and diphenhydramine 30 minutes before starting