Med Surg Exam #3 Chapter 32-42
A client is prescribed 325 mg/day of oral ferrous sulfate. The nurse includes in client teaching, "Take your iron pill And decrease fruits and juices in your diet" Along with a decreased amount of dietary fiber" With dairy products" 1 hour before breakfast"
1 hour before breakfast"
Place the following steps in order when determining the type and severity of a transfusion reaction. 1-Assess the client. 2-Stop the transfusion. 3-Send the tubing and container to the blood bank. 4- Notify the blood bank. 5-Notify the health care provider.
2-Stop the transfusion. 1-Assess the client. 5-Notify the health care provider. 4- Notify the blood bank. 3-Send the tubing and container to the blood bank.
Which client is not a candidate for blood donation according to the American Heart Association? 86 year old male with blood pressure 110/70 mmHg 50 year old female with pulse 95 beats/minute 26 year old female with hemoglobin 11.0 g/dL 18 year old male weighing 52 kg.
26 year old female with hemoglobin 11.0 g/dL
A client with a history of congestive heart failure has an order to receive 1 unit of packed red blood cells (RBCs). If the nurse hangs the blood at 12:00 pm, by what time must the infusion be completed? 2:00 pm 6:00 pm 3:00 pm 4:00 pm
4:00 pm When packed red blood cells (PRBCs) or whole blood is transfused, the blood should be administered within a 4-hour period because warm room temperatures promote bacterial growth.
A client's family member asks the nurse why disseminated intravascular coagulation (DIC) occurs. Which statement by the nurse correctly explains the cause of DIC? "DIC is a complication of an autoimmune disease that attacks the body's own cells." "DIC is caused by abnormal activation of the clotting pathway, causing excessive amounts of tiny clots to form inside organs." "DIC occurs when the immune system attacks platelets and causes massive bleeding." "DIC is caused when hemolytic processes destroy erythrocytes."
DIC is caused by abnormal activation of the clotting pathway, causing excessive amounts of tiny clots to form inside organs
The nurse is caring for a client who had undergone hemodilution during surgery. Immediately after surgery, the nurse expects to see which lab result? Elevated creatinine Critically low arterial oxygen saturation Elevated erythrocyte concentration Decreased hematocrit
Decreased hematocrit
A patient is undergoing platelet pheresis at the outpatient clinic. What does the nurse know is the most likely clinical disorder the patient is being treated for? Sickle cell anemia Renal transplantation Essential thrombocythemia Extreme leukocytosis
Essential thrombocythemia
When assessing a client with a disorder of the hematopoietic or the lymphatic system, which assessment is most essential? Menstrual history Health history, such as bleeding, fatigue, or fainting Age and gender Lifestyle assessments, such as exercise routines
Health history, such as bleeding, fatigue, or fainting
Which term describes the percentage of blood volume that consists of erythrocytes? Erythrocyte sedimentation rate (ESR) Hematocrit Differentiation Hemoglobin
Hematocrit
A client with severe anemia reports symptoms of tachycardia, palpitations, exertional dyspnea, cool extremities, and dizziness with ambulation. Laboratory test results reveal low hemoglobin and hematocrit levels. Based on the assessment data, which nursing diagnoses is most appropriate for this client? Risk for falls related to complaints of dizziness Fatigue related to decreased hemoglobin and hematocrit Ineffective tissue perfusion related to inadequate hemoglobin and hematocrit Imbalanced nutrition, less than body requirements, related to inadequate intake of essential nutrients
Ineffective tissue perfusion related to inadequate hemoglobin and hematocrit
A client involved in a motor vehicle accident arrives at the emergency department unconscious and severely hypotensive. The nurse suspects he has several fractures in the pelvis and legs. Which parenteral fluid is the best choice for the client's current condition? Lactated Ringer's solution Normal saline solution Packed red blood cells (RBCs) Fresh frozen plasma
Packed red blood cells (RBCs)
A 18-year-old client presents to the emergency department with a severe open fracture of the lower extremity. The health care provider tells the client that the client will need a blood transfusion. The client refuses, despite the advise of the health care provider. What does the nurse understand is the legal implication of the scenario? The client has a right to refuse the transfusion. The client can only refuse the transfusion if the consent form has not been signed. The health care provider may first call the client's parents if the client refuses. The health care provider may ask for a court order if the client refuses.
The client has a right to refuse the transfusion.
The nurse caring for a client with acute liver failure should expect which assessment finding? Generalized edema Elevated blood pressure Decreased pulse Elevated albumin level
Generalized edema
Which initial intervention should a nurse perform for a client with external bleeding? Application of a tourniquet Direct pressure Pressure point control Elevation of the extremity
Direct pressure
A nurse practitioner provides nutritional information for a patient diagnosed with an iron-deficiency anemia. Select the best advice the nurse would give. Take an iron supplement with meals to reduce gastric irritation. Decrease the intake of high-fat red meats, especially organ meats. Decrease the intake of citrus fruits because they interfere with iron absorption. Increase the intake of green, leafy vegetables.
Increase the intake of green, leafy vegetables.
A client with a diagnosis of pernicious anemia comes to the clinic complaining of numbness and tingling in their arms and legs. What do these symptoms indicate? Loss of vibratory and position senses Neurologic involvement Severity of the disease Insufficient intake of dietary nutrients
Neurologic involvement Explanation: In clients with pernicious anemia, numbness and tingling in the arms and legs, and ataxia are the most common signs of neurologic involvement. Some affected clients lose vibratory and position senses. Jaundice, irritability, confusion, and depression are present when the disease is severe. Insufficient intake of dietary nutrients is not indicated by these symptoms.
Which type of lymphocyte is responsible for cellular immunity? T lymphocyte Plasma cell B lymphocyte Basophil
T lymphocyte Explanation: T lymphocytes are responsible for delayed allergic reactions, rejection of foreign tissue (e.g., transplanted organs), and destruction of tumor cells. This process is known as cellular immunity. B lymphocytes are responsible for humoral immunity. A plasma cell secretes immunoglobulin. A basophil contains histamine and is an integral part of hypersensitivity reactions.
A client in end-stage renal disease is prescribed epoetin alfa (Epogen) and oral iron supplements. Before administering the next dose of epoetin alfa and oral iron supplement, the nurse Ensures the client has completed dialysis treatment Assesses the hemoglobin level Questions the administration of both medications Holds the epoetin alfa if the BUN is elevated
Assesses the hemoglobin level
A nurse cares for several mothers and babies in the postpartum unit. Which mother does the nurse recognize as being most at risk for a febrile nonhemolytic reaction? Rh-positive mother; Rh-negative child Rh-negative mother; Rh-positive child Rh-positive mother; Rh-positive child Rh-negative mother; Rh-negative child
Rh-negative mother; Rh-positive child
When teaching a client with iron deficiency anemia about appropriate food choices, the nurse encourages the client to increase the dietary intake of which foods? Berries and orange vegetables Beans, dried fruits, and leafy, green vegetables Fruits high in vitamin C, such as oranges and grapefruits Dairy products
Beans, dried fruits, and leafy, green vegetables
A client tells the nurse that he would like to donate blood before his abdominal surgery next week. What should be the nurse's first action? Provide the client with a list of the nearest donation centers. Tell the client that 2 units of blood will be needed. Remind the client to take supplemental iron before donation. Explain the time frame needed for autologous donation.
Explain the time frame needed for autologous donation.
Albumin is important for the maintenance of fluid balance within the vascular system. Albumin is produced by which of the following? Liver Pancreas Large intestine Kidney
Liver
Parents arrive to the clinic with their young child and inform the nurse the child has just been diagnosed with sickle cell disease. The parents ask the nurse how this could have happened and which one of them is the carrier. What is the best response by the nurse? "Most likely, the father is the carrier of the gene." "The child must inherit two defective genes, one from each parent." "The trait is passed down through the mother." "It is an acquired, not a hereditary disorder."
"The child must inherit two defective genes, one from each parent."
The nurse should be alert to which adverse assessment finding when transfusing a unit of packed red blood cells (PRBCs) too rapidly? Oral temperature of 97°F Pain and tenderness in calf area Crackles auscultated bilaterally Respiratory rate of 10 breaths/minute
Crackles auscultated bilaterally
Which of the following describes a red blood cell (RBC) that has pale or lighter cellular contents? Normocytic Hypochromic Hyperchromic Microcytic
Hypochromic
The client's CBC with differential reveals small-shaped hemoglobin molecules. The nurse expects to administer which medication to this client? Folate Vitamin B12 Fresh frozen plasma Iron
Iron
A patient who has long-term packed RBC (PRBC) transfusions has developed symptoms of iron toxicity that affect liver function. What immediate treatment should the nurse anticipate preparing the patient for that can help prevent organ damage? Therapeutic phlebotomy Oxygen therapy Iron chelation therapy Anticoagulation therapy
Iron chelation therapy
The nurse is preparing a patient for a bone marrow aspiration and biopsy from the site of the posterior superior iliac crest. What position will the nurse place the patient in? Lithotomy position Lateral position with one leg flexed Jackknife position Supine with head of the bed elevated 30 degrees
Lateral position with one leg flexed
Vitamin B and folic acid deficiencies are characterized by production of abnormally large erythrocytes called Megaloblasts. Monocytes. Mast cells. Blast cells.
Megaloblasts.
A nurse practitioner reviewed the blood work of a male patient suspected of having microcytic anemia. The nurse suspected occult bleeding. Identify the laboratory result that would indicate this initial stage of iron deficiency. Serum iron: 100 ?g/dL Serum ferritin: 15 ng/mL Hemoglobin: 16 g/dL T otal iron-binding capacity: 300 ?g/dL
Serum ferritin: 15 ng/mL
The client is to receive a unit of packed red blood cells. The first intervention of the nurse is to Observe for gas bubbles in the unit of packed red blood cells. Ensure that the intravenous site has a 20-gauge or larger needle. Check the label on the unit of blood with another registered nurse. Verify that the client has signed a written consent form.
Verify that the client has signed a written consent form.
A client verbalizes fear of infection from a blood transfusion. What is the nurse's best response? "The risk of transmission of HIV is so low, there's no need to worry." "There is no need for testing unless you have a history of a transfusion reaction." "Blood typing is more important than testing for infection." "Every unit of donated blood is typed and tested for antibodies to infections."
"Every unit of donated blood is typed and tested for antibodies to infections."
The nurse is collecting data for a client who has been diagnosed with iron-deficiency anemia. What subjective findings does the nurse recognize as symptoms related to this type of anemia? "I have an increase in my appetite." "I have a difficult time falling asleep at night." "I have difficulty breathing when walking 30 feet." "I feel hot all of the time."
"I have difficulty breathing when walking 30 feet." Most clients with iron-deficiency anemia have reduced energy, feel cold all the time, and experience fatigue and dyspnea with minor physical exertion. The heart rate usually is rapid even at rest. The CBC and hemoglobin, hematocrit, and serum iron levels are decreased.
A patient will need a blood transfusion for the replacement of blood loss from the gastrointestinal tract. The patient states, "That stuff isn't safe!" What is the best response from the nurse? "I understand your concern. The blood is carefully screened but is not completely risk free." "You will have to decide if refusing the blood transfusion is worth the risk to your health." "The blood is carefully screened, so there is no possibility of you contracting any illness or disease from the blood." "I agree that you should be concerned with the safety of the blood, but it is important that you have this transfusion."
"I understand your concern. The blood is carefully screened but is not completely risk free."
A female client with the beta-thalassemia trait plans to marry a man of Italian ancestry who also has the trait. Which client statement indicates that she understands the teaching provided by the nurse? "If my fiancé was of Middle Eastern descent, I wouldn't be worried about having children." "I'll see a genetic counselor before starting a family." "I need to learn how to give myself vitamin B12 injections." "Thalassemia is treated with iron supplements."
"I'll see a genetic counselor before starting a family."
A nurse cares for a client with megaloblastic anemia who had a total gastrectomy three years ago. What statement will the nurse include in the client's teaching regarding the condition? "The condition is likely caused by a folate deficiency." "The condition is likely caused by a vitamin B12 deficiency." "The condition causes abnormally rigid red blood cells." "The condition causes abnormally small red blood cells."
"The condition is likely caused by a vitamin B12 deficiency."
A nurse is caring for a client who will undergo total knee replacement and will have an autologous transfusion. Which statement will the nurse include when teaching the client about the transfusion? "You typically donate blood the day of the surgery." "You will likely not need the blood that is donated." "You will be prescribed calcium to replace what is lost during donation." "You typically donate blood 4 to 6 weeks before the surgery."
"You typically donate blood 4 to 6 weeks before the surgery."
A patient with sickle cell anemia is to begin treatment for the disease with hydroxyurea (Hydrea). What does the nurse inform the patient will be the benefits of treatment with this medication? (Select all that apply.) -Lower incidence of acute chest syndrome -Decreased need for other analgesic medications -Ability to reverse the damage done from sickling of cells -Fewer painful episodes of sickle cell crisis -Decreased need for blood transfusions
-Fewer painful episodes of sickle cell crisis -Lower incidence of acute chest syndrome -Decreased need for blood transfusions
A complete blood count is commonly performed before a client goes into surgery. What does this test seek to identify? Electrolyte imbalance that could affect the blood's ability to coagulate properly Abnormally low hematocrit (HCT) and hemoglobin (Hb) levels Potential hepatic dysfunction indicated by decreased blood urea nitrogen (BUN) and creatinine levels Low levels of urine constituents normally excreted in the urine
Abnormally low hematocrit (HCT) and hemoglobin (Hb) levels
A client with Hodgkin disease had a bone marrow biopsy yesterday and reports aching at the biopsy site, rated a 5 (on a 1-10 scale). After assessing the biopsy site, which nursing intervention is most appropriate? Notify the physician Administer aspirin (ASA) 325 mg po, as ordered Reposition the client to a high Fowler position and continue to monitor the pain Administer acetaminophen 500 mg po, as ordered
Administer acetaminophen 500 mg po, as ordered
A client with sickle cell crisis is admitted to the hospital in severe pain. While caring for the client during the crisis, which is the priority nursing intervention? Administering and evaluating the effectiveness of opioid analgesics Limit foods that contain folic acid Limiting the client's intake of oral and IV fluids Encouraging the client to ambulate immediately
Administering and evaluating the effectiveness of opioid analgesics
A nurse is assigned to care for a patient with ascites, secondary to cirrhosis. The nurse understands that the fluid accumulation in the peritoneal cavity results from a combination of factors including an alteration in oncotic pressure gradients and increased capillary permeability. Therefore, the nurse monitors the serum level of the plasma protein responsible for maintaining oncotic pressure, which is: Fibrinogen. Prothrombin. Globulin. Albumin.
Albumin.
The physician performs a bone marrow biopsy from the posterior iliac crest on a client with pancytopenia. What intervention should the nurse perform after the procedure? Administer a topical analgesic to control pain at the site Apply pressure over the site for 5-7 minutes Pack the wound with half-inch sterile gauze Elevate the head of the bed to 45 degrees
Apply pressure over the site for 5-7 minutes
Which nursing intervention should be incorporated into the plan of care to manage the delayed clotting process due to thrombocytopenia in a client with leukemia? Monitoring temperature at least once per shift Eliminating direct contact with others who are infectious Applying prolonged pressure to needle sites or other sources of external bleeding Implementing neutropenic precautions
Applying prolonged pressure to needle sites or other sources of external bleeding
Which of the following cells are capable of differentiating into plasma cells? T lymphocytes B lymphocytes Neutrophils Eosinophils
B lymphocytes
Which type of leukocyte contains histamine and is an important part of hypersensitivity reactions? Basophils Plasma cell Neutrophil B lymphocyte
Basophils
Which is a symptom of hemochromatosis? Inflammation of the tongue Weight gain Bronzing of the skin Inflammation of the mouth
Bronzing of the skin
A client with a history of sickle cell anemia has developed iron overload from repeated blood transfusions. What treatment does the nurse anticipate will be prescribed? White blood cell filter Hepatitis B immunization Red blood cell phenotyping Chelation therapy
Chelation therapy
A nurse working with clients diagnosed with sickle cell disease notices that sickle cell crisis cases increase in the winter months. What is the primary pathophysiological reason for this? Colder temperatures increases vessel pressures. Colder temperatures slows the blood flow. Colder temperatures worsens sickling. Colder temperatures impairs oxygen uptake.
Colder temperatures slows the blood flow
A male client has been receiving a continuous infusion of weight-based heparin for more than 4 days. The client's PTT is at a level that requires an increase of heparin by 100 units per hour. The client has the laboratory findings shown above. The most important action of the nurse is to Consult with the physician about discontinuing heparin. Continue with the present infusion rate of heparin. Increase the heparin infusion by 100 units per hour. Begin treatment with the prescribed warfarin (Coumadin).
Consult with the physician about discontinuing heparin.
The nurse is instructing the client with polycythemia vera how to perform isometric exercises such as contracting and relaxing the quadriceps and gluteal muscle during periods of inactivity. What does the nurse understand is the rationale for this type of exercise? Contraction of skeletal muscle compresses the walls of veins and increases the circulation of venous blood as it returns to the heart. This type of exercise increases arterial circulation as it returns to the heart. Isometric exercise programs are inclusive of all muscle groups and have an aerobic effect to increase the heart rate. Isometric exercise decreases the workload of the heart and restores oxygenated blood flow.
Contraction of skeletal muscle compresses the walls of veins and increases the circulation of venous blood as it returns to the heart.
The nurse is instructing a client about taking a liquid iron preparation for the treatment of iron-deficiency anemia. What should the nurse include in the instructions? Do not take medication with orange juice because it will delay absorption of the iron. Dilute the liquid preparation with another liquid such as juice and drink with a straw. Discontinue the use of iron if your stool turns black. Iron may cause indigestion and should be taken with an antacid such as Mylanta.
Dilute the liquid preparation with another liquid such as juice and drink with a straw.
A client receiving a unit of packed red blood cells (PRBCs) has been prescribed morphine 1 mg intravenously now for pain. What is the best method for the nurse to administer the morphine? Administer the morphine into the closest tubing port to the client for fast delivery. Disconnect the blood tubing, flush with normal saline, and administer morphine. Add the morphine to the blood to be slowly administered. Inject the morphine into a distal port on the blood tubing.
Disconnect the blood tubing, flush with normal saline, and administer morphine.
The charge nurse should intervene when observing a new nurse perform which action after a client has suffered a possible hemolytic blood transfusion reaction? Informing the client to leave a urine sample after the client's next void. Disposing of the blood container and tubing in biohazard waste. Notifying the blood bank of the reaction. Documenting the reaction in the client's medical record.
Disposing of the blood container and tubing in 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 client is a young, thin woman who is prescribed iron dextran intramuscularly. The nurse, when administering the medication, Rubs the site vigorously Injects into the deltoid muscle Uses a 23-gauge needle Employs the Z-track technique
Employs the Z-track technique Explanation: When iron medications are given intramuscularly, the nurse uses the Z-track technique to avoid local pain and staining of the skin
A client receiving a blood transfusion complains of shortness of breath, appears anxious, and has a pulse of 125 beats/minute. What is the best action for the nurse to take after stopping the transfusion and awaiting further instruction from the healthcare provider? Remove the intravenous line. Administer prescribed PRN anti-anxiety agent. Ensure there is an oxygen delivery device at the bedside. Place the client in a recumbent position with legs elevated.
Ensure there is an oxygen delivery device at the bedside.
A client is prescribed an intravenous dose of iron dextran. The nurse Realizes that use of this medication will produce a false-positive when checking stool for blood Informs the client that one dose will reverse iron-deficiency anemia Ensures that epinephrine is available Checks the client's hemoglobin level the following day
Ensures that epinephrine is available Explanation: When iron is given intravenously, the nurse should have emergency medications, such as epinephrine, available in case of anaphylaxis.
The nurse observes the laboratory studies for a client in the hospital with fatigue, feeling cold all of the time, and hemoglobin of 8.6 g/dL and a hematocrit of 28%. What finding would be an indicator of iron-deficiency anemia? An increased number of erythrocytes Erythrocytes that are macrocytic and hyperchromic Erythrocytes that are microcytic and hypochromic Clustering of platelets with sickled red blood cells
Erythrocytes that are microcytic and hypochromic
A patient with chronic anemia has had many blood transfusions over the last 3 years. What type of transfusion reaction should the nurse monitor for that is commonly found in patients who frequently receive blood transfusions? Acute hemolytic reaction Circulatory overload Allergic reactions Febrile nonhemolytic reactions
Febrile nonhemolytic reactions Explanation: A febrile nonhemolytic reaction is caused by antibodies to donor leukocytes that remain in the unit of blood or blood component; it is the most common type of transfusion reaction. It occurs more frequently in patients who have had previous transfusions (exposure to multiple antigens from previous blood products) and in Rh-negative women who have borne Rh-positive children
A nurse administers blood products to a client with Hodgkin disease. During the administration, the nurse notes the client has a fever and diffuse reddened skin rash. From what condition does the nurse suspect the client is suffering? Delayed hemolytic reaction Bacterial contamination Creutzfeld-Jakob disease Graft-versus-host disease
Graft-versus-host disease Explanation: Graft-versus-hold disease (GVHD) occurs in only severely immunocompromised recipients (such as those with Hodgkin disease). The transfused lymphocytes attack the host lymphocytes or body tissues; symptoms or signs may include fever, diffuse reddened skin rash, nausea, vomiting, and diarrhea. The other answer choices are complications that can occur as a result of blood transfusion.
A client complains of extreme fatigue. Which system should the nurse suspect is most likely affected? Neurological Hematological Respiratory Integumentary
Hematological
A patient with ESRD is taking recombinant erythropoietin for the treatment of anemia. What laboratory study does the nurse understand will have to be assessed at least monthly related to this medication? Creatinine level Potassium level Folate levels Hemoglobin level
Hemoglobin level
A nurse is caring for a patient who has had a bone marrow aspiration with biopsy. What complication should the nurse be aware of and monitor the patient for? Hemorrhage Shock Splintering of bone fragments Blood transfusion reaction
Hemorrhage
When conducting a health assessment on a client suspected for having a hematological disorder, the nurse should collect which data? Select all that apply. Hair color Herbal supplements Dietary intake Medication use Ethnicity
Herbal supplements Dietary intake Medication use Ethnicity
Which blood cell type is matched correctly with its function? Plasma cell: Cell-mediated immunity B lymphocyte: Secretes immunoglobulin T lymphocyte: Humoral immunity Leukocyte: Fights infection
Leukocyte: Fights infection Explanation: Various blood cell types have unique, major functions. Leukocytes fight infection, T lymphocytes are integral in cell-mediated immunity, plasma cells secrete immunoglobulin, and B lymphocytes are integral in humoral immunity.
A client with sickle cell anemia has a High hematocrit. Normal blood smear. Low hematocrit. Normal hematocrit.
Low hematocrit.
Which term refers to a form of white blood cell involved in immune response? Thrombocyte Spherocyte Granulocyte Lymphocyte
Lymphocyte Explanation: Mature lymphocytes are the principal cells of the immune system, producing antibodies and identifying other cells and organisms as "foreign." Both B and T lymphocytes respond to exposure to antigens. Granulocytes include basophils, neutrophils, and eosinophils. A spherocyte is a red blood cell without central pallor, seen with hemolysis. A thrombocyte is a platelet
A nurse is reviewing a client's morning laboratory results and notes a left shift in the band cells. Based on this result, the nurse can interpret that the client May be developing anemia. Has leukopenia. Has thrombocytopenia. May be developing an infection.
May be developing an infection.
A nursing instructor is evaluating a student caring for a neutropenic client. The instructor concludes that the nursing student demonstrates accurate knowledge of neutropenia based on which intervention? Monitoring the client's heart rate and reviewing the client's hemoglobin Monitoring the client's breathing and reviewing the client's arterial blood gases Monitoring the client's blood pressure and reviewing the client's hematocrit Monitoring the client's temperature and reviewing the client's complete blood count (CBC) with differential
Monitoring the client's temperature and reviewing the client's complete blood count (CBC) with differential
Which cell of hematopoiesis is responsible for the production of red blood cells (RBCs) and platelets? Monocyte Myeloid stem cell Lymphoid stem cell Neutrophil
Myeloid stem cell
The body responds to infection by increasing the production of white blood cells (WBCs). The nurse knows to evaluate the differential count for the level of __________, the first WBCs to respond to an inflammatory event. Eosinophils Monocytes Basophils Neutrophils
Neutrophils
A nurse is caring for a client admitted with pernicious anemia. Which set of findings should the nurse expect when assessing the client? Angina pectoris, double vision, and anorexia Pallor, tachycardia, and a sore tongue Pallor, bradycardia, and reduced pulse pressure Sore tongue, dyspnea, and weight gain
Pallor, tachycardia, and a sore tongue
The nurse reviewing laboratory results of a client recovering from abdominal surgery notices an elevated number of reticulocytes. What is the nurse's first action? Notify the healthcare provider. Perform an abdominal assessment. Document the findings as expected results. Hold the prescribed blood transfusion.
Perform an abdominal assessment.
Which is a symptom of severe thrombocytopenia? Petechiae Dyspnea Inflammation of the tongue Inflammation of the mouth
Petechiae
Which is the major function of neutrophils? Destruction of tumor cells Phagocytosis Rejection of foreign tissue Production of immunoglobulins
Phagocytosis
Which of the following is considered an antidote to heparin? Vitamin K Narcan Ipecac Protamine sulphate
Protamine sulphate
An older adult patient presents to the physician's office with a complaint of exhaustion. The nurse, aware of the most common hematologic condition affecting the elderly, knows that which laboratory values should be assessed? Levels of plasma proteins WBC count Thrombocyte count RBC count
RBC count
The nurse obtains a unit of blood for the client, Donald D. Smith. The name on the label on the unit of blood reads Donald A. Smith. All the other identifiers are correct. The nurse Checks with Blood Bank first and then administers the blood with their permission Asks the client if he was ever known as Donald A. Smith Refuses to administer the blood Administers the unit of blood
Refuses to administer the blood
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? Obtain blood and urine samples from the client Send the blood back to the blood bank Position the client in an upright position with the feet in a dependent position Resume the transfusion
Resume the transfusion Some patients 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 [Benadryl]), the transfusion may be resumed.
A nurse reviews a client's laboratory results and notes the client has a decreased lymphocyte count. What nursing diagnosis will the nurse use when planning the client's care? Impaired oxygenation Risk for bleeding Impaired tissue integrity Risk for infection
Risk for infection
An 84-year-old woman 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. The best nursing intervention is to: Slow the rate of the transfusion and obtain an order for furosemide (Lasix) Administer oxygen through nasal cannula at 2 L/minute Obtain blood and urine specimens for a transfusion reaction Contact the physician and obtain an order for diphenhydramine (Benadryl)
Slow the rate of the transfusion and obtain an order for furosemide (Lasix)
A nurse is transfusing whole blood to a client with impaired renal function. During the transfusion, the client tells the nurse, "I feel very short of breath all of a sudden." What is the nurse's primary action? Call the health care provider. Slow the infusion. Stop the infusion. Assess the client's vital signs
Stop the infusion.
The nurse began transfusing the first unit of packed red blood cells (PRBCs) fifteen minutes ago. The client begins complaining of shortness of breath, nausea, and is restless. What is the nurse's priority action? Notify the primary care provider. Stop the infusion. Flush the blood tubing with normal saline. Discontinue the intravenous line.
Stop the infusion.
A nurse, caring for a patient with human immunodeficiency virus (HIV), reviews the patient's differential WBC count to check the level of which of the following? T lymphocytes B lymphocytes Monocytes Leukocytes
T lymphocytes
The physician believes that the patient has a deficiency in the leukocyte responsible for cell-mediated immunity. What should the nurse check the WBC count for? T lymphocytes Monocytes Plasma cells Basophils
T lymphocytes
The nurse is caring for a client with hypoxia. What does the nurse understand is true regarding the client's oxygen level and the production of red blood cells? The brain senses low oxygen levels in the blood and stimulates hemoglobin, which binds to more red blood cells. The bone marrow is stimulated by low oxygen levels in the blood and stimulates erythropoietin, maturing the red blood cells. The kidneys sense low oxygen levels in the blood and stimulate erythropoietin, stimulating the marrow to produce more red blood cells. The kidneys sense low oxygen levels in the blood and stimulate hemoglobin, stimulating the marrow to produce more red blood cells.
The kidneys sense low oxygen levels in the blood and stimulate erythropoietin, stimulating the marrow to produce more red blood cells.
A nursing instructor is reviewing the role and function of stem cells in the bone marrow with a group of nursing students. After providing the explanation, the instructor asks the students to use their knowledge of anatomy and physiology to determine an alternate way in which adults with diseases that destroy marrow can resume production of blood cells. Which explanation by the students is correct? Fat found in yellow bone marrow can be replaced by active marrow when more blood cell production is required. The remaining stem cells have the ability to continue with the process of self-replication, creating an endless supply. The liver and spleen can resume production of blood cells through extramedullary haematopoiesis. The three cell types—erythrocytes, leukocytes, and platelets—can resume production of stem cells.
The liver and spleen can resume production of blood cells through extramedullary haematopoiesis.
The Pediatric Nurse Practitioner is doing a physical examination of a client with sickle cell anemia. Why would the nurse practitioner auscultate the lungs and heart? To detect the abnormal sounds suggestive of acute chest syndrome and heart failure To detect the evidence of infection such as fever and tachycardia To detect the evidence of dehydration that might have triggered a sickle cell crisis To detect the motor strength and stroke-related signs and symptoms
To detect the abnormal sounds suggestive of acute chest syndrome and heart failure The nurse auscultates the lungs and heart to detect abnormal sounds that indicate pneumonia, acute chest syndrome, and heart failure. The nurse assesses vital signs to detect evidence of infection, such as fever and tachycardia. During the physical examination, the nurse observes the client's appearance, looking for evidence of dehydration, which may have triggered a sickle cell crisis. The nurse assesses mental status, verbal ability, and motor strength to detect stroke-related signs and symptoms.
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? Bacterial contamination of blood Exacerbation of congestive heart failure Transfusion-related acute lung injury Delayed hemolytic reaction
Transfusion-related acute lung injury
A nurse on a hematology/oncology floor is caring for a client with aplastic anemia. Which would not be included in the client's discharge instructions? Avoid contact with family/friends who are sick. Use a disposable razor when shaving. Plan for frequent periods of rest. Encourage frequent handwashing.
Use a disposable razor when shaving.
While caring for a client, the nurse notes petechiae on the client's trunk and lower extremities. What precaution will the nurse take when caring for this client? Apply supplemental oxygen to maintain the client's oxygenation. Elevate the client's head of the bed. Where a mask when entering the client's room. Use an electric razor when assisting client with shaving.
Use an electric razor when assisting client with shaving.
A nurse is caring for a client with thrombocytopenia. What is the best way to protect this client? Encourage the client to use a wheelchair. Use the smallest needle possible for injections. Maintain accurate fluid intake and output records. Limit visits by family members.
Use the smallest needle possible for injections.
Which medication is the antidote to warfarin? Aspirin Vitamin K Protamine sulfate Clopidogrel
Vitamin K
During preparation for bowel surgery, a client receives an antibiotic to reduce intestinal bacteria. The nurse knows that hypoprothrombinemia may occur as a result of antibiotic therapy interfering with synthesis of which vitamin? Vitamin K Vitamin E Vitamin A Vitamin D
Vitamin K Intestinal bacteria synthesize such nutritional substances as vitamin K, thiamine, riboflavin, vitamin B12, folic acid, biotin, and nicotinic acid. Therefore, antibiotic therapy may interfere with synthesis of these substances, including vitamin K.
The nurse should provide further teaching when a preoperative client considering blood donation makes which of the following statements? "I could donate my own blood in case I need a transfusion." "I should expect blood withdrawal to take about 15 minutes." "My family will donate blood, because it's safer." "Donated blood is tested for blood type and infections."
"My family will donate blood, because it's safer."
The nurse is completing a pretransfusion assessment to determine a female client's history of previous transfusions as well as previous reactions to transfusions. Which is the most important information to obtain from this client before the transfusion? Number of pregnancies Age Diagnosis Family history of transfusion reactions
Number of pregnancies Explanation: The history should include the type of reaction, its manifestations, the interventions required, and whether any preventive interventions were used in subsequent transfusions. The nurse assesses the number of pregnancies a woman has had because a high number can increase her risk of reaction due to antibodies developed from exposure to fetal circulation. Other concurrent health problems should be noted, with careful attention paid to cardiac, pulmonary, and vascular disease.
The nurse is caring for an older adult client who has a hemoglobin of 9.6 g/dL and a hematocrit of 34%. To determine where the blood loss is coming from, what intervention can the nurse provide? Observe the gums for bleeding after the client brushes teeth. Observe client for facial droop. Observe the sputum for signs of blood. Observe stools for blood.
Observe stools for blood. Explanation: Iron-deficiency anemia is unusual in older adults. Normally, the body does not eliminate excessive iron, causing total body iron stores to increase with age and necessitating maintenance of hydration. If an older adult is anemic, blood loss from the gastrointestinal or genitourinary tracts is suspected. Observing the stool for blood will help detect blood from GI loss. Bleeding gums may indicate periodontal disease, or anticoagulation from medication is not related to age. Blood in sputum can be an indicator of various lung disorders that may affect all age groups. Facial droop may indicate an impending stroke or Bell's palsy and would not be a reason for blood loss.
A client with multiple myeloma is complaining of severe pain when the nurse comes in to give a bath and change position. What is the priority intervention by the nurse? Obtain the pain medication and delay the bath and position change until the medication reaches its peak. Inform the client that the position must be changed, and then you will give her pain medication and omit the bath. Inform the client that the bath and positioning is an important part of client care and will be done right after pain medication administration. Inform the client that she will feel better after receiving a bath and clean sheets.
Obtain the pain medication and delay the bath and position change until the medication reaches its peak.
A nurse cares for an older adult client with acute myeloid leukemia (AML). What concept does the nurse understand leads to the increased risk of an older adult acquiring myeloid malignancies such as AML? Older adults acquire damage to the DNA of stem cells over time. Older adults are exposed to more infectious disease over time. Older adults have an increasing number of leukocytes over time. Older adults acquire damage to the bone marrow over time.
Older adults acquire damage to the DNA of stem cells over time.
