Chapter 28 Assessment of Hematologic Function and Treatment Modalities PrepU

The nurse is completing a physical assessment on a client's lymphatic system. The nurse should palpate for enlarged nodes in which areas? Select all that apply. Popliteal Inguinal Spinal Submental Neck

Popliteal Inguinal Submental Neck Explanation: Palpable lymph node areas include: popliteal, inguinal, submental, and neck. The spinal region does not contain palpable lymph nodes.

Place the following steps in order when determining the type and severity of a transfusion reaction. Use all options. Stop the transfusion. Notify the blood bank. Send the tubing and container to the blood bank. Notify the health care provider. Assess the client.

Stop the transfusion. Assess the client. Notify the health care provider. Notify the blood bank. Send the tubing and container to the blood bank. Explanation: It is important for the nurse to take the proper steps when determining the type and severity of a transfusion reaction. The priority action is to stop the infusion and then assess the client. Next, the health care provider will be notified, followed by the blood bank. Finally, the nurse should send the tubing and container to the blood bank for analysis.

A nurse is preparing a dose of furosemide for an older adult with heart failure. The health care provider orders furosemide 1 mg/kg to be given intravenously. The client weighs 50 kg. The concentration of the drug is 40 mg/4mL (10 mg/mL). How many milliliters would the nurse administer? Record your answer using a whole number.

5 Explanation: 1 mg/kg X 50 kg = 50 mg then divide by 10 mg/mL = 5 mL

A client seeks medical attention for the spontaneous development of bruises over the arms and legs. Which laboratory tests will the nurse anticipate being prescribed for this client? Select all that apply. Bilirubin Blood urea nitrogen Complete blood count International normalized ratio Activated partial prothrombin time

Complete blood count International normalized ratio Activated partial prothrombin time Explanation: For most hematologic conditions, continued monitoring via specific blood tests is required because it is very important to assess for changes in test results over time. Tests commonly used include the complete blood count, which identifies the total number of blood cells, hemoglobin, hematocrit, and RBC indices. The international normalized ratio and activated partial thromboplastin time are used to evaluate clotting ability. Bilirubin is used to measure liver function. BUN is a renal function test.

The nurse assesses a client experiencing frequent nosebleeds. Which findings indicate to the nurse that additional assessment would be needed for thrombocytopenia? Select all that apply. Headache Cloudy urine Ecchymoses on the skin Conjunctival hemorrhage Petechiae over lower extremities

Headache Ecchymoses on the skin Conjunctival hemorrhage Petechiae over lower extremities Explanation: A history of nosebleeds (epistaxis) is a potential indication of thrombocytopenia. Additional findings associated with thrombocytopenia include a headache associated with central nervous system involvement. Ecchymoses, conjunctival hemorrhage, and petechiae over the lower extremities suggest thrombocytopenia is affecting the skin and associated structures of the head and neck. Cloudy urine would be associated with a urinary tract infection. Hematuria would be the finding if thrombocytopenia is affecting the genitourinary system.

When teaching about the advantages of autologous blood transfusion to a client, the nurse should include which information? Select all that apply. The primary advantage is prevention of viral infections. It is safer for clients with a history of transfusion reactions. It resolves anemia for clients with a hemoglobin less than 11g/dL. Blood can be transfused to family members and close relatives. If not needed immediately, the blood can be frozen for future use

The primary advantage is prevention of viral infections. It is safer for clients with a history of transfusion reactions. If not needed immediately, the blood can be frozen for future use Explanation: The primary advantage of autologous transfusions is the prevention of viral infections from another person's blood. Other advantages include safe transfusion for client with a history of transfusion reactions; and if the blood is not required immediately, it can be frozen until the donor needs it. It is the policy of the American Red Cross that autologous blood is transfused only to the donor. Hemoglobin level less than 11g/dL is a contraindication to autologous blood donation.