Chapter 32 PREPU- Med Surg I

After withdrawing the needle from blood donor's arm, the site begins to bleed excessively. What is the nurse's first action?

Hold firm pressure on the venipuncture site.

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?

Iron chelation therapy

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-negative mother; Rh-positive child

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?

Use an electric razor when assisting client with shaving.

Which client is not a candidate for blood donation according to the American Heart Association?

26 year old female with hemoglobin 11.0 g/dL

The nurse expects which assessment finding when caring for a client with a decreased hemoglobin level?

Decreased oxygen level

A client with chronic kidney disease has chronic anemia. What pharmacologic alternative to blood transfusion may be used for this client?

Erythropoietin

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?

Essential thrombocythemia

Which is a symptom of severe thrombocytopenia?

Petechiae

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 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 kidneys sense low oxygen levels in the blood and stimulate erythropoietin, stimulating the marrow to produce more red blood cells.

The physician orders a transfusion with packed red blood cells (RBCs) for a client hospitalized with severe iron deficiency anemia. When blood is administered, what is the most important action the nurse can take to prevent a transfusion reaction?

Verify the client's identity according to hospital policy

A client verbalizes fear of infection from a blood transfusion. What is the nurse's best response?

"Every unit of donated blood is typed and tested for antibodies to infections."

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."

A nurse is teaching a client with a vitamin B12 deficiency about appropriate food choices to increase the amount of B12 ingested with each meal. The nurse knows the teaching is effective based on which statement by the client?

"I will eat a meat source such as chicken or pork with each meal." B12= ONLY in foods from animals

A preoperative client is discussing blood donation with the nurse. Which statement by the client indicates to the nurse the need for further teaching?

"My family will donate blood, because it's safer." *family not any safer than donated

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?

4:00 pm

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?

Administer acetaminophen 500 mg po, as ordered

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:

Albumin

The nurse is obtaining the health history of a client suspected of having a hematological condition. The nurse notes the client has a history of alcohol abuse. Which clinical presentation is related to alcohol consumption?

Anemia

Which of the following cells are capable of differentiating into plasma cells?

B lymphocytes

Which type of leukocyte contains histamine and is an important part of hypersensitivity reactions?

Basophils

A nursing instructor in a BSN program is preparing for a lecture on disorders of the hematopoietic system. Included in the lecture are conditions caused by reduced levels or absence of blood-clotting proteins. Which of the following is the instructor most likely referring to?

Coagulopathy

The nurse should be alert to which adverse assessment finding when transfusing a unit of packed red blood cells (PRBCs) too rapidly?

Crackles auscultated bilaterally

Post transfusion, the donor stands up immediately after the needle is withdrawn. The nurse should be alert for which vital sign change?

Decreased blood pressure.

The nurse is caring for a client who had undergone hemodilution during surgery. Immediately after surgery, the nurse expects to see which lab result?

Decreased hematocrit

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

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 in biohazard waste.

A client receiving a blood transfusion reports 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 health care provider?

Ensure there is an oxygen delivery device at the bedside.

A nurse cares for a client with myelodysplastic syndrome who requires frequent PRBC transfusions. What blood component does the nurse recognize as being most harmful if accumulated in the tissues due to chronic blood transfusions?

Iron

A client reports feeling faint after donating blood. What is the nurse's best action?

Keep client in recumbent position to rest.

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?

Lateral position with one leg flexed

The nurse is providing health education to an older adult client who has low red blood cell levels. To promote red blood cell production, the nurse should encourage intake of what foods? Select all that apply.

Leafy green vegetables Lean meats Nuts and seeds

Which blood cell type is matched correctly with its function?

Leukocyte: Fights infection

Which term refers to a form of white blood cell involved in immune response?

Lymphocyte

Vitamin B and folic acid deficiencies are characterized by production of abnormally large erythrocytes called

Megaloblasts

Which nursing intervention should be incorporated into the plan of care for a client with impaired liver function and a low albumin concentration?

Monitor for edema at least once per shift

Which cell of hematopoiesis is responsible for the production of red blood cells (RBCs) and platelets?

Myeloid stem cell

The body responds to infection by increasing the production of white blood cells (WBCs). The nurse should evaluate the differential count for what type of WBCs, which are the first WBCs to respond to an inflammatory event?

Neutrophils

Which is the major function of neutrophils?

Phagocytosis

An older adult client presents to the health care provider's office and reports exhaustion. The nurse, aware of the most common hematologic condition affecting the elderly, knows that which laboratory values should be assessed?

RBC count

The nurse is working at a blood donation clinic. What teaching should the nurse provide to the donor immediately after blood donation?

Remain for observation after eating and drinking.

Place the following procedural steps in order for transfusing a unit of packed red blood cells (PRBCs).

Start an intravenous line. Obtain the unit of PRBCs from the blood bank. Double check the labels with another nurse to ensure correct ABO group and Rh type. Initiate the blood transfusion within 30 minutes of receipt. Monitor closely for signs of a transfusion reaction.

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?

Stop the infusion.

Which type of lymphocyte is responsible for cellular immunity?

T lymphocyte

The health care provider believes that the client has a deficiency in the leukocyte responsible for cell-mediated immunity. What should the nurse check the WBC count for?

T lymphocytes

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. If not needed immediately, the blood can be frozen for future use.

The client is to receive a unit of packed red blood cells. What is the nurse's first action?

Verify that the client has signed a written consent form.

The nurse caring for a client with acute liver failure should expect which assessment finding?

generalized edema

Which term describes the percentage of blood volume that consists of erythrocytes?

hematocrit

The client's CBC with differential reveals small-shaped hemoglobin molecules. The nurse expects to administer which medication to this client?

iron

What food should the nurse recommend for a client diagnosed with vitamin B12 deficiency?

lean meat

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 an infection.

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

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 vitamin B12 deficiency."

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?

Apply pressure over the site for 5-7 minutes

G-CSF (filgrastim) is prescribed for a client with bone marrow suppression. What medication administration teaching should the nurse provide to the client?

Assist the client in identifying appropriate subcutaneous injection sites

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.

When conducting a health assessment on a client suspected for having a hematological disorder, the nurse should collect which data? Select all that apply.

Dietary intake Medication use Ethnicity Herbal supplements

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?

Disconnect the blood tubing, flush with normal saline, and administer morphine.

Place the following steps in order when determining the type and severity of a transfusion reaction.

Stop the transfusion. Assess the client. Notify the health care provider. Notify the blood bank. Send the tubing and container to the blood bank.

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

A nurse is caring for a client with a diagnosis of lymphocytopenia. Which assessment finding will the nurse consider most concerning when caring for this client?

Temperature of 37.7 degrees Celsius

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?

The liver and spleen can resume production of blood cells through extramedullary hematopoiesis.

Place the order of the steps of primary hemostasis in correct order.

The severed blood vessel constricts. The circulating platelets aggregate at the site and adhere to the vessel. An unstable hemostatic plug is formed. Circulating inactive clotting factors convert to active forms.

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