Oncology/Hematology/Immunity 2

The nurse has received a prescription to transfuse a client with a unit of packed red blood cells. Before explaining the procedure to the client, the nurse should ask which initial question?

"Have you ever had a transfusion before?"

The home care nurse is making a monthly visit to a client with a diagnosis of pernicious anemia who has been receiving a monthly injection of cyanocobalamin. Before administering the injection, the nurse evaluates the effects of the medication and determines that a therapeutic effect is occurring if the client makes which statement?

"I feel stronger and have a much better appetite." Rationale: Cyanocobalamin is essential for DNA synthesis. It can take up to 3 years for the vitamin B12 stores to be depleted and for symptoms of pernicious anemia to appear. Symptoms can include weakness, fatigue, anorexia, loss of taste, and diarrhea. To correct deficiencies, a crystalline form of vitamin B12, cyanocobalamin, can be given intramuscularly. The client statements in options 1, 2, and 3 do not identify a therapeutic effect of the medication

The nurse has provided instruction to a client with chronic kidney disease who has a prescription for epoetin alfa. Which statement by the client indicates that teaching was effective?

"I have to receive this medication subcutaneously."

The nurse has provided medication instructions to a client with an iron deficiency anemia who will be taking iron supplements. Which statement made by the client indicates an understanding of this medication?

"I need to increase my fluid intake." Rationale: Iron preparations can be very irritating to the stomach and are best taken between meals. Because iron supplements may be associated with constipation, the client should increase fluids and fiber in the diet to counteract this side effect of therapy. Iron preparations should be taken with a substance that is high in vitamin C to increase its absorption. The tablet is swallowed whole and not chewed.

The nurse is providing instructions to a client being discharged from the hospital following removal of a chest tube that was inserted after thoracic surgery. Which statement made by the client indicates a need for further teaching?

"I should remove the chest tube site dressing as soon as I get home."

The nurse teaches skin care to a client receiving external radiation therapy. Which client statement indicates the need for further instruction?

"I will limit sun exposure to 1 hour daily."

As part of chemotherapy education, the nurse teaches a female client about the risk for bleeding and self-care during the period of greatest bone marrow suppression (the nadir). The nurse understands that further teaching is needed if the client makes which statement?

"I'm going to take aspirin for my headache as soon as I get home."

The nurse has provided instructions to the mother of a child with sickle cell disease regarding measures that will prevent a sickle cell crisis. Which client statement indicates an understanding of these measures?

"My child needs to avoid situations that may lead to an infection." Rationale: The child should avoid infections, which can increase metabolic demands and cause dehydration, precipitating a sickle cell crisis. Fluids are important to prevent dehydration, which could lead to sickle cell crisis. Warm weather and mild exercise do not need to be avoided, but measures need to be taken to avoid dehydration during these conditions.

The nurse is providing dietary instructions to the client with anemia. The client tells the nurse that the iron pills are very expensive, and it will be difficult to pay for the pills and buy the proper food. What is the most appropriate nursing response?

"Would you like for me to check into some other options for you?"

A clinic nurse prepares a teaching plan for a client receiving an antineoplastic medication. When implementing the plan, the nurse should make which statement to the client?

"You need to consult with the primary health care provider (PHCP) before receiving immunizations."

A client has a prescription to receive a unit of packed red blood cells. The nurse should obtain which intravenous (IV) solution from the IV storage area to hang with the blood product at the client's bedside?

0.9% sodium chloride Rationale: Sodium chloride 0.9% (normal saline) is a standard isotonic solution used to precede and follow infusion of blood products. Dextrose is not used because it could result in clumping and subsequent hemolysis of red blood cells (RBCs). Lactated Ringer's is not the solution of choice with this procedure.

A client is returning from surgery after a pulmonary lobectomy. Which pieces of equipment should the nurse have at the bedside? Select all that apply.

1. Clamp 4. Vaseline gauze 6. Suction equipment

The nurse is caring for a client with a dry suction chest drainage system. During assessment of the drainage system, what should the nurse expect to find? Select all that apply.

1. The dry suction control regulation set to the prescribed amount 5. The drainage in the collection chamber marked each shift to monitor the amount of drainage

The nurse who is about to begin a blood transfusion knows that blood cells start to deteriorate after a certain period of time. The nurse takes which actions in order to prevent a complication of the blood transfusion as it relates to deterioration of blood cells? Select all that apply.

1.Checks the expiration date 5.Hangs the blood within the specified time frame per agency policy

The nurse is assisting in monitoring a client who is receiving a transfusion of packed red blood cells (PRBCs). Before leaving the room, the nurse tells the client to immediately report which symptoms of a transfusion reaction? Select all that apply.

1.Chills 4.Chest pain 5.Lower back pain 6.Difficulty breathing Rationale: The nurse should instruct the client to immediately report signs of a transfusion reaction, which can include chest pain, lower back pain, chills, itching, rash, or difficulty breathing. These signs of transfusion reaction would require the nurse to stop the transfusion. Fatigue and sleepiness are unrelated to transfusion reaction.

The nurse is caring for a client with lung cancer and bone metastasis. What signs and symptoms would the nurse recognize as indications of a possible oncological emergency? Select all that apply.

1.Facial edema in the morning 3.Serum calcium level of 12 mg/dL (3.0 mmol/L) 6.Numbness and tingling of the lower extremities ationale: Oncological emergencies include sepsis, disseminated intravascular coagulation, syndrome of inappropriate antidiuretic hormone, spinal cord compression, hypercalcemia, superior vena cava syndrome, and tumor lysis syndrome. Blockage of blood flow to the venous system of the head resulting in facial edema is a sign of superior vena cava syndrome. A serum calcium level of 12 mg/dL (3.0 mmol/L) indicates hypercalcemia. Numbness and tingling of the lower extremities could be a sign of spinal cord compression. Mild hypokalemia and weight loss are not oncological emergencies. A sodium level of 136 mg/dL (136 mmol/L) is a normal level.

A client who is intubated and receiving mechanical ventilation is at risk for infection. The nurse should include which measures in the care of this client? Select all that apply.

1.Monitor the client's temperature. 2.Use sterile technique when suctioning. 3.Use the closed-system method of suctioning. 4.Monitor sputum characteristics and amounts.

The nurse is preparing to perform an assessment on a child being admitted to the hospital with a diagnosis of sickle cell crisis, vaso-occlusive crisis. Which findings should the nurse expect to note on assessment of the child? Select all that apply.

1.Pallor 2.Fever 3.Joint swelling 5.Abdominal pain Rationale: Sickle cell crises are acute exacerbations of the disease. Vaso-occlusive crisis is caused by stasis of blood with clumping of cells in the microcirculation, ischemia, and infarction. Manifestations include pallor; fever; painful swelling of hands, feet, and joints; and abdominal pain. Blurred vision is not a manifestation of vaso-occlusive crisis.

A client with carcinoma of the lung develops syndrome of inappropriate antidiuretic hormone (SIADH) as a complication of the cancer. The nurse anticipates that the primary health care provider will request which prescriptions? Select all that apply.

1.Radiation 2.Chemotherapy 5.Serum sodium level determination 6.Medication that is antagonistic to antidiuretic hormone Rationale: Cancer is a common cause of SIADH. In SIADH, excessive amounts of water are reabsorbed by the kidney and put into the systemic circulation. The increased water causes hyponatremia (decreased serum sodium levels) and some degree of fluid retention. The syndrome is managed by treating the condition and cause and usually includes fluid restriction, increased sodium intake, and medication with a mechanism of action that is antagonistic to antidiuretic hormone. Sodium levels are monitored closely because hypernatremia can develop suddenly as a result of treatment. The immediate institution of appropriate cancer therapy, usually radiation or chemotherapy, can cause tumor regression so that antidiuretic hormone synthesis and release processes return to normal.

The nurse is reviewing the prescriptions for a client admitted to the hospital with a diagnosis of idiopathic autoimmune hemolytic anemia. The nurse prepares the client for treatment of this disorder, understanding that which may be recommended? Select all that apply.

1.Transfusions 2.Splenectomy 4.Corticosteroid medication 5.Immunosuppressive agents Rational: Idiopathic autoimmune hemolytic anemia is a decrease in the number of red blood cells due to increased destruction by the body's defense (immune) system. It is an acquired disease that occurs when antibodies form against a person's own red blood cells. In the idiopathic form of this disease, the cause is unknown. Idiopathic autoimmune hemolytic anemia is treated with corticosteroids. Other treatments that may be prescribed as necessary include transfusions, splenectomy, and, occasionally, immunosuppressive medications. Radiation therapy is not used to treat this disorder.

The nurse has a prescription to administer a dose of iron by the intramuscular route to the client. What are the most appropriate nursing actions? Select all that apply.

1.Use a Z-track method. 4.Use an air lock when drawing up the medication. 5.Change the needle after drawing up the dose and before injection.

The nurse is evaluating the results of laboratory studies for a client receiving epoetin alfa. When should the nurse expect to note a therapeutic effect of this medication?

After 2 weeks of therapy

A client is returned to the nursing unit after thoracic surgery with chest tubes in place. During the first few hours postoperatively, what type of drainage should the nurse expect?

Bloody Rationale: In the first few hours after surgery, the drainage from the chest tube is bloody. After several hours, it becomes serosanguineous. The client should not experience frequent clotting. Proper chest tube function should allow for drainage of blood before it has the chance to clot in the chest or the tubing.

The nurse has assisted the primary health care provider (PHCP) with the insertion of a chest tube. The nurse monitors the client and notes fluctuation of the fluid level in the water seal chamber after the tube is inserted. Based on this assessment finding, which action is most appropriate?

Continue to monitor the client.

The nurse determines that the client with a chest tube to a closed drainage system is experiencing an air leak. Which finding is indicative of this?

Continuous bubbling is observed in the water seal chamber during inspiration and expiration.

One unit of packed red blood cells has been prescribed for a client with severe anemia. The client has received multiple transfusions in the past, and it is documented that the client has experienced urticaria-type reactions from the transfusions. The nurse anticipates that which medication will be prescribed before administration of the red blood cells to prevent this type of reaction?

Diphenhydramine Rationale: An urticaria-type reaction is characterized by a rash accompanied by pruritus. This type of transfusion reaction is prevented by pretreating the client with an antihistamine such as diphenhydramine. The remaining medications would not prevent an urticaria-type reaction. Acetaminophen may be prescribed before the administration to assist in preventing an elevated temperature.

The nurse is monitoring the chest tube drainage system in a client with a chest tube. The nurse notes intermittent bubbling in the water seal chamber. Which is the most appropriate nursing action?

Document the findings.

Which should the nurse do when caring for a client with a chest tube attached to a chest drainage system?

Ensure the water level in the water seal chamber is at the 2cm level.

A client with chronic kidney disease is receiving epoetin alfa. Which laboratory result would indicate a therapeutic effect of the medication?

Hematocrit of 33% (0.33) Rationale: Epoetin alfa is synthetic erythropoietin, which the kidneys produce to stimulate red blood cell production in the bone marrow. It is used to treat anemia associated with chronic kidney disease. The normal hematocrit level is 42% to 52% (0.42 to 0.52) for males and 37% to 47% (0.37 to 0.47) for females. Therapeutic effect is seen when the hematocrit reaches between 30% and 33% (0.30 and 0.33). The normal platelet count is 150,000 to 400,000 mm3 (5 to 10 × 109/L). Platelet production, white blood cell production, and blood urea nitrogen do not respond to erythropoietin.

A nursing student is developing a plan of care for a client with a chest tube that is attached to a chest drainage system. Which intervention in the care plan indicates the need for further teaching for the student?

Instruct the client to avoid coughing and deep breathing.

The nurse is caring for a client with acute respiratory distress syndrome (ARDS). What should the nurse expect to note in the client?

Low arterial PaO2

A client enters the hospital emergency department with a nosebleed. On assessment, the client tells the nurse that the nosebleed just suddenly began. The nurse notes no obvious facial injury. Which is the initial nursing action?

Sit the client down, ask the client to lean forward slightly, and apply pressure to the nose for 5 to 10 minutes.

The nurse is providing teaching to a client who will undergo chemotherapy for cancer, and alopecia is expected from the chemotherapeutic agent. Which statement made by the client indicates a need for further teaching?

"I can't believe my hair loss will be permanent." Rationale: Alopecia refers to loss of hair and is a temporary side effect of many chemotherapeutic agents. Excessive brushing and use of electric appliances on the hair may hasten hair loss once chemotherapy is started. Cutting the hair short before starting the chemotherapy helps the client to gradually adapt to the loss.

The nurse enters the room of a client who began receiving a blood transfusion 45 minutes earlier to check on the client. The client is complaining of "itching all over" and has a generalized rash. The client's temperature has not changed from baseline and the lungs are clear to auscultation. Which complication of blood transfusion therapy should the nurse determine that this client is most likely experiencing?

Allergic transfusion reaction

The nurse is caring for the client who is suspected of having lung cancer. The nurse should assess the client for which most frequent early symptom of lung cancer?

Cough Rationale: Cough is the most frequent early symptom of lung cancer, which begins as nonproductive and hacking and progresses to productive. In the smoker who already has a cough, a change in the character and frequency of cough usually occurs. Hoarseness indicates that the affected tissue is in the upper airway. Wheezing and blood-streaked sputum (hemoptysis) are later signs of lung cancer. Pain is a very late sign and is usually pleuritic in nature.

The client in chronic kidney disease is receiving epoetin alfa. The nurse should monitor this client for which side/adverse effect of this medication?

HTN

Laboratory studies are performed for a client suspected to have iron deficiency anemia. The nurse reviews the laboratory results, knowing that which result indicates this type of anemia?

Red blood cells that are microcytic and hypochromic Rationale: In iron deficiency anemia, iron stores are depleted, resulting in a decreased supply of iron for the manufacture of hemoglobin in red blood cells. The results of a complete blood cell count in clients with iron deficiency anemia show decreased hemoglobin levels and microcytic and hypochromic red blood cells. The red blood cell count is decreased. The reticulocyte count is usually normal or slightly elevated.

The nurse is monitoring the function of a client's chest tube that is attached to a drainage system. The nurse notes that the fluid in the water seal chamber rises with inspiration and falls with expiration. The nurse determines that which is occurring?

Tidaling is present

A client is diagnosed with iron deficiency anemia, and ferrous sulfate is prescribed. The nurse should tell the client that it would be best to take the medication with which food?

Tomato juice

The nurse has obtained a unit of blood from the blood bank and has checked the blood bag properly with another nurse. Just before beginning the transfusion, the nurse should assess which priority item?

Vital signs Rationale: A change in vital signs during the transfusion from baseline may indicate that a transfusion reaction is occurring. This is why the nurse assesses vital signs before the procedure and again after the first 15 minutes and thereafter per agency policy. The other options do not identify assessments that are a priority just before beginning a transfusion.

The nurse is providing instructions to the parent of a child with iron deficiency anemia about the administration of a liquid oral iron supplement. Which statement, if made by the parent, indicates an understanding of the administration of this medication?

"I should use a medicine dropper and place the iron near the back of the throat."

A client requiring surgery is anxious about the possible need for a blood transfusion during or after the procedure. The nurse suggests to the client to take which actions to reduce the risk of possible transfusion complications? Select all that apply.

1.Ask a family member to donate blood ahead of time. 2.Give an autologous blood donation before the surgery.

The nurse has a prescription to administer packed red blood cells (PRBCs) to a client who does not currently have an intravenous (IV) line inserted. When obtaining supplies to start the blood infusion, the nurse should select an angiocatheter of at least which size?

19 gauge

The nurse is monitoring a client who is receiving epoetin alfa for adverse effects of the medication. Which finding indicates a side/adverse effect?

HTN

A chest x-ray report for a client indicates the presence of a left apical pneumothorax. The nurse would assess the status of breath sounds in that area by placing the stethoscope in which location?

Just under the left clavicle

Chemotherapy dosage is frequently based on total body surface area (BSA), so it is important for the nurse to perform which assessment before administering chemotherapy?

Measure the client's current weight and height.

Epoetin alfa by the subcutaneous route is prescribed for a client. What is the most appropriate nursing action?

Refrigerate the medication until used.

The nurse has provided discharge instructions to the client who has had a pneumonectomy. Which statement, if made by the client, indicates an understanding of appropriate home care measures?

"I should perform arm exercises 2 or 3 times a day." Rationale: The client should be instructed to perform arm and shoulder exercises 2 or 3 times a day to prevent frozen shoulder. The client is encouraged to drink liquids to liquefy secretions, making them easier to expectorate. The client is told to expect soreness in the chest and shoulder and an altered feeling of sensation around the incision site for several weeks. It is not necessary to contact the primary health care provider if these symptoms occur.

The nurse is providing immediate postprocedure care to a client who had a thoracentesis to relieve a tension pneumothorax that resulted from rib fractures. The goal is that the client will exhibit normal respiratory functioning, and the nurse provides instructions to assist the client with this goal. Which client statement indicates that further instruction is needed?

"I will lie on the affected side for an hour." Rationale: After the procedure the client usually is turned onto the unaffected side for 1 hour to facilitate lung expansion. Tachypnea, dyspnea, cyanosis, retractions, or diminished breath sounds, which may indicate pneumothorax, should be reported to the primary health care provider. A chest x-ray may be performed to evaluate the degree of lung reexpansion or pneumothorax. Subcutaneous emphysema (crepitus) may follow this procedure because air in the pleural cavity leaks into subcutaneous tissues. The involved tissues feel like lumpy paper and crackle when palpated (crepitus). Usually subcutaneous emphysema causes no problems unless it is increasing and constricting vital organs, such as the trachea.

The nurse is assessing a dark-skinned client for signs of anemia. The nurse should focus the assessment on which structures? Select all that apply.

1. Lips 4.Conjunctiva 5.Mucous membranes

The nurse is preparing a client with thrombocytopenia for discharge. Which statement by the client about measures minimizing injury indicates that discharge teaching was effective? Select all that apply.

1."I may continue to use an electric shaver." 2."I will not blow my nose if I get a cold." "I should use a soft-bristled toothbrush to avoid mouth trauma." Rationale: Bleeding precautions are used to protect the client with thrombocytopenia from bleeding. The client with thrombocytopenia may experience internal and external bleeding. Bleeding is frequently provoked by trauma, but it also may be spontaneous. The client with thrombocytopenia should be educated about activities that increase the risk for bleeding, such as contact sports and trauma to oral, nasal, and rectal mucosa. This will help to eliminate options 3 and 4.

The nurse is picking up a unit of packed red blood cells at the hospital blood bank. After putting the pen down, the nurse glances at the clock, which reads 1300. The nurse calculates that the transfusion must be started by which time?

1300 Rationale: Blood must be hung as soon as possible (within 30 minutes) after it is obtained from the blood bank. After that time, the blood temperature will be higher than 50º F (10º C), and the blood could be unsafe for use. If blood will not be used within 30 minutes, it should be returned to the blood bank. For this reason, the remaining options are incorrect.

Which interventions are the most appropriate for a client who is experiencing thrombocytopenia? Select all that apply.

3.Check secretions for frank or occult blood. 5.Encourage fluid intake to avoid constipation. 6.Provide oral sponges or a soft toothbrush for oral care. Rational: Thrombocytopenia is a condition in which the platelets fall below the number needed for normal coagulation. When a client has thrombocytopenia, the risk of bleeding is greatly increased. To monitor for bleeding, the nurse should check all secretions for frank or occult blood. Valsalva maneuvers (as in straining to have a stool, vomiting, or sneezing) could cause intracerebral bleeding when the platelet count is low. To avoid constipation, the nurse would encourage the client to take more fluids and increase his or her dietary fiber. The nurse should encourage the client to use a soft toothbrush or oral sponges to decrease irritation to the mouth and bleeding from the gums. An electric razor is recommended for shaving during times when the client is thrombocytopenic. The nurse should not take rectal temperatures or use any rectal suppositories because of the risk for injury to the rectal membranes with resultant bleeding. Medications should not be given subcutaneously or intramuscularly because use of these routes carries a risk for hemorrhage into the tissues.

The nurse is assessing the functioning of a chest tube drainage system in a client who has just returned from the recovery room following a thoracotomy with wedge resection to remove a cancerous tumor. Which are the expected assessment findings? Select all that apply.

3.Drainage system maintained below the client's chest 4.50 mL of drainage in the drainage collection chamber 5.Occlusive dressing in place over the chest tube insertion site 6.Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation Rationale: The bubbling of water in the water seal chamber indicates air drainage from the client and usually is seen when intrathoracic pressure is higher than atmospheric pressure, and may occur during exhalation, coughing, or sneezing. Excessive bubbling in the water seal chamber may indicate an air leak, an unexpected finding. Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation is expected. An absence of fluctuation may indicate that the chest tube is obstructed or that the lung has reexpanded and that no more air is leaking into the pleural space. Gentle (not vigorous) bubbling should be noted in the suction control chamber. A total of 50 mL of drainage is not excessive in a client returning to the nursing unit from the recovery room. Drainage that is more than 70 to 100 mL/hour is considered excessive and requires notification of the primary health care provider. The chest tube insertion site is covered with an occlusive (airtight) dressing to prevent air from entering the pleural space. Positioning the drainage system below the client's chest allows gravity to drain the pleural space.

The nurse is instructing a client with iron deficiency anemia regarding the administration of a liquid oral iron supplement. Which instruction should the nurse tell the client?

Administer the iron through a straw. Rationale: In iron deficiency anemia, iron stores are depleted, resulting in a decreased supply of iron for the manufacture of hemoglobin in red blood cells. An oral iron supplement should be administered through a straw or medicine dropper placed at the back of the mouth, because the iron stains the teeth. The client should be instructed to brush or wipe their teeth after administration. Iron is administered between meals, because absorption is decreased if there is food in the stomach. Iron requires an acid environment to facilitate its absorption in the duodenum. Iron is not mixed with cereal or other food items.

A client with chronic kidney disease is receiving epoetin alfa for the past 2 months. What should the nurse determine is an indicator that this therapy is effective?

An increase in serum hematocrit

A client with severe blood loss resulting from multiple trauma requires rapid transfusion of several units of blood. The nurse asks another health team member to obtain which device for use during the transfusion procedure to help reduce the risk of cardiac dysrhythmias?

Blood-warming device Rationale: If several units of blood are to be administered rapidly, a blood warmer should be used. Rapid transfusion of cool blood places the client at risk for cardiac dysrhythmias. To prevent this, the nurse warms the blood with a blood-warming device. Pulse oximetry and cardiac monitoring equipment are useful for the early assessment of complications but do not reduce the occurrence of cardiac dysrhythmias. Electronic infusion devices are not helpful in this case because the infusion must be rapid, and infusion devices generally are used to control the flow rate. In addition, not all infusion devices are made to handle blood or blood products.

The nurse is caring for a chemotherapy client with a low platelet aggregation level. Which likely caused this decreased platelet production?

Bone marrow suppression Rational: Suppression of bone marrow function is a result of many chemotherapy medications leading to inhibition of platelet production. Because of bone marrow suppression, chemotherapy clients are at risk of bruising and bleeding, and these risks are increased by medications that inhibit platelet function, such as most conventional nonsteroidal anti-inflammatory drugs (NSAIDs). Aspirin is especially dangerous because it causes irreversible inhibition of platelet aggregation. The other options are incorrect.

The nurse is assessing the perineal wound in a client who has returned from the operating room following an abdominal perineal resection and notes serosanguineous drainage from the wound. Which nursing intervention is most appropriate?

Change the dressing as prescribed. Rationale: Immediately after surgery, profuse serosanguineous drainage from the perineal wound is expected. Therefore, the nurse should change the dressing as prescribed. A surgical drain should not be clamped, because this action will cause the accumulation of drainage within the tissue. The nurse does not need to notify the surgeon at this time. Drains and packing are removed gradually over a period of 5 to 7 days as prescribed. The nurse should not remove the perineal packing.

The nurse caring for a client with a pneumothorax and who has had a chest tube inserted notes continuous gentle bubbling in the water seal chamber. What action is most appropriate?

Check for an air leak because the bubbling should be intermittent.

The nurse has just received a prescription to transfuse a unit of packed red blood cells for an assigned client. What action should the nurse take next?

Check to be sure that consent for the transfusion has been signed.

The nurse enters a client's room to assess the client, who began receiving a blood transfusion 45 minutes earlier, and notes that the client is flushed and dyspneic. On assessment, the nurse auscultates the presence of crackles in the lung bases. The nurse determines that this client most likely is experiencing which complication of blood transfusion therapy?

Circulatory overload Rationale: Circulatory overload is caused by the infusion of blood at a rate too rapid for the client to tolerate. With circulatory overload, crackles are present in addition to dyspnea. An allergic reaction, which is one type of blood transfusion reaction, would produce symptoms such as flushing, dyspnea, itching, and a generalized rash. Hypovolemia is not likely a complication of a blood transfusion. With bacteremia, the client would have a fever, which is not part of the clinical picture presented.

The nurse who is participating in a client care conference with other members of the health care team is discussing the condition of a client with acute respiratory distress syndrome (ARDS). The primary health care provider (PHCP) states that as a result of fluid in the alveoli, surfactant production is falling. What does the nurse anticipate as a physiological consequence?

Collapse of alveoli and decreased compliance Rationale: Surfactant is a phospholipid produced in the lungs that decreases surface tension in the lungs. This prevents the alveoli from sticking together and collapsing at the end of exhalation. When alveoli collapse, the lungs become "stiff" because of decreased compliance. Common causes of decreased surfactant production are ARDS and atelectasis. The remaining options are incorrect.

The nurse is caring for a client who is receiving a blood transfusion and is complaining of a cough. The nurse checks the client's vital signs, which include a temperature of 97.2º F (36.2º C), pulse of 108 beats per minute, blood pressure of 152/76 mm Hg, respiratory rate of 24 breaths per minute, and an oxygen saturation level of 95% on room air. The client denies pain at this time. Based on this information, what initial action should the nurse take?

Compare current data to baseline data. Rationale: For the client receiving a blood transfusion, the nurse should monitor for potential complications of a transfusion. One of the complications is circulatory overload. Signs and symptoms of circulatory overload include cough, dyspnea, chest pain, wheezing on auscultation of the lungs, headache, hypertension, tachycardia and a bounding pulse, and distended neck veins. Based on the data in the question, the nurse should compare current data to baseline data. The nurse should also further assess the client for other signs and symptoms of circulatory overload. If the nurse still suspects this complication after comparing to baseline data, the nurse should then place the client in an upright position with the feet in a dependent position and slow the rate of the infusion. Collection of a urine sample should occur if the nurse suspects a transfusion reaction, such as a hemolytic reaction.

The nurse overhears a primary health care provider (PHCP) stating that a client diagnosed with disseminated intravascular coagulation (DIC) requires a transfusion. Which blood product should the nurse anticipate that the PHCP will write a prescription for?

Cryoprecipitate Rationale: Cryoprecipitate is useful in treating bleeding from hemophilia or DIC because it is rich in clotting factors. Albumin may be used as a plasma expander in hypovolemia with or without shock. Platelets are used when the client's platelet count is low. Packed red blood cells replace erythrocytes, not fibrinogen.

The nurse is preparing to care for a client with chronic kidney disease and anemia. Which describes the relationship between chronic kidney disease and anemia?

Decreased production of erythropoietin is causing anemia. Rationale: Clients with chronic kidney disease do not manufacture adequate amounts of erythropoietin, which is a glycoprotein needed to synthesize red blood cells. Renin, aldosterone, and angiotensin are substances that assist in maintaining blood pressure.

The nurse is caring for a client who was just admitted to the hospital for the treatment of iron overload. The nurse anticipates that the primary health care provider will prescribe which medication to treat the iron overload?

Deferoxamine

Packed red blood cells have been prescribed for a female client with a hemoglobin level of 7.6 g/dL (76 mmol/L) and a hematocrit level of 30% (0.30). The nurse takes the client's temperature before hanging the blood transfusion and records 100.6º F (38.1º C) orally. Which action should the nurse take?

Delay hanging the blood and notify the primary health care provider (PHCP).

Packed red blood cells have been prescribed for a female client with anemia who has a hemoglobin level of 7.6 g/dL (76 mmol/L) and a hematocrit level of 30% (0.30). The nurse takes the client's temperature before hanging the blood transfu¬sion and records 100.6° F (38.1° C) orally. Which action should the nurse take?

Delay hanging the blood and notify the primary health care provider (PHCP). Rationale: If the client has a temperature higher than 100° F (37.8° C), the unit of blood should not be hung until the primary PHCP is notified and has the opportunity to give further prescriptions. The PHCP likely will prescribe that the blood be administered regardless of the temperature, or may instruct the nurse to administer prescribed acetaminophen and wait until the temperature has decreased before administration, but the decision is not within the nurse's scope of practice to make. The nurse needs a PHCP's prescription to administer medications to the client.

When obtaining assessment data from a client with a microcytic normochromic anemia, which should the nurse question the client about?

Dietary intake of iron Rationale: Microcytic normochromic anemias involve the presence of small, pale-colored red blood cells. Causes are iron deficiency anemia, thalassemia, and lead poisoning. The only choice that fits this description is option 2. Folic acid deficiency is caused by macrocytic normochromic cells; these are large red blood cells. Gastric surgery can result in vitamin B12 deficiency. Sickle cell anemia results in sickled cells and erythrocyte destruction.

A client is prescribed a liquid iron preparation that has the potential to stain the teeth. The nurse should instruct the client to take which action to prevent staining of the teeth?

Dilute the iron in juice, drink it through a straw, and rinse the mouth afterward.

The emergency department nurse is assessing a client who has sustained a blunt injury to the chest wall. Which finding indicates the presence of a pneumothorax in this client?

Diminished breath sounds Rationale: This client has sustained a blunt or closed-chest injury. Basic symptoms of a closed pneumothorax are shortness of breath and chest pain. A larger pneumothorax may cause tachypnea, cyanosis, diminished breath sounds, and subcutaneous emphysema. Hyper-resonance also may occur on the affected side. A sucking sound at the site of injury would be noted with an open chest injury.

The nurse is monitoring a client who is receiving a blood transfusion. After 30 minutes of the infusion, the client begins to have chills and back pain. His temperature is 100.1º F (37.8º C). What action should the nurse take first?

Discontinue the infusion and start an infusion of normal saline using new tubing. Rationale: Signs of a transfusion reaction include fever, chills, tachycardia, tachypnea, dyspnea, hives or skin rash, flushing, backache, and decreased blood pressure. If the client shows any symptoms of a blood transfusion reaction, the nurse needs to discontinue the infusion immediately and start an infusion of normal saline using new tubing connected to the hub of the intravenous insertion site. The nurse should stay with the client and monitor his or her condition while asking a colleague to notify the primary health care provider immediately.

A client who was diagnosed with toxic shock syndrome (TSS) now exhibits petechiae, oozing from puncture sites, and coolness of the digits of the hands and feet. Clotting times determined for this client are prolonged. The nurse interprets these clinical signs as being most compatible with which condition?

Disseminated intravascular coagulopathy (DIC) Rationale: TSS is caused by infection and often is associated with tampon use. The client's clinical signs in this question are compatible with DIC, which is a complication of TSS. The nurse assesses the client at risk and notifies the primary health care provider promptly when signs and symptoms of DIC are noted. Although signs of bleeding may be seen with each of the conditions listed in the incorrect options, the initial diagnosis of TSS makes DIC the logical correct option.

The nurse is assisting the primary health care provider (PHCP) with insertion of a chest tube. The nurse notes fluctuation of the fluid level in the water seal chamber after the tube is inserted. Based on this observation, the nurse should take which action?

Document the accurate functioning of the tube.

The nurse is developing a plan of care for a client at risk for acute respiratory distress syndrome (ARDS). As part of the plan, the nurse will assess for which sign or symptom for early detection of this disorder?

Dyspnea Rationale: In most cases of ARDS, tachypnea and dyspnea are the first clinical manifestations. Blood-tinged frothy sputum would be a later sign after the development of pulmonary edema. Breath sounds in the early stages of ARDS usually are clear. Edema is not directly associated with ARDS.

The nurse is providing home care instructions to the client who just had surgery for squamous cell carcinoma. The nurse provides follow-up teaching and explains to the client to watch for which characteristics of this type of skin carcinoma?

Firm, nodular lesion topped with a crust or with a central area of ulceration Rationale: Squamous cell carcinoma presents with a firm, nodular lesion topped with a crust or with a central area of ulceration. Option 1 describes melanoma. Option 2 describes actinic keratosis. Option 3 describes basal cell carcinoma.

A client is brought to the emergency department having experienced blood loss related to an arterial laceration. Which blood component should the nurse expect the primary health care provider to prescribe?

Fresh-frozen plasma Rationale: Fresh-frozen plasma is often used for volume expansion as a result of fluid and blood loss. It is rich in clotting factors and can be thawed quickly and transfused quickly. Platelets are used to treat thrombocytopenia and platelet dysfunction. Granulocytes may be used to treat a client with sepsis or a neutropenic client with an infection that is unresponsive to antibiotics. Packed red blood cells are a blood product used to replace erythrocytes.

A client has experienced high blood pressure and crackles in the lungs during previous blood transfusions. The client asks the nurse whether it is safe to receive another transfusion. The nurse explains that which medication most likely will be prescribed before the transfusion is begun?

Furosemide Rationale: Fluid overload is one of the potential complications of a blood transfusion and is characterized by a variety of signs, including high blood pressure, fluid in the lungs manifesting as crackles, and distended jugular veins. This type of transfusion reaction is prevented by pretreating the client with a diuretic such as furosemide. Acetaminophen and aspirin are analgesics, which can also be used for analgesia. These medications may reduce fever as well but do not treat fluid overload.

The nurse is assessing a client with multiple trauma who is at risk for developing acute respiratory distress syndrome. The nurse should assess for which earliest sign of acute respiratory distress syndrome?

Increased respiratory rate Rationale: The earliest detectable sign of acute respiratory distress syndrome is an increased respiratory rate, which can begin from 1 to 96 hours after the initial insult to the body. This is followed by increasing dyspnea, air hunger, retraction of accessory muscles, and cyanosis. Breath sounds may be clear or consist of fine inspiratory crackles or diffuse coarse crackles

The nurse is preparing a plan of care for a child with sickle cell crisis who will be admitted to the nursing unit. The nurse should include which intervention as a priority in the plan of care for the child?

Initiate an intravenous (IV) line for the administration of fluids. Rationale: The priorities in management of sickle cell crisis are hydration therapy and pain relief. To achieve this, the child is given IV fluids to promote hydration and reverse the agglutination of sickled cells in small blood vessels. Opioid analgesics may be given to relieve the pain that accompanies the crisis. Genetic counseling is recommended but not during the acute phase of illness. Red blood cell transfusion may be done in selected circumstances such as aplastic crisis or when the episode is refractive to other therapy. Oxygen would be administered according to individual need, but the client would not require intubation and mechanical ventilation.

The nurse is caring for a postoperative pneumonectomy client. Which finding on assessment of the client is an adverse sign or symptom indicating pulmonary edema?

Lung crackles in the remaining lung Rationale: The client with pulmonary edema that developed after pneumonectomy demonstrates dyspnea, cough, frothy sputum, crackles, and possibly cyanosis. Pain with deep breathing is expected and is managed with analgesics. The client with pneumonectomy most likely will not have a chest tube because the lung has been removed. A respiratory rate of 20 breaths/minute is within normal limits.

The nurse is caring for a client with a chest tube drainage system and notes constant bubbling in the water seal chamber. Which nursing action is appropriate?

Notify the primary health care provider (PHCP).

The nurse is providing dietary teaching for a client with a diagnosis of chronic gastritis. The nurse instructs the client to include which foods rich in vitamin B12 in the diet? Select all that apply

Nuts Liver Lentils Rationale: Chronic gastritis causes deterioration and atrophy of the lining of the stomach, leading to the loss of function of the parietal cells. The source of intrinsic factor is lost, which results in an inability to absorb vitamin B12, leading to development of pernicious anemia. Clients must increase their intake of vitamin B12 by increasing consumption of foods rich in this vitamin, such as nuts, organ meats, dried beans, citrus fruits, green leafy vegetables, and yeast.

A client with a chest injury has suffered flail chest. The nurse assesses the client for which most distinctive sign of flail chest?

Paradoxical chest movement Rationale: Flail chest results from multiple rib fractures. This results in a "floating" section of ribs. Because this section is unattached to the rest of the bony rib cage, this segment results in paradoxical chest movement. This means that the force of inspiration pulls the fractured segment inward, while the rest of the chest expands. Similarly, during exhalation, the segment balloons outward while the rest of the chest moves inward. This is a characteristic sign of flail chest.

The nurse is assisting a primary health care provider with the removal of a chest tube. The nurse should instruct the client to take which action?

Perform the Valsalva maneuver.

The nurse is monitoring a client for signs and symptoms related to superior vena cava syndrome. Which is an early sign of this oncological emergency?

Periorbital edema Rationale: Superior vena cava syndrome occurs when the superior vena cava is compressed or obstructed by tumor growth. Early signs and symptoms generally occur in the morning and include edema of the face, especially around the eyes, and client complaints of tightness of a shirt or blouse collar. As the compression worsens, the client experiences edema of the hands and arms. Cyanosis and mental status changes are late signs.

The nurse monitoring an oncological client assesses for which early sign of vena cava syndrome?

Periorbital edema Rationale: Vena cava syndrome occurs when the superior vena cava is compressed or obstructed by tumor growth. Early signs and symptoms generally occur in the morning and include edema of the face, especially around the eyes, and client complaints of tightness of a shirt or blouse collar. As the compression worsens, the client experiences edema of the hands and arms. Mental status changes and cyanosis are late signs.

Following infusion of a unit of packed red blood cells, the client has developed new onset of tachycardia, bounding pulses, crackles, and wheezes. Which action should the nurse implement first?

Place the client in high-Fowler's position. Rationale: New onset of tachycardia, bounding pulses, and crackles and wheezes posttransfusion is evidence of fluid overload, a complication associated with blood transfusions. Placing the client in a high-Fowler's (upright) position will facilitate breathing. Measures that increase blood return to the heart, such as leg elevation and administration of IV fluids, should be avoided at this time. In addition, administration of fluids cannot be initiated without a prescription. Consulting with the PHCP regarding administration of oxygen may be necessary, but positional changes take a short amount of time to do and should be initiated first.

The nurse should be prepared to institute bleeding precautions in the client receiving antineoplastic medication if which result was reported from the laboratory?

Platelet count 50,000 mm3 (50 × 109/L) Rationale: Platelets are the building blocks of blood clots. The normal platelet count is 150,000 to 400,000 mm3 (150 to 400 × 109/L). Bleeding precautions should be instituted when the platelet count drops to a low level, as defined by agency policy. Bleeding precautions include avoiding all trauma, such as rectal temperatures or injections. The normal clotting time is 8 to 15 seconds. The normal ammonia value is 10 to 80 mcg/dL (6 to 47 mcmol/L). The normal WBC count is 5000 to 10,000 mm3 (5 to 10 × 109/L). When the WBC count drops, neutropenic precautions should be implemented

The nurse is performing an assessment on a client with a diagnosis of pernicious anemia. Which finding would the nurse expect to note in this client?

Red tongue that is smooth and sore Classic signs of pernicious anemia include weakness, mild diarrhea, and a smooth red tongue that is sore. The client also may have nervous system signs and symptoms such as paresthesias, difficulty with balance, and occasional confusion. The client does not exhibit dyspnea, the mucous membranes do not become dusky, and the client does not exhibit shortness of breath.

The nurse determines that a client is having a transfusion reaction. After the nurse stops the transfusion, which action should be taken next?

Run normal saline at a keep-vein-open rate. Rationale: If the nurse suspects a transfusion reaction, the nurse stops the transfusion and infuses normal saline at a keep-vein-open rate pending further primary health care provider prescriptions. This maintains a patent IV access line and aids in maintaining the client's intravascular volume. The nurse would not remove the IV line because then there would be no IV access route. Obtaining a culture of the tip of the catheter device removed from the client is incorrect. First, the catheter should not be removed. Second, cultures are performed when infection, not transfusion reaction, is suspected. Normal saline is the solution of choice over solutions containing dextrose because saline does not cause red blood cells to clump

A client receiving a transfusion of packed red blood cells (PRBCs) begins to vomit. The client's blood pressure is 90/50 mm Hg from a baseline of 125/78 mm Hg. The client's temperature is 100.8º F (38.2º C) orally from a baseline of 99.2º F (37.3º C) orally. The nurse determines that the client may be experiencing which complication of a blood transfusion?

Septicemia Rationale: Septicemia occurs with the transfusion of blood contaminated with microorganisms. Signs include chills, fever, vomiting, diarrhea, hypotension, and the development of shock. Hyperkalemia causes weakness, paresthesias, abdominal cramps, diarrhea, and dysrhythmias. Circulatory overload causes cough, dyspnea, chest pain, wheezing, tachycardia, and hypertension. A delayed transfusion reaction can occur days to years after a transfusion. Signs include fever, mild jaundice, and a decreased hematocrit level.

The nurse is performing an assessment on a client with a diagnosis of anemia that developed as a result of blood loss after a traumatic injury. The nurse should expect to find which sign or symptom in the client as a result of the anemia?

Shortness of breath with activity Rationale: The client with anemia is likely to experience shortness of breath and complain of fatigue because of the decreased ability of the blood to carry oxygen to the tissues to meet metabolic demands. The client is likely to have tachycardia, not bradycardia, as a result of efforts by the body to compensate for the effects of anemia. Muscle cramps are an unrelated finding. Increased respiratory rate is not an associated finding.

A client with an endotracheal tube attached to mechanical ventilation begins to cough, and the client's face appears flushed. Which action should the nurse take first?

Suction the client through the endotracheal tube.

A primary health care provider (PHCP) is about to remove a chest tube from a client. After the dressing is removed and the sutures have been cut, the nurse assisting the PHCP should ask the client to perform which procedure?

Take a deep breath and hold it

The nurse is monitoring a client who has a closed chest tube drainage system. The nurse notes fluctuation of the fluid level in the water seal chamber during inspiration and expiration. On the basis of this finding, the nurse should make which interpretation?

The chest tube is functioning as expected.

The nurse caring for a client with a closed chest drainage system notes that the fluctuation (tidaling) in the water seal chamber has stopped. On the basis of this assessment finding, the nurse would suspect which occurrence?

The chest tube may be obstructed

A client has a chest tube attached to a water seal drainage system. As part of routine nursing care, the nurse should ensure that which intervention is implemented?

The connection between the chest tube and the drainage system is taped, and an occlusive dressing is maintained at the insertion site.

The nurse caring for a client who has a pneumothorax notes continuous bubbling in the water seal chamber of the client's closed chest drainage system. How should the nurse interpret this finding?

There is an air leak somewhere in the system Rationale: Continuous bubbling through both inspiration and expiration indicates that there is air leaking into the system. A resolving pneumothorax or a full drainage chamber would not cause bubbling with respiration in the water seal chamber. Shutting off the suction to the system stops bubbling in the suction control chamber but does not affect the water seal chamber.