MED SURG 1- PrepU Chapter 28: Assessment of Hematologic Function and Treatment Modalities
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 agree that you should be concerned with the safety of the blood, but it is important that you have this transfusion." "The blood is carefully screened, so there is no possibility of you contracting any illness or disease from the blood." "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."
"I understand your concern. The blood is carefully screened but is not completely risk free." Explanation: Despite advances in donor screening and blood testing, certain diseases can still be transmitted by transfusion of blood components (Chart 32-4).
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." "I should expect blood withdrawal to take about 15 minutes." "Donated blood is tested for blood type and infections." "I could donate my own blood in case I need a transfusion."
"My family will donate blood, because it's safer." Explanation: Directed donations from friends and family members are not any safer than those provided by random donors. Withdrawal of 450 mL of blood usually takes about 15 minutes. Specimens from donated blood are tested to detect infections and to identify the specific blood type. Autologous blood donation is useful for many elective surgeries where the potential need for transfusion is high.
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 causes abnormally small red blood cells." "The condition is likely caused by a vitamin B12 deficiency." "The condition causes abnormally rigid red blood cells."
"The condition is likely caused by a vitamin B12 deficiency." Explanation: Vitamin B12 combines with intrinsic factor produced in the stomach. The vitamin B12 -intrinsic factor complex is absorbed in the distal ileum. Clients who have had a partial or total gastrectomy may have limited amounts of intrinsic factor, and the absorption of vitamin B12 may be diminished. Megaloblastic anemia may be caused by a folate deficiency; however, the client's history of gastrectomy indicates the likely cause is a vitamin B12 deficiency. Megaloblastic anemia causes large erythrocytes (RBCs), not small or rigid.
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 be prescribed calcium to replace what is lost during donation." "You typically donate blood 4 to 6 weeks before the surgery." "You will likely not need the blood that is donated."
"You typically donate blood 4 to 6 weeks before the surgery." Explanation: With autologous donation, a client's own blood may be collected for future transfusion; this is an effective method for orthopedic surgery, where the likelihood of transfusion is high. Preoperative donation is ideally collected 4-6 weeks before surgery. The nurse will not tell the client that the blood will not be needed; orthopedic surgeries often require transfusion of blood. The client will be prescribed iron supplements during the donation time, not calcium.
Which client is not a candidate to be a blood donor according to the American Red Cross? 86-year-old male with blood pressure 110/70 mm Hg 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 Explanation: Clients must meet a number of criteria to be eligible as blood donors, including the following: body weight at least 50 kg; pulse rate regular between 50 and 100 bpm; systolic BP 90-100 to 180 mm Hg and diastolic 50 to 100 mm Hg; hemoglobin level at least 12.5 g/dL. There is no upper age limit to donation.
A nurse is reviewing a client's most recent platelet count and identifies the need to institute bleeding precautions. Which result would the nurse most likely have noted? 200,000 /mm3 110,000/mm3 90,000/mm3 45,000/mm3
45,000/mm3 Explanation: Bleeding precautions are recommended for clients with a platelet count of less than 50,000/mm3.
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 3:00 pm 4:00 pm 6:00 pm
4:00 pm Explanation: 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 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. _____ mL
5 Explanation: 1 mg/kg X 50 kg = 50 mg then divide by 10 mg/mL = 5 mL
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. _______ mL
5 Explanation: 1 mg/kg X 50 kg = 50 mg then divide by 10 mg/mL = 5 mL
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 Administer acetaminophen 500 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 Explanation: After a marrow sample is obtained, pressure is applied to the site for several minutes. The site is then covered with a sterile dressing. Most clients have no discomfort after a bone marrow biopsy, but the site of a biopsy may ache for 1 or 2 days. Warm tub baths and a mild analgesic agent (e.g., acetaminophen) may be useful. Aspirin-containing analgesic agents should be avoided it the immediate post-procedure period because they can aggravate or potentiate bleeding.
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. Globulin. Fibrinogen. Prothrombin.
Albumin. Explanation: Albumin, only produced in the liver, is essential for maintaining oncotic pressure in the vascular system. A decrease in oncotic pressure due to low albumin causes fluid to leak into the peritoneal cavity.
Which type of leukocyte contains histamine and is an important part of hypersensitivity reactions? Basophils B lymphocyte Plasma cell Neutrophil
Basophils Explanation: Basophils contain histamine and are an integral part of hypersensitivity reactions. B lymphocytes are responsible for humoral immunity. A plasma cell secretes immunoglobulins. The neutrophil functions in preventing or limiting bacterial infection via phagocytosis.
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 Explanation: Chelation therapy is prescribed to treat iron overload. Hepatitis B immunization helps immunize against hepatitis B. Red blood cell phenotyping helps decreased sensitization. A white blood cell filter protects against cytomegalovirus and some sensitization and febrile reactions.
A client with myelodysplastic syndromes (MDS) receives routine blood transfusions. Which treatment will the nurse expect to be prescribed to prevent the development of iron overload? Romiplostim Eltrombopag Epoetin alpha Chelation therapy
Chelation therapy Explanation: Iron overload is a problem for clients with MDS, especially in those who routinely receive PRBC transfusions (transfusion dependent). Surplus iron is deposited in cells within the reticuloendothelial system, and later in parenchymal organs. To prevent or reverse the complications of iron overload, iron chelation therapy is commonly implemented. Romiplostim and eltrombopag are used to stimulate the proliferation and differentiation of megakaryocytes into platelets within the bone marrow. Epoetin alpha may be used to improve anemia and decrease the need for blood transfusions.
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 Aplastic anemia Pancytopenia Sickle cell disease
Coagulopathy Explanation: The term coagulopathy refers to conditions in which a component that is necessary to control bleeding is missing or inadequate.
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? 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. This type of exercise increases arterial circulation as it returns to the heart. Contraction of skeletal muscle compresses the walls of veins and increases the circulation of venous blood as it returns to the heart.
Contraction of skeletal muscle compresses the walls of veins and increases the circulation of venous blood as it returns to the heart. Explanation: Isometric exercise induce contraction of skeletal muscle so that it compresses the walls of veins and increases the circulation of venous blood as it returns to the heart. Isometric exercises do not have an aerobic effect and should not increase the heart rate; although, it may increase blood pressure. Isometric exercise does not decrease the workload of the heart. Arterial flow moves blood flow away from the heart after being oxygenated.
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 Respiratory rate of 10 breaths/minute Oral temperature of 97°F Pain and tenderness in calf area
Crackles auscultated bilaterally Explanation: Increasing the flow rate of a blood transfusion too rapidly can result in circulatory overload. Fluid overload can be manifested by crackles in the lungs. A decreased respiratory rate and decreased temperature are not manifestations of fluid overload. Pain and tenderness in the calf area may indicate a thrombosis which is not as common a manifestation as fluid overload.
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 Decreased total iron-binding capacity Increased mean corpuscular volume Increased reticulocyte count
Decreased level of erythropoietin Explanation: Differentiation of the primitive myeloid stem cell into an erythroblast is stimulated by erythropoietin, a hormone produced primarily by the kidney. If the kidney detects low levels of oxygen, as occurs when fewer red cells are available to bind oxygen (i.e., anemia), or with people living at high altitudes with lower atmospheric oxygen concentrations, erythropoietin levels increase. The increased erythropoietin then stimulates the marrow to increase production of erythrocytes. The entire process of erythropoiesis typically takes 5 days (Cook, Ineck, & Lyons, 2011). For normal erythrocyte production, the bone marrow also requires iron, vitamin B12, folate, pyridoxine (vitamin B6), protein, and other factors. A deficiency of these factors during erythropoiesis can result in decreased red cell production and anemia.
The nurse expects which assessment finding when caring for a client with a decreased hemoglobin level? Bright red venous blood. Elevated temperature. Decreased oxygen level. Increased bruising.
Decreased oxygen level. Explanation: Hemoglobin carries oxygen; a decreased hemoglobin level results in decreased oxygen. An elevated temperature is a sign of infection and can result from decreased white blood cells. Arterial blood is more oxygen saturated and brighter red in color than venous blood. Increased bruising results from a decreased platelet level, not decreased hemoglobin.
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? Add the morphine to the blood to be slowly administered. Inject the morphine into a distal port on the blood tubing. 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.
Disconnect the blood tubing, flush with normal saline, and administer morphine. Explanation: Never add medications to blood or blood products. The transfusion must be temporarily stopped in order to administer the morphine.
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? Place the client in a recumbent position with legs elevated. Remove the intravenous line. Ensure there is an oxygen delivery device at the bedside. Administer prescribed PRN anti-anxiety agent.
Ensure there is an oxygen delivery device at the bedside. Explanation: The client is exhibiting signs of circulatory overload. After stopping the transfusion and notifying the healthcare provider, the nurse should place the client in a more upright position with the legs dependent to decrease workload on the heart. The IV line is kept patent in case emergency medications are needed. Oxygen and morphine may be needed to treat severe dyspnea. Administering an anti-anxiety agent is not a priority action over ensuring oxygen is available.
A client with severe anemia is admitted to the hospital. Because of religious beliefs, the client is refusing blood transfusions. The nurse anticipates pharmacologic therapy with which drug to stimulate the production of red blood cells? Filgrastim Sargramostim Epoetin alfa Eltrombopag
Epoetin alfa Explanation: Erythropoietin (epoetin alfa) is an effective alternative treatment for clients with chronic anemia secondary to diminished levels of erythropoietin. This medication stimulates erythropoiesis. Filgratism ( Neupogen) and Sargramostim stimulate granulocytosis( increasing WBC count) , Eltrombopag (Promacta) is used to treat aplastic anemia and thrombocytopenia.
A client with chronic kidney disease has chronic anemia. What pharmacologic alternative to blood transfusion may be used for this client? GM-CSF Erythropoietin Eltrombopag Thrombopoietin
Erythropoietin Explanation: Erythropoietin (epoetin alfa [Epogen, Procrit]) is an effective alternative treatment for clients with chronic anemia secondary to diminished levels of erythropoietin, as in chronic renal disease. This medication stimulates erythropoiesis.
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 Extreme leukocytosis Sickle cell anemia Renal transplantation
Essential thrombocythemia Explanation: Platelet pheresis is used to remove platelets from the blood in patients with extreme thrombocytosis or essential thrombocythemia (temporary measure)or in a single-donor platelet transfusion.
A client wants to donate blood before his or her abdominal surgery next week. What should be the nurse's first action? Provide the client with a list of the nearest donation centers. Explain the time frame needed for autologous donation. Remind the client to take supplemental iron before donation. Tell the client that 2 units of blood will be needed.
Explain the time frame needed for autologous donation. Explanation: Preoperative autologous donations are ideally collected 4 to 6 weeks before surgery. The nurse should first explain that time frame to this client. Surgery is scheduled in one week which means that autologous blood donation may not be an option for this client. A list of donation centers can be provided to the client; and even though iron is recommended and 2 units of blood may be suggested, the first action is to tell the client about the needed time frame for donation.
A nurse is completing a detailed health history and assessment in the electronic medical record (EMR) for a client with a disorder of the hematopoietic system. Which symptom is the most commonly reported in association with hematologic diseases? Extreme fatigue Severe headaches Dyspnea Blurred vision
Extreme fatigue Explanation: When assessing a client with a disorder of the hematopoietic system, it is essential to assess for the most common symptom in hematologic diseases, which is extreme fatigue.
Which term refers to the percentage of blood volume that consists of erythrocytes? Hematocrit Differentiation Erythrocyte sedimentation rate (ESR) Hemoglobin
Hematocrit Explanation: Hematocrit is the percentage of blood volume consisting of erythrocytes. Differentiation is development of functions and characteristics that differ from those of the parent stem cell. ESR is a laboratory test that measures the rate of settling of RBCs; an elevated rate is indicative of inflammation. Hemoglobin is the iron-containing protein of RBCs.
Which term describes the percentage of blood volume that consists of erythrocytes? Hematocrit Differentiation Erythrocyte sedimentation rate (ESR) Hemoglobin
Hematocrit Explanation: Hematocrit is the percentage of blood volume consisting of erythrocytes. Differentiation is the development of functions and characteristics that differ from those of the parent stem cell. ESR is a laboratory test that measures the rate of settling of red blood cells (RBCs); an elevated rate is indicative of inflammation. Hemoglobin is the iron-containing protein of RBCs.
A client's electronic health record states that the client receives regular transfusions of factor IX. The nurse would be justified in suspecting that this client has what diagnosis? Leukemia Hemophilia Hypoproliferative anemia Hodgkin lymphoma
Hemophilia Explanation: Administration of clotting factors is used to treat diseases where these factors are absent or insufficient; hemophilia is among the most common of these diseases. Factor IX is not used in the treatment of leukemia, lymphoma, or anemia.
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 Blood transfusion reaction Shock Splintering of bone fragments
Hemorrhage Explanation: Hazards of either bone marrow aspiration or biopsy include bleeding and infection. The risk of bleeding is somewhat increased if the patient's platelet count is low or if the patient has been taking a medication (e.g., aspirin) that alters platelet function.
A client is scheduled for surgery to remove an abdominal mass. The nurse knows that which reason hemodilution would be contraindicated as a method to provide blood to the client during the surgery? History of renal disease Previous thyroidectomy Treatment for osteoarthritis Takes medications for seasonal allergies
History of renal disease Explanation: Hemodilution is the removal of 1 to 2 units of blood after induction of anesthesia and replaced with a colloid or crystalloid solution. The blood is then reinfused after the surgery. The purpose of this approach is to reduce the amount of erythrocytes lost during the surgery because the intravenous fluids dilute the concentration of red blood cells and lowers the hematocrit. Hemodilution has been linked to tissue ischemia in the kidneys and would be contraindicated in the client with a history of renal disease. Hemodilution would not be contraindicated for a previous thyroidectomy, treatment for osteoarthritis, or medication used to treat seasonal allergies.
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 Oxygen therapy Therapeutic phlebotomy Anticoagulation therapy
Iron chelation therapy Explanation: Iron overload is a complication unique to people who have had long-term PRBC transfusions. One unit of PRBCs contains 250 mg of iron. Patients with chronic transfusion requirements can quickly acquire more iron than they can use, leading to iron overload. Over time, the excess iron deposits in body tissues and can cause organ damage, particularly in the liver, heart, testes, and pancreas. Promptly initiating a program of iron chelation therapy can prevent end-organ damage from iron toxicity.
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 Lithotomy position Supine with head of the bed elevated 30 degrees Jackknife position
Lateral position with one leg flexed Explanation: Bone marrow aspiration procedure. The posterior superior iliac crest is the preferred site for bone marrow aspiration and biopsy because no vital organs or vessels are nearby. The patient is placed either in the lateral position with one leg flexed or in the prone position.
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 Animal fats Organic foods
Leafy green vegetables Lean meats Nuts and seeds Explanation: A healthy diet that includes lean meats, nuts, seeds and green vegetables can promote red cell production. Animal fats are not known to promote red cell production. Organic foods are not necessarily more likely to promote red cell synthesis.
Albumin is important for the maintenance of fluid balance within the vascular system. Albumin is produced by which of the following? Liver Pancreas Kidney Large intestine
Liver Explanation: Albumin is produced by the liver. Albumin is not produced in the pancreas, kidney, or large intestine.
Which term refers to a form of white blood cell involved in immune response? Granulocyte Lymphocyte Spherocyte Thrombocyte
Lymphocyte Explanation: 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.
Which cell of hematopoiesis is responsible for the production of red blood cells (RBCs) and platelets? Myeloid stem cell Lymphoid stem cell Monocyte Neutrophil
Myeloid stem cell Explanation: Myeloid stem cells are responsible not only for all nonlymphoid white blood cells (WBC) but also for the production of red blood cells and platelets. Lymphoid cells produce either T or B lymphocytes. A monocyte is large WBC that becomes a macrophage when is leaves the circulation and moves into body tissues, and not responsible for RBC production. A neutrophil is a fully mature WBC capable of phagocytosis and not responsible for RBC production.
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? Basophils Neutrophils Eosinophils Monocytes
Neutrophils Explanation: Neutrophils, the most abundant type of white blood cell, are the first of the WBCs to respond to infection or inflammation. The normal value is 3,000 to 7,000/cmm (males) and 1,800 to 7,700/cmm (females).
Which is a symptom of severe thrombocytopenia? Petechiae Inflammation of the mouth Inflammation of the tongue Dyspnea
Petechiae Explanation: Clients with severe thrombocytopenia have petechiae, which are pinpoint hemorrhagic lesions, usually more prominent on the trunk or anterior aspects of the lower extremities.
A client is diagnosed with extreme thrombocytosis. The nurse knows this condition is a result of which elevated blood cell count? Neutrophils Platelets Erythocytes Eosinophils
Platelets Explanation: Extreme thrombocytosis is an elevation in platelets.
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-negative child Rh-positive mother; Rh-negative child Rh-negative mother; Rh-positive child Rh-positive mother; Rh-positive child
Rh-negative mother; Rh-positive child Explanation: A mother who is Rh-negative and gives birth to an Rh-positive child is at greatest risk for a febrile nonhemolytic reaction because exposure to an Rh-positive fetus raises antibody levels in the Rh-negative mother. An Rh-negative mother can carry an Rh-negative child without being at greatest risk for a febrile nonhemolytic reaction; however, these mothers are often treated prophylactically. An Rh-positive mother may carry either an Rh-positive or Rh-negative child without increased risk.
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? Assess the client's vital signs. Stop the infusion. Call the health care provider. Slow the infusion.
Stop the infusion. Explanation: A client with impaired renal function is at increased risk for transfusion-associated circulatory overload (TACO). Signs of circulatory overload include dyspnea, orthopnea, tachycardia, an increase in blood pressure, and sudden anxiety. If the symptoms are mild, the nurse may be able to slow the infusion and administer diuretics; however, sudden shortness of breath should clue the nurse to immediately stop the infusion and sit the client upright with feet dangling. Next, the nurse will notify the health care provider after normal saline is infused into the site. Only after stopping the infusion will the nurse obtain the client's vital signs.
Which type of lymphocyte is responsible for cellular immunity? B lymphocyte Plasma cell T 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 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? Monocytes B lymphocytes Leukocytes T lymphocytes
T lymphocytes Explanation: Lymphocytes (T cells, B cells, and natural killer cells) are WBCs that are the major components of the body's immune response. T cells are primarily responsible for cell-mediated immunity, whereas B cells are involved in antibody production.
A 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 health care provider may first call the client's parents if the client refuses. The client can only refuse the transfusion if the consent form has not been signed. The health care provider may ask for a court order if the client refuses.
The client has a right to refuse the transfusion. Explanation: An 18-year-old client may refuse transfusion if the client is of sound mind and has been provided education on the risks and benefits of the transfusion. An 18-year-old client is considered an adult and does not require the consent of his or her parent.
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 an allergic reaction to the blood. The client is experiencing vascular collapse. The client is having decrease in tissue perfusion from a shock state. The client is having a febrile nonhemolytic reaction.
The client is having a febrile nonhemolytic reaction. Explanation: The signs and symptoms of a febrile nonhemolytic transfusion reaction are chills (minimal to severe) followed by fever (more than 1°C elevation). The fever typically begins within 2 hours after the transfusion is begun. Although the reaction is not life threatening, the fever, and particularly the chills and muscle stiffness, can be frightening to the client.
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 produce erythropoietin, stimulating the bone marrow to produce more red blood cells. The bone marrow is stimulated by low oxygen levels in the blood to produce erythropoietin, maturing the red blood cells. The brain senses low oxygen levels in the blood and produces hemoglobin, which binds to more red blood cells. The kidneys sense low oxygen levels in the blood and produce hemoglobin, stimulating the marrow to produce more red blood cells.
The kidneys sense low oxygen levels in the blood and produce erythropoietin, stimulating the bone marrow to produce more red blood cells. Explanation: If normally functioning kidneys detect low levels of blood oxygen, they produce more of the hormone erythropoietin (EPO). As EPO levels increase, the bone marrow responds by producing more erythrocytes (red blood cells). EPO is not made by the bone marrow. Hemoglobin, an iron-rich protein that allows erythrocytes to transport oxygen, is synthesized in the erythrocytes as they mature.
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 bone marrow is stimulated by low oxygen levels in the blood and stimulates erythropoietin, maturing the red blood cells. The brain senses low oxygen levels in the blood and stimulates hemoglobin, which binds to 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 Explanation: If the kidney detects low levels of oxygen, as occurs when fewer red cells are available to bind oxygen (as with anemia), erythropoietin levels increase, stimulating the marrow to produce more erythrocytes (red blood cells).
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. Elevate the client's head of the bed. Where a mask when entering the client's room. Apply supplemental oxygen to maintain the client's oxygenation.
Use an electric razor when assisting client with shaving. Explanation: Petechiae are associated with severe thrombocytopenia, placing the client at risk for bleeding. The nurse should use an electric razor when assisting the client with shaving. Elevating the head of the bed and applying supplemental oxygen would be appropriate for a client with decreased oxygenation. Wearing a mask when entering the client's room would be appropriate for a client with neutropenia, not thrombocytopenia.
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 Administer the blood as soon as it arrives Premedicate the client with acetaminophen Assess the client 30 minutes after the start of the initial transfusion
Verify the client's identity according to hospital policy Explanation: Acute hemolytic transfusion reactions are preventable. Improper identification is responsible for the majority of hemolytic transfusion reactions. Meticulous attention to detail in labeling blood samples and blood components and accurately identifying the recipient cannot be overemphasized. It is the nurse's responsibility to ensure that the correct blood component is transfused to the correct client. The nurse must assess the client during the initial start of the transfusion and frequently, if the nurses delays the assessment time for 30 minutes the client may have begun to experience acute hemolytic transfusion reaction, this puts the client's safety at risk.
Vitamin B and folic acid deficiencies are characterized by production of abnormally large erythrocytes called blast cells. megaloblasts. mast cells. monocytes.
megaloblasts. Explanation: Megaloblasts are abnormally large erythrocytes.Blast cells are primitive WBCs. Mast cells are cells found in connective tissue involved in defense of the body and coagulation. Monocytes are large WBCs that become macrophages when they leave the circulation and move into body tissues.
