Med Surg Prep U Chapter 28
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."
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 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 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
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 client is being treated for idiopathic thrombocytopenia purpura. Which blood component will the nurse expect to be prescribed to the client?
Immunoglobulin
Which is a symptom of severe thrombocytopenia?
Petechiae
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
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
Which type of lymphocyte is responsible for cellular immunity?
T lymphocyte
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.
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 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."
Which client is not a candidate to be a blood donor according to the American Red Cross?
26-year-old female with hemoglobin 11.0 g/dL
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?
45,000/mm3
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
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
The nurse is caring for a client who has a unit of whole blood removed every 6 weeks as treatment for polycythemia vera. Which laboratory test will the nurse monitor to determine if the procedure is adversely affecting the client?
Iron
A patient who has long-term packed RBC (PRBC) transfusions has developed symptoms of iron toxicity that affect liver function. What immediate treatment should the nurse anticipate preparing the patient for that can help prevent organ damage?
Iron chelation therapy
A client in acute renal failure has been prescribed 2 units of packed red blood cells (PRBCs). The nurse explains to the client that the blood transfusion is most likely needed for which reason?
Lack of erythropoietin
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
A client involved in a motor vehicle accident arrives at the emergency department unconscious and severely hypotensive. The nurse suspects the client has several fractures in the pelvis and legs. Which parenteral fluid is the best choice for the client's current condition?
Packed red blood cells (RBCs)
The client is planned to have a splenectomy. The nurse should prepare which medication to administer to this client?
Pneumococcal vaccine
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.
In normal blood, monocytes account for approximately what percentage of the total leukocyte count?
5%
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.
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 nurse is preparing a dose of furosemide for an older adult with heart failure. The health care provider orders furosemide 1 mg/kg to be given intravenously. The client weighs 50 kg. The concentration of the drug is 40 mg/4mL (10 mg/mL). How many milliliters would the nurse administer? Record your answer using a whole number.
5
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
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?
Chelation therapy
Which blood cell type is matched correctly with its function?
Leukocyte: Fights infection
Albumin is important for the maintenance of fluid balance within the vascular system. Albumin is produced by which of the following?
Liver
A client with myelodysplastic syndromes (MDS) routinely takes oral chelation therapy. Which assessment findings indicate to the nurse that the client is experiencing side effects from this treatment? Select all that apply.
Skin rash Diarrhea Abdominal cramping